Harvard Pilgrim has conducted an annual review of a number of policies for oncology-related medical drugs, which are managed through our partnership with OncoHealth (formerly Oncology Analytics).

At the December 13, 2021 meeting, the Harvard Pilgrim Pharmacy & Therapeutics Committee reviewed certain medications and decided the following.

Harvard Pilgrim has developed medical policies for commercial medical review of the Watchman Device, as well as FMT for Clostridium Difficile Infection, and prior authorization is not required.

Harvard Pilgrim has updated our billing requirements to reflect recent changes regarding telehealth place of service codes 02 and 10, as well as the modifiers FQ and FR.

Harvard Pilgrim is updating our commercial medical policy for Mohs micrographic surgery to specify that as of March 1, the procedure will only be considered reasonable and medically necessary when performed by a dermatologist certified by the American College of Mohs Surgery.

In the coming weeks, you may receive a request for copies of medical records for certain patients related to the NCQA’s annual HEDIS project, and we appreciate your assistance in helping us measure clinical quality.

Effective for dates of service beginning March 1, 2022, Harvard Pilgrim is updating our commercial medical policy for electric tumor treating field devices to require prior authorization for HCPCS code A4555.

Harvard Pilgrim is adding a number of codes to our commercial New Technology Assessment and Non-Covered Services Medical Policy, some effective as of Jan. 1 and some effective for dates of service beginning March 1.

As a reminder, it’s important to use a Harvard Pilgrim contracted ambulance provider when coordinating ground ambulance services for our members. In addition, please note that Fallon Ambulance no longer participates in our ambulance network in Massachusetts.

Harvard Pilgrim’s Specialty Pharmacy Program has added a number of medications. Refer to this article for information about treatment indications and pharmacy coverage.

With cases of COVID on the rise again, Massachusetts has established three state supported mobile units for monoclonal antibody treatment for high-risk individuals who have been exposed to or have COVID-19.

As we announced in the Oct. issue of Network Matters, as of Jan. 1, 2022, Harvard Pilgrim Health Care is no longer offering Stride (HMO) Medicare Advantage plans in Massachusetts and Maine, and many former Massachusetts Stride members chose a Tufts Medicare Preferred plan for coverage this year.