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

April 2018

Reminder: Medical Drugs & Buy-and-Bill or Specialty Pharmacy


As you know, Harvard Pilgrim requires prior authorization on approximately 200 medical drugs. While providers use the buy-and-bill process to obtain the majority of these drugs, a subset is available through the specialty pharmacy as well. Having two pathways offers providers greater flexibility, but sometimes results in confusion about the appropriate prior authorization process. The following information can help ensure that your prior authorization request is processed correctly, enabling you to be reimbursed appropriately.

Harvard Pilgrim has about 35-40 medical drugs that can be obtained through either buy-and-bill or specialty pharmacy, including Acthar HP, Botox, Cinryze, Eylea, Lupron Depot, Prolia, and Xolair. The prior authorization process varies depending on which pathway you choose to obtain the medication.

Prior Authorization for Medical Drugs Available Via Buy-and-Bill or Specialty Pharmacy

If you obtain the medical drug through:  Prior authorization process overview

How to request authorization

Where to find criteria and request forms

Buy-and-Bill

Authorization request is made through CVS Health–NovoLogix, provider purchases the drug, bills Harvard Pilgrim when administered, and Harvard Pilgrim processes the claim. 

Contact CVS Health–NovoLogix via phone (844-387-1435) or fax (844-851-0882).

Criteria and forms are available in the Medical Drug Prior Authorization Chart

(When navigating from www.harvardpilgrim.org/providers, click on Medical Management then commercial Prior Authorization Medical Review Criteria)

Specialty Pharmacy

Authorization request is made through MedImpact, which processes the claim. CVS Specialty delivers the medication to the provider’s office (white bagging).

Fax completed request forms to MedImpact Health Systems at 888-807-6643.

Criteria and forms are available in Medication Request Forms and Clinical Coverage Criteria 

(When navigating from www.harvardpilgrim.org/providers, click on Pharmacy and then Medication Request Forms and Clinical Coverage Criteria)

It’s important to note that CVS Specialty and CVS Health-NovoLogix are distinct entities. A common prior authorization error for certain medical drugs, such as Botox, is that the provider’s office obtains an authorization through MedImpact, then submits a buy-and-bill claim for the Botox to Harvard Pilgrim, not realizing that the MedImpact authorization is not valid for buy-and-bill.

By requesting authorization from the appropriate entity, your practice can avoid unnecessary denials for lack of authorization. If you have any additional questions, please contact the Provider Service Center at 800-708-4414.

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PUBLICATION INFORMATION

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Senior Vice President, Corporate Network Strategy

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Writer

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Production Coordinator