CommercialCoverageMedium impact
Reminders on pain management and opioid antagonists
Harvard Pilgrim Health Care·Pain Management, Pharmacy, Psychiatry +1 more·Reimbursement
We identified it
Jul 9, 2026
Summary
Point32Health issued a reminder policy on pain management and opioid antagonist coverage. The policy emphasizes coverage of non-opioid alternatives (acupuncture, physical therapy, behavioral therapy, chiropractic) and clarifies billing for opioid antagonists (naloxone and naltrexone), noting that naloxone reimbursement may occur as part of bundled rates using specific HCPCS codes. Billing teams must ensure correct coding and follow applicable formularies and Provider Manuals.
Action Required
Immediately: Billing team must verify current billing practices for naloxone (J0571-J0575) and naltrexone (J2310-J2311) to confirm compliance with bundled rate requirements. Review the applicable Point32Health formulary and Pharmacy Medical Necessity Guidelines to understand coverage criteria for opioid antagonists. Ensure providers are aware that naloxone reimbursement may be bundled and should not be billed separately in those cases. Update internal billing guidelines to reflect that pain management plan services (acupuncture, physical therapy, behavioral therapy, chiropractic) are covered alternatives. Providers should reference the Point32Health Provider Manual for current claims and billing guidance for opioid antagonist claims.