Earlier this year, Harvard Pilgrim expanded our prior authorization program for select medical drugs and is continuing efforts to ensure the safe, cost-effective, and appropriate use of medications through a new maximum allowed dosage policy.
Effective for dates of service beginning Feb. 26, 2018, Harvard Pilgrim will apply industry standard claims edits and will not reimburse for drug dosages above limits in accordance with FDA-approved labeling, accepted compendia, and/or evidence-based practice guidelines for the medical drugs listed here for our commercial members.
Under our new Drug Dosage and Frequency Medical Policy, the drug dosage, frequency and route of administration should be supported by one or more of the following for the treatment indication:
- U.S. Food and Drug Administration prescribing information
- National Comprehensive Cancer Network Drug & Biologics Compendium
- American Hospital Formulary Service Drug Information
- DRUGDEX System
Harvard Pilgrim reserves the right to conduct post-payment review and audit of claims submitted for drugs and may recover payments made for amounts in excess of the FDA labelling.
For more information, please refer to the Drug Dosage and Frequency Medical Policy and the Medical Drug Management Prior Authorization Policy. Also, look for additional information in upcoming issues of Network Matters.