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Medication Request Forms (MRF) and Clinical Coverage Criteria

Medication Request Forms (MRF) 
Harvard Pilgrim’s prior authorization program ensures that our members are using the safest and most cost-effective medications for their condition. Completed forms should be faxed to MedImpact Healthcare Systems at 888-807-6643. If you have any questions regarding this process, please contact MedImpact's Customer Service at 800-788-2949. 

Please note: The following drugs/drug classes should be submitted on the designated drug-specific form, listed below (NH providers excluded):

Hepatitis C
(Epclusa, Daklinza, Harvoni, Mavyret, Olysio, Sovaldi, Technivie, Viekira Pak/XR, Vosevi, Zepatier) PCSK9
(Praluent, Repatha)

Synagis

Clinical Criteria 
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. Harvard Pilgrim makes our clinical criteria available to physicians, as a reference. You can find our clinical criteria below, listed alphabetically by drug name.

    Medication
    Clinical Coverage Criteria*
    Abstral
    (fentanyl citrate)

    Criteria

    Actemra
    (tocilizumab)

    Criteria

    Acthar
    (corticotropin)

    Criteria

    Actiq
    (fentanyl citrate)

    Criteria

    adapalene-benzoyl

    Criteria

    Addyi
    (flibanserin)

    Criteria

    Adcirca
    (tadalafil)

    Criteria

    Adlyxin

    Criteria

    Afrezza
    (human insulin regular)

    Criteria

    AirDuo Respiclick4
    (fluticasone/salmeterol)

    Criteria

    Aktipak4
    (erythromycin/benzoyl peroxide)

    Criteria

    Akynzeo3
    (netupitant/ palonosetron)

    Criteria

    Alogliptan benzoate
    (alogliptan benzoate)

    Criteria

    Ambien2
    (zolpidem)

    Criteria

    Alunbrig 4
    (brigatinib)

    Criteria

    Ambien CR2
    (zolpidem CR)

    Criteria

    Amerge2
    (naratriptan)

    Criteria

    Androderm
    (testosterone transdermal)

    Criteria

    Androgel
    (testosterone 1%)

    Criteria

    Aplenzin
    (bupropion)

    Criteria

    Aralast
    (alpha 1-proteinase
    inhibitor)

    Criteria

    Aranesp
    (darbepoetin)

    Criteria

    Armodafinil
    (armodafinil)

    Criteria

    Armonair4
    (fluticasone propionate)

    Criteria

    Atralin1
    (tretinoin topical)

    Criteria

    Austedo4
    (deutetrabenazine)

    Criteria

    AUVI-Q
    (epinephrine)

    Criteria

    Avita1
    (tretinoin)

    Criteria

    Axert2
    (almotriptan)

    Criteria

    Axiron
    (testosterone)

    Criteria

    Basaglar Kwikpen
    (insulin glargine, hum.rec. anlog)

    Criteria

    Baxdela4
    (delafloxacin meglumine)

    Criteria

    Belsomra
    (suvorexant)

    Criteria

    Benlysta4
    (belimumab)

    Criteria

    Bepreve3
    (bepotastine besilate)

    Criteria

    Bevyxxa4
    (betrixaban maleate)

    Criteria

    Botox
    (botulinum toxin A)

    Criteria

    Briviact
    (brivaracetam)

    Criteria

    Bydureon2
    (exenatide microspheres)

    Criteria

    Bydureon Bcise
    (exenatide microspheres)

    Criteria

    Byetta2
    (exenatide)

    Criteria

    Carac3
    (fluorouracil)

    Criteria

    Carospir4
    (spironolactone)

    Criteria

    Celexa2
    (citalopram)

    Criteria

    Cialis1
    (tadalafil)

    Criteria

    ciclodan 8% solution
    (ciclopirox)

    Criteria

    Cimzia
    (certolizumab pegol)

    Criteria

    Cinryze
    (C1 Inhibitor (human))

    Criteria

    clindamycin/tretinoin
    (clindamycin/tretinoin)

    Criteria

    Compound Exceptions

    Criteria

    Corlanor
    (ivabradine hcl)

    Criteria

    Cosentyx
    (secukinumab)

    Criteria

    Cotempla XR-ODT 4
    (methylphenidate)

    Criteria

    Cresemba3
    (isavuconazonium sulfate)

    Criteria

    Cuprimine
    (penicillamine)

    Criteria

    Cymbalta2
    (duloxetine)

    Criteria

    Daklinza
    (daclatasvir)
  • MRF (Non-MA & Non-NH providers)
  • MA Standard PA form
  • NH Standard PA form
  • Criteria
  • Daraprim
    (pyrimethamine)

    Criteria

    Delatestryl
    (testosterone)

    Criteria

    Depen
    (penicillamine)

    Criteria

    Depo-Testosterone
    (testosterone)

    Criteria

    Dermapak Plus
    (tretinoin 0.025%)

    Criteria

    Dexilant3
    (dexlansoprazole)

    Criteria

    Diabetic Test Strips

    Criteria

    Diclofenac sodium

    Criteria

    Differin1
    (adapalene)

    Criteria

    Duavee3
    (conjugated estrogens/ bazedoxifene)

    Criteria

    Duexis
    (ibuprofen/ famotidine)

    Criteria

    Dupixent
    (dupilumab)

    Criteria

    Durlaza
    (aspirin ER)

    Criteria

    Duzallo4
    (lenisurad/allopurinol)

    Criteria

    Dysport
    (abobotulinum toxin A)

    Criteria

    Edluar2
    (zolpidem)

    Criteria

    Effexor/XR2
    (venlafaxine)

    Criteria

    Egrifta
    (tesamorelin)

    Criteria

    Elidel
    (pimecrolimus)

    Criteria

    Emflaza
    (deflazacort)

    Criteria

    Enbrel
    (etanercept)

    Criteria

    Entresto
    (sacubitril/ valsartan)

    Criteria

    Epclusa
    (sofosbuvir/ velpatasvir)
  • MRF (Non-MA & Non-NH providers)
  • MA Standard PA form 
  • NH Standard PA form  
  • Criteria
  • Epiduo1
    (adepalene/ benzoyl peroxide)

    Criteria

    Epiduo Forte
    (adapalene/ benzoyl peroxide)

    Criteria

    Epogen
    (epoetin alpha)

    Criteria

    Ertaczo3
    (sertaconazole)

    Criteria

    Esomeprazole magnesium
    (esomeprazole magnesium)

    Criteria

    Eucrisa4
    (crisabarole)

    Criteria

    Evzio
    (naloxone HCl)

    Criteria

    Eylea
    (aflibercept)

    Criteria

    TR>
    Fabior
    (tazarotene)

    Criteria

    Farxiga3
    (dapagliflozin propanediol)

    Criteria

    fentora
    (fentanyl citrate)

    Criteria

    Fetzima2
    (levomilnacipran hydrochloride)

    Criteria

    Fiasp4
    (insulin apart (niacinamide))

    Criteria

    Flolipid4
    (simvastatin)

    Criteria

    Fluoroplex3
    (fluorouracil)

    Criteria

    Fluorouracil3

    Criteria

    Fluoxetine 60mg tabs
    (fluoxetine)

    Criteria

    Follistim AQ2
    (follitropin beta)

    Criteria

    Formulary Exception Request Form

    Criteria

    Forteo
    (teriparatide)

    Criteria

    Fortesta
    (testosterone)

    Criteria

    Frova2
    (frovatriptan)

    Criteria

    Gattex
    (teduglutide)

    Criteria

    Genotropin
    (somatropin)

    Criteria

    Glumetza
    (metformin)

    Criteria

    Gocovri 4
    (amantadine HCl)
    Granix
    (tbo-filgrastim)

    Criteria

    Haegarda4
    (c1 esterase inhibitor)

    Criteria

    Harvoni
    (ledipasvir/ sofosbuvir)
    Hemangeol3
    (propranolol HCL)

    Criteria

    Hetlioz
    (tasimelteon)

    Criteria

    Humatrope
    (somatropin)

    Criteria

    Humira
    (adalimumab)

    Criteria

    Idhifa
    (enadisenib mesylate)

    Criteria

    Ilaris
    (canakinumab)

    Criteria

    Imitrex tabs2
    (sumatriptan)

    Criteria

    Increlex
    (mecasermin recombinant)

    Criteria

    Ingrezza4
    (valbenazine tosylate)

    Criteria

    Injectable MRF

    Criteria

    Intermezzo2
    (zolpidem tartrate subl tab)

    Criteria

    Irenka
    (duloxetine)

    Criteria

    itraconazole
    (itraconazole)

    Criteria

    Jublia
    (efinaconazole)

    Criteria

    Kalydeco
    (ivacaftor)

    Criteria

    Kerydin
    (tavaborole)

    Criteria

    Keveyis3
    (dichlorphenamide)

    Criteria

    Kevzara4
    (sarilumab)

    Criteria

    Khedezla2
    (desvenlafaxine)

    Criteria

    Kineret
    (anakinra)

    Criteria

    Kisqali
    (ribociclib succinate)

    Criteria

    Kisqali Femara Co-Pack
    (ribociclib succinate/letrozole)

    Criteria

    Krystexxa
    (pegloticase)

    Criteria

    Lazanda
    (fentanyl citrate)

    Criteria

    Levitra1
    (vardenafil)

    Criteria

    Lexapro2
    (escitalopram)

    Criteria

    Lipitor
    (atorvastatin)

    Criteria

    Lunesta2
    (eszopiclone)

    Criteria

    Lupron Depot
    (leuprolide acetate)

    Criteria

    Lupron Depot Ped
    (leuprolide acetate)

    Criteria

    Luvox CR2
    (fluvoxamine)

    Criteria

    Luzu3
    (luliconazole)

    Criteria

    Lyrica2
    (pregabalin)

    Criteria

    Makena
    (hydroxyprogesterone caproat/pf)

    Criteria

    Mavyret
    (glecaprevir/pibrentasvir)
    Maxalt/ MLT2
    (rizatriptan; oral disintegrating tablet)

    Criteria

    Mentax3
    (butenafine)

    Criteria

    Minitran3
    (nitroglycerin)

    Criteria

    Mircera
    (methoxy peg-epoetin beta)

    Criteria

    Mirvaso3
    (brimonidine tartrate)

    Criteria

    modafinil
    (modafinil)

    Criteria

    Mydayis4
    (dextroamphetamine/amphetamine)

    Criteria

    Myobloc
    (botulinum toxin B)

    Criteria

    Mytesi
    (crofelemer)

    Criteria

    Natesto
    (testosterone, nasal gel)

    Criteria

    Naulasta
    (pegfilgrastim)

    Criteria

    Neo-Synalar3
    (neomycin/fluocinolone)

    Criteria

    Nerlynx 4
    (NERATINIB MALEATE)

    Nesina2
    (alogliptin benzoate)

    Criteria

    Neupogen
    (filgrastim)

    Criteria

    New to Market

    Criteria

    Nexium
    (esomeprazole)

    Criteria

    Nityr4
    (nitisinone)

    Criteria

    Norditropin/ Nordiflex
    (somatropin)

    Criteria

    Novolog/Mix 70/30
    (insulin aspart)

    Criteria

    Novolin N/R/70/30
    (human insulin)

    Criteria

    Nuplazid
    (pimavanserin tartrate)

    Criteria

    Nutropin/ AQ/ AQ Nuspin
    (somatropin)

    Criteria

    Nuvigil
    (armodafinil)

    Criteria

    Ocaliva
    (obethicholic acid)

    Criteria

    Octreotide
    (octreotide acetate)

    Criteria

    Olysio
    (simeprevir sodium)
    Omeppi4
    (omeprazole/sodium bicarbonate)

    Criteria

    Omnitrope
    (somatropin)

    Criteria

    Onfi
    (clobazam)

    Criteria

    Onglyza2
    (saxagliptin)

    Criteria

    Onmel
    (itraconazole)

    Criteria

    Onzetra Xsail
    (sumariptan succinate)

    Criteria

    Orencia
    (abatacept)

    Criteria

    Orkambi
    (lumacaftor/ ivacaftor)

    Criteria

    Otezla
    (apremilast)

    Criteria

    Paxil/ CR2
    (paroxetine)

    Criteria

    Pedipirox-4
    (ciclopirox 8.0% solution)

    Criteria

    Penlac
    (ciclopirox)

    Criteria

    Pennsaid
    (diclofenac sodium)

    Criteria

    Pexeva2
    (paroxetine)

    Criteria

    Picato3
    (ingenol mebutate)

    Criteria

    Praluent
    (alirocumab)

    Pristiq2
    (desvenlafaxine)

    Criteria

    Procrit
    (epoetin alpha)

    Criteria

    Profeno4
    (fenoprofen calcium)

    Criteria

    Prolastin
    (alpha 1-proteinase inhibitor)

    Criteria

    Prolia
    (denosumab)

    Criteria

    Protopic
    (tacrolimus)

    Criteria

    Provigil
    (modafinil)

    Criteria

    Prozac/ Weekly2
    (fluoxetine/ fluoxetine hcl)

    Criteria

    Quantity Limit Exceptions

    Criteria

    Qtern4
    (dapagliflozin/saxagliptin)

    Criteria

    Rayaldee
    (calcifediol)

    Criteria

    Rayos
    (prednisone)

    Criteria

    Relistor
    (methylnaltrexone)

    Criteria

    Repatha
    (evolocumab)

  • MRF (Non-MA & Non-NH providers)
  • Criteria
  • Revatio
    (sildenafil citrate)
    Rescula
    (unoprostone isopropyl)

    Retin-A/ Micro1
    (tretinoin)

    Rexulti
    (brexpiprazole)

    Criteria

    Rhofade
    (oxymetazoline hcl)

    Criteria

    Rozerem2
    (ramelteon)

    Criteria

    Rydapt4
    (midostaurin)

    Criteria

    Rytary
    (carbidopa/ levodopa)

    Criteria

    Saizen
    (somatropin)

    Sarafem2
    (fluoxetine)
    Savella
    (milnacipran)

    Criteria

    Selfemra2
    (fluoxetine)

    Criteria

    Serostim
    (somatropin)
    Silenor 2
    (doxepin)

    Criteria

    Siliq4
    (broadalumab)

    Criteria

    Simponi
    (golimumab)

    Criteria

    Sirturo3
    (bedaquiline fumarate)

    Criteria

    Solaraze3
    (diclofenac sodium)

    Criteria

    Soliqua

    Criteria

    Solodyn
    (minocycline)
    Somatuline Depot
    (lanreotide acetate)

    Criteria

    Sovaldi
    (sofosbuvir)
    Sonata2
    (zaleplon)

    Criteria

    Sporanox
    (itraconazole)
    Staxyn1
    (vardenafil)

    Criteria

    Stelara
    (ustekinumab)

    Criteria

    Stendra1
    (avanfil)

    Criteria

    Striant
    (testosterone)

    Criteria

    Striverdi Respimat3
    (olodaterol)

    Criteria

    Subsys
    (fentanyl citrate spray)

    Criteria

    Symproic4
    (naldemedine tosylate)

    Criteria

    Synagis
    (palivizumab)
    Syprine
    (trientine hydrochloride)

    Criteria

    Taltz
    (ixekizumab)

    Criteria

    Tanzeum
    (albiglutide)

    Criteria

    Tazorac1
    (tazarotene)
    Technivie
    (ombitasvir/
    paritaprevir/ ritonavir)
    Testim
    (testosterone 1%)

    Criteria

    Tev-Tropin
    (somatropin)
    Thiola
    (tiopronin)
    Trelegy Ellipta 4
    (fluticasone/umeclidinium/vilanterol)

    Criteria

    Tremfya4
    (guselkumab)
    Tresiba
    (insulin degludec)

    Criteria

    Tresiba Flextouch
    (insulin degludec)

    Criteria

    Tretin-X1
    (tretinoin)

    tretinoin1

    Treximet
    (sumatriptan/
    naproxen)

    Criteria

    Trintellix2
    (vortioxetine hydrobromide)

    Criteria

    Trulance
    (plecanatide)

    Criteria

    Trulicity
    (dulaglutide)

    Criteria

    Tuzistra XR3
    (chlorpheniramine/ codeine)

    Criteria

    Tymlos4
    (abaloparatide)

    Criteria

    Uptravi
    (selexipag)

    Criteria

    Viekira Pak
    (ombitasvir/
    paritaprevir/ ritonavir/ dasabuvir)
    Velphoro3
    (sucroferric oxyhydroxide)

    Criteria

    Veltin1
    (clindamycin/tretinoin)
    Venlafaxine ER
    (venlafaxine er)

    Criteria

    Verzenio4
    (abemaciclib)

    Criteria

    Viagra 1
    (sildenafil)

    Criteria

    Victoza 2
    (liraglutide)

    Criteria

    Viibryd 2
    (vilazodone)

    Criteria

    Vimovo (naproxen/ esomeprazole mag)

    Criteria

    Vivlodex
    (meloxicam)

    Criteria

    Vogelxo
    (testosterone)

    Criteria

    Vosevi
    (Sofosbuvir/velpatasvir/voxilaprevir)
    Vraylar
    (cariprazine)

    Criteria

    Wellbutrin/ SR/ XL2
    (bupropion/
    bupropion ER)
    Xadago4
    (safinamide mesylate)

    Criteria

    Xeljanz
    (tofacitinib citrate)

    Criteria

    Xeomin
    (incobotulinum toxin A)

    Criteria

    Xermelo
    (telotristat etiprate)

    Criteria

    Xgeva
    (denosumab)

    Criteria

    Xigduo XR3
    (dapagliflozin/metformin HCL)

    Criteria

    Xolair
    (omalizumab)

    Criteria

    Xtampza ER
    (oxycodone myristate)

    Criteria

    Xultophy
    (insulin degludec/ liraglutide)

    Criteria

    Xyrem
    (sodium oxybate)

    Criteria

    Zarxio
    (filgrastim-sndz)

    Criteria

    Zejula4
    (niraparib tosylate)

    Criteria

    Zemaira
    (alpha 1-proteinase inhibitor)

    Criteria

    Zembrace
    (sumatriptan- subcutaneous)

    Criteria

    Zepatier
    (elbasvir/ grazoprevir)
    Ziana1
    (tretinoin)
    Zinbryta
    (daclizumab)

    Criteria

    Zodex4
    (dexamethasone)

    Criteria

    Zohydro ER
    (hydrocodone
    bitartrate)

    Criteria

    Zoledronic acid

    Criteria

    Zoloft2
    (sertraline)
    Zolpimist2
    (zolpidem)

    Criteria

    Zomig/ ZMT2
    (zolmatriptan)

    Criteria

    Zontivity3
    (vorapaxar sulfate)

    Criteria

    Zorbtive
    (somatropin)
    Zurampic
    (lesinurad)

    Criteria

    Key

    1 Prior Authorization is required only when quantity limitation or restriction is exceeded

    2 Prior Authorization is required only when Step Therapy requirement is not met

    3 Prior Authorization is required for Value formulary only

    4 Prior Authorization is required for Premium formulary only


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