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. 

• Massachusetts (MA providers only)
• New Hampshire (NH providers only)
• Harvard Pilgrim (for all other providers)

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

• MA Hepatitis C (MA providers only)
• Harvard Pilgrim Hepatitis C (All Non-MA and Non-NH providers)

• Harvard Pilgrim PCSK9 (All Non-MA and Non-NH providers)

Synagis

• MA Synagis (MA providers only)
• Harvard Pilgrim Synagis (All Non-MA and Non-NH providers)

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.

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

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