As a reminder, when filling out a standard medication request form to request coverage for a pharmacy drug that requires prior authorization, please be sure to reference Harvard Pilgrim’s pharmacy clinical criteria for that drug to ensure that you are providing all the appropriate information.
Pharmacy medications requiring prior authorization have clinical guidelines developed by licensed clinical pharmacists, which reflect the latest in evidence-based medicine and are used as a tool to promote quality, safety, and cost-effective pharmacotherapy. The drug-specific clinical criteria that Harvard Pilgrim makes available to providers contains in-depth information that is often not explicitly detailed in the standard medication request forms. Because of this, it is important to review the criteria for the drug you are requesting coverage for and include any information outlined in the criteria on your pharmacy medication request form.
Providing the appropriate information makes for a quicker, more efficient prior authorization process because it can decrease the volume of outreach calls from the reviewer to obtain missing details. If outreach is made and the necessary information is not supplied to Harvard Pilgrim in a timely manner, we would have to deny the request if the clinical criteria are not met.
Some examples of information that is commonly omitted include:
- For Dupixent: Whether the requesting provider provides a BSA, EASI score, or IGA/PGA score
- For Hepatitis C drugs: Whether the requesting provider has consulted their patient on drug-to-drug interactions
In addition to reviewing the drug-specific criteria when submitting medication requests, it is also important to be as specific and comprehensive as possible when referencing prior drug therapies that have been tried and failed.
By working collaboratively together, Harvard Pilgrim and prescribers can streamline the prior authorization process, increasing efficiency and enhancing the member experience.