Harvard Pilgrim Health Care Home
  Learn more.
  Sign up for HPHConnect.
Medical Management
For Your Patient
News Center
Network Matters
Newsletter Archives
Newsletter Registration
Office Support
Provider Manual
Medicare Advantage
Research & Teaching
Resources & Links
Print    Text Size

Network Matters
News and Information for the
Harvard Pilgrim Health Care Network

April 2016

Updates to Harvard Pilgrim’s Nexium Coverage

Harvard Pilgrim now covers Nexium 24HR, the over-the-counter formulation of Nexium, at Tier 1 on all formularies. For dates of service beginning June 1, 2016, prior authorization will be required for other formulations of Nexium as follows:

  • Premium formulary  — Prior authorization is required for prescription brand-name Nexium and its generic equivalent esomeprazole.
  • Value formulary — Prior authorization is required for esomeprazole (brand name Nexium is not covered on the Value formulary).

This prior authorization requirement will apply to members new to treatment, as well as those currently being prescribed these proton-pump inhibitors (PPIs) to treat their gastroesophageal reflux (GERD). Coverage for prescription Nexium in powder packet form will not be affected by this change; it will continue to be covered without prior authorization.

Harvard Pilgrim will cover Nexium 24HR, available in a 20mg-strength capsule, when it is prescribed by the provider and dispensed at the patient’s pharmacy.

If any of your Harvard Pilgrim patients are currently taking prescription Nexium and esomeprazole for GERD, please consider moving them to the over-the-counter version since this will allow them to incur lower out-of-pocket costs.

Harvard Pilgrim’s Nexium Clinical Review Criteria detail the requirements that must be met in order to obtain prior authorization. To request prior authorization, please complete the Nexium Medication Request Form and fax it to MedImpact Healthcare Systems at 888-807-6643. For more information, refer to the Pharmacy section of Harvard Pilgrim's provider website.

Email this article to a colleague   

Network Matters Archives

Download printer-friendly version


Important Referral Reminders for PCPs

New Medicare Advantage FDR Compliance Program Website Available


Vaccine Policy: Updates Regarding State-Supplied Vaccines

Clinical Policy and Prior Authorization Updates

Upcoming Clinical Reviews: Give Us Your Feedback

Updates to Harvard Pilgrim’s Nexium Coverage

Diabetes Outreach Program for Medicare Advantage Members

Harvard Pilgrim’s Commitment to Health Equity

P&T Committee Updates

Specialty Pharmacy Program Updates

Reminder Regarding Annual Well Visits


Benefit from the Convenience of Electronic Funds Transfer

Reminder: Use of Non-Participating Ambulance Providers


Eric H. Schultz,
President and Chief Executive Officer

Robert Farias,
Vice President, Network Services

Annmarie Dadoly,

Joseph O'Riordan,

Kristin Edmonston,
Production Coordinator