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

January 2018

Maximum Dosages for Medical Drugs

As we announced in last month’s issue of Network Matters, Harvard Pilgrim 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.

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Network Matters Archives

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Genetic Testing Prior Authorization for Commercial Members

Maximum Dosages for Medical Drugs

HPI to Administer Boston Medical Center Plan

Update for Dartmouth-Hitchcock and Alice Peck Medical Benefit Plans

Coverage for Out-of-Area Dependents


Prior Authorization Policy Updates

Substance Abuse and Depression in Primary Care


2018 Fee Schedule Updates

Payment Policy Updates: Billing for Multiple Dates of Service


Eric H. Schultz,
President and Chief Executive Officer

Robert Farias,
Senior Vice President, Network Strategy

Annmarie Dadoly,

Joseph O'Riordan,

Kristin Edmonston,
Production Coordinator