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

May 2017

Medical Drug Prior Authorization Program with CVS Health–NovoLogix


Harvard Pilgrim has selected CVS Health–NovoLogix to oversee and expand our prior authorization program for medical drugs to optimize treatment outcomes and promote the safe and cost-effective use of these medications. CVS Health–NovoLogix will perform medical necessity and utilization review for select medical drugs on behalf of Harvard Pilgrim*.

Prescription drugs, and in particular specialty medications, account for a significant and growing proportion of health care spending. Harvard Pilgrim anticipates that our partnerships with CVS for medical drug utilization management and specialty pharmacy services (see article below) will ensure that these medications are being used in a clinically appropriate and effective manner for our members.

Beginning July 14, 2017, prior authorizations for select medical drugs for our commercial members will be required through CVS Health–NovoLogix. Under this program, Harvard Pilgrim will utilize industry-standard medical necessity criteria developed and maintained by CVS Health–NovoLogix for approximately 200 medical drugs. While CVS Health–NovoLogix will provide the prior authorization review for medical drugs, Harvard Pilgrim will continue to be responsible for claims adjudication and appeals.

For detailed information, please refer to the new criteria and prior authorization forms posted on our provider website at www.harvardpilgrim.org/medicaldrugpa. Please note:

  • CVS Health–Novologix will begin processing prior authorization requests for select medical drugs beginning July 3, 2017.
  • Harvard Pilgrim will require prior authorization through CVS Health–Novologix for most of these drugs for dates of service on or after July 14, 2017. An additional 24 medical drugs will be added to the program and will require prior authorization by CVS Health–Novologix for dates of service on or after August 10, 2017.
  • Harvard Pilgrim has existing prior authorization criteria and policies in place for some drugs covered under the medical benefit (indicated in the chart with **). The Harvard Pilgrim policies and procedures will remain in effect until the transition occurs. For the drugs currently on Harvard Pilgrim’s prior authorization list that are scheduled to transition to CVS Health–Novologix in August, providers should continue to contact Harvard Pilgrim for authorization until August 1.
  • Authorizations approved by Harvard Pilgrim prior to July 3 will be grandfathered and will not require authorization from CVS Health–NovoLogix until the existing authorization expires. If there is a material change to the authorization, however, providers must submit a new request made to CVS Health–NovoLogix.
  • You may submit your request to CVS Health–NovoLogix via phone (844-387-1435) or fax (844-851-0882); an online portal is being developed for rollout later this year.

Harvard Pilgrim and CVS Health–NovoLogix will be mailing letters to members and providers affected by these changes to inform them about these policies and procedures. Also look to next month’s issue of Network Matters for more information and an FAQ.

*Pending regulatory approval in Rhode Island.

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PUBLICATION INFORMATION

Eric H. Schultz,
President and Chief Executive Officer

Robert Farias,
Vice President, Network Services

Annmarie Dadoly,
Editor

Joseph O'Riordan,
Writer

Kristin Edmonston,
Production Coordinator