Harvard Pilgrim would like to remind our network that prior authorization is required for all formulas and enteral nutrition requested for members enrolled in commercial products.
Harvard Pilgrim offers coverage of medically necessary special medical formulas and enteral nutrition so that at-risk patients receive the nutritional support needed to prevent clinical deterioration.
Please refer to the Formulas and Enteral Nutrition Medical Review Criteria for the criteria that must be met for coverage and the list of codes that require prior authorization.
When requesting authorization, please complete the Pedi/Adult Formula Prior Authorization Request Form and include the following clinical documentation:
- For infants and pediatric patients: weight for age, weight for height growth charts, and Body Mass Index (BMI) charts (if applicable)
- For adults: documentation of BMI and/or weight measured over time.