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

June 2017

Reminder: Expanded Medical Drug Prior Authorization Program

As we announced in last month’s issue of Network Matters, beginning July 14, 2017, prior authorizations for select medical drugs for our commercial members will be required through CVS Health–NovoLogix.*

Harvard Pilgrim 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 utilization management for approximately 200 medical drugs on behalf of Harvard Pilgrim. 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. For the drugs currently on Harvard Pilgrim’s prior authorization list that are scheduled to transition to CVS Health–Novologix in August, Harvard Pilgrim policies and procedures will remain in effect until the transition occurs  and providers should continue to contact Harvard Pilgrim for authorization until August 1.
  • Authorizations approved by Harvard Pilgrim prior to July 3 remain in effect, 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.

Please refer to this FAQ for additional information. Harvard Pilgrim is also sending letters to members and providers affected by these changes to inform them about these policies and procedures.

*Pending regulatory approval in Rhode Island.

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Network Matters Archives

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Changes to Sleep Diagnostic and Sleep Therapy Program

Review of Inpatient Admissions for Appropriate Level of Care

Reminder: Concurrent Review for Inpatient Stays

New Publication on Healthy Eating for Older Adults


Reminder: Expanded Medical Drug Prior Authorization Program

ACA Risk Adjustment Data Validation Reminder: Medical Chart Requests

Update to StrideSM (HMO) Medicare Advantage Hysterectomy Criteria

Updates to Bariatric Surgeries Medical Review Criteria

Updates to Varicose Vein Procedures Medical Review Criteria

Update to Cardiac Event Monitors Medical Policy

Prescribing Statins to Members with Diabetes

Members’ Rights and Responsibilities

Biological Effects of Cannabis and Detriments to Adolescent Development


Telemedicine/Telehealth Payment Policy

Change in Format of Newly Assigned Practitioner and Provider ID Numbers

Credentialing Reminder: Keep Provider Information Up to Date in CAQH

Keep Panel Status and Demographic Information Up to Date


Eric H. Schultz,
President and Chief Executive Officer

Robert Farias,
Vice President, Network Services

Annmarie Dadoly,

Joseph O'Riordan,

Kristin Edmonston,
Production Coordinator