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

November 2018

New Pharmacy Prior Authorizations for 2019

Effective Jan. 1, 2019, Harvard Pilgrim will require prior authorization for coverage of attention deficit hyperactivity disorder (ADHD) medications, antineoplastic medications, and medications used to treat pulmonary arterial hypertension for members of our commercial plans. We are creating new pharmacy prior authorization clinical guidelines for these categories of medications, which will outline the criteria that must be met for coverage and serve as a tool to promote quality, safety, and cost-effective pharmacotherapy. These new prior authorization requirements will apply only to patients being newly prescribed these medications; patients who are currently taking these medications today will be able to continue being prescribed them without a prior authorization. The criteria required for prior authorization of ADHD medications, antineoplastic medications, and pulmonary arterial hypertension medications will include, but not be limited to:

ADHD medications:

  • The prescriber must ensure that ADHD is the appropriate diagnosis.
  • If the request is for a multi-source brand, the patient is required to have first tried and failed a sufficient course of therapy with the generic version of the requested medication and at least two alternative formulary medications.

Antineoplastic medications:

  • The patient must have a confirmed diagnosis of one of the FDA-approved or National Comprehensive Cancer Network (NCCN)-recognized indications.

Pulmonary arterial hypertension medications:

  • The prescriber must ensure the appropriate utilization of the medication indicated for pulmonary arterial hypertension based on FDA-approved indications and appropriate clinical criteria.

The complete coverage criteria for these medications will be detailed in the prior authorization guidelines that will be posted in the Pharmacy section of Harvard Pilgrim’s website by Jan. 1, 2019, along with the appropriate Medication Request Forms.

Please keep the following in mind when making an authorization request: The drug-specific clinical criteria that Harvard Pilgrim makes available to providers contains in-depth information that is not always explicitly detailed in the standard medication request forms. To expedite your authorization request and help ensure it can be evaluated properly, 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.

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