2020 Pharmacy Benefits

Formulary (list of covered drugs)

Harvard Pilgrim partners with OptumRx to deliver pharmacy benefits. Visit their website to search the formulary.

You’ll need to know the name of your plan (which can be found on the front of your ID card).

To find out if, and how, your drug is covered, including the tier on which it’s covered and if there are any requirements or limits on its coverage:

If your drug is not on our formulary or is restricted in some way, please use our Medicare drug determination request form.

Coverage Requirements

Some drugs require you get our approval in advance (prior authorization) or try a different drug first (step therapy). To find out what the criteria are for these restrictions, view our prior authorization criteria or step therapy criteria.

If you are taking a drug that requires prior authorization or step therapy, please use our Medicare drug determination request form (pdf).

Formulary Changes

We may add or remove drugs from our formulary during the year. In the rare circumstance that we decide to remove a drug from our formulary, add prior authorization, step therapy restrictions and/or quantity limits to a drug or move a drug to a higher cost-sharing tier, we will notify members taking the affected drug at least 30 days before the date that the change becomes effective. If there are upcoming changes to our formulary during the plan year they will be listed below.

Extended Day Supplies

Members have two options for getting up to a 90-day supply1 of their prescription drugs:

At a retail pharmacy in our Retail90 network
Through our Mail Order Program
1Certain drugs, including controlled substances, may be subject to dispensing limitations, exclusions or restrictions as required by state and federal law

Retail90 Network

Bring your prescription for a 90-day supply to a retail pharmacy participating in our Retail90 network. All retail pharmacies in our network participate in this program. You will pay three times your applicable 30-day cost-sharing amount for the 90-day supply, which may be as little as $0 for drugs covered on Tier 1. Use our pharmacy locator to find a Retail90 Network pharmacy.

Mail Order through OptumRx Home Delivery

You will pay a reduced cost-share for the 90-day supply of drugs on Tiers 1 through 4 – refer to your Evidence of Coverage for details. If you are ready to sign up, you can register online, by mail or by phone:

  • Online: OptumRx Website
  • By mail: Complete the Mail Order Form (pdf)
    Include the appropriate payment and the original written prescriptions (for new orders only). Be sure to have your physician prescribe a 90-day supply, plus refills. Mail it to OptumRx Home Delivery. You will receive your order in approximately two weeks.
  • By phone: (855) 524-0380
    Have your Harvard Pilgrim member ID number, prescription number(s) and credit card information ready whenever you call.

Specialty Pharmacy

As a Harvard Pilgrim Stride member you have the flexibility of filling your medications at the network pharmacy of your choice. If you pay a coinsurance for your specialty medication, your out of pocket costs may be lower should you choose to fill your specialty medication with CVS Specialty Pharmacy. Medications available through CVS Specialty Pharmacy are identified in our drug list with the following note: “Available through CVS Specialty (1-800-237-2767).”

Other Pharmacies are available in our network. Information about what other pharmacies are available in our network can be accessed from the Harvard Pilgrim Health Care Pharmacy Directory (available on our website or by request), or by calling our Medicare Advantage Member Services Department at 1-888-609-0692 or TTY 711. Our hours are October 1 – March 31, from 8 a.m. – 8 p.m , 7 days a week and from April 1 – September 30, from 8 a.m. – 8 p.m., Monday through Friday.

Harvard Pilgrim is an HMO/HMO-POS plan with a Medicare contract. Enrollment in Stride℠ (HMO) depends on contract renewal.