Reminder: Stride Medicare Advantage to be discontinued
As a reminder, we will no longer offer the Harvard Pilgrim Stride Medicare Advantage plan as of Jan. 1, 2025.
Insights and Updates for Providers
November 2024
Observation Stay Payment Policy and process change
Effective Jan. 1, 2025, Point32Health is making a change to our review process for short inpatient stays and observation services.
Updates regarding Tufts Health Public Plans claim appeals
We’re updating our rules and requirements associated with appeals submission and timely filing limits for Tufts Health Public Plans claims.
Update on our behavioral health network
With our robust, insourced behavioral health network now firmly established, effective Jan. 1, 2025, non-contracted Harvard Pilgrim providers will no longer be considered in network.
Point32Health Medicare products: 2025 benefit changes
We are providing updated benefit information for 2025 related to our Tufts Health Plan Senior Products, Tufts Medicare Preferred HMO/PPO and Tufts Health Plan Senior Care Options.
Senior Products: 2025 formulary coverage changes
Point32Health is incorporating a number of updates to our Tufts Health Plan Senior Products drug formularies for the 2025 plan year.
Pharmacy coverage changes
The following changes to Point32Health’s Pharmacy program take effect on Jan. 1, 2025, including prior authorization, drug status, and formulary updates for various products.
Removing certain drugs from white bagging program
Effective for dates of service beginning Jan. 1, 2025, certain medications will be removed from the Office-Administered Medical Drugs list.
Other 2025 Pharmacy program updates
We are providing pharmacy updates for the 2025 plan year regarding formularies, weight loss prescription drugs and diabetic GLP-1 coverage, and adalimumab.
Point32Health Medical Necessity Guideline updates
Providers and office staff can refer to the following chart to review changes and updates to Point32Health’s Medical Necessity Guidelines.
New prior authorizations for Senior Products in 2025
We continually evaluate the prior authorization requirements we have in place to promote medical necessity and clinical appropriateness, and are instituting new requirements for a number of services.
Non-emergent medical transportation (ambulance) updates
Point32Health is making updates to our prior authorization requirements for non-emergent medical transportation effective Jan. 1, 2025 for Tufts Medicare Preferred only.
Point32Health medical drug program updates
Providers and office staff can refer to the following chart to review updates to our medical benefit drug program.
MassHealth updates to Unified Formulary
MassHealth recently announced updates to the MassHealth Unified Formulary, which will be available on the MassHealth Drug List.
2025 medical benefit step therapy program
The chart in this article outlines a new medical benefit step therapy program, which will be effective for fill dates on or after Jan. 1, 2025.
Expansion of cryopreservation and storage coverage
Our cryopreservation and storage benefit now includes coverage for ovarian tissue and testicular tissue, in addition to the previous coverage for sperm, eggs, and embryos.
Clinical documentation required for radiology services
As of Jan. 1, Point32Health will require clinical documentation for outpatient advanced imaging services for Tufts Health Plan Commercial and Tufts Health Public Plans members.
New CBHI performance specifications
We would like to remind providers of Children’s Behavioral Health Initiative services that MassHealth and EOHHS have implemented revised Medical Necessity Guidelines.
Upcoming changes to MassHealth ABA provider policies
ABA providers are reminded that effective Jan. 1, 2025, MassHealth is implementing changes to contracting requirements, Medical Necessity Guidelines, and performance specifications.
Reminder – New 2024 Model of Care training available
Tufts Health Plan Senior Care Options PCPs and specialists are encouraged to complete the new 2024 SCO Model of Care training as soon as possible.
One Care training requirement
Point32Health offers resources in the Training section of our website for providers and office staff to complete comprehensive training on the One Care program.
Point32Health Vaccines and Immunizations Payment Policy
We have developed an integrated Point32Health Vaccines and Immunizations Payment Policy and archived the previous legacy Harvard Pilgrim Health Care and Tufts Health Plan policies.
New ICD-10 codes available for diabetic shoes
Effective Nov. 1, 2024, Harvard Pilgrim Health Care Commercial members can use newly released ICD-10 codes for diabetic shoes.