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2019 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, Viekira Pak/XR, Vosevi, Zepatier)

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

     

    Medication
    Clinical Coverage Criteria*
    Abstral
    (fentanyl citrate)

    Criteria

    Actemra
    (tocilizumab)

    Criteria

    Adapalene
    (adapalene)

    Criteria

    adapalene-benzoyl

    Criteria

    Addyi
    (flibanserin)

    Criteria

    Adcirca
    (tadalafil)

    Criteria

    Adempas
    (riociguat)

    Criteria

    Adlyxin

    Criteria

    Adzenys
    (amphetamine)

    Criteria

    Afinitor
    (everolimus)

    Criteria

    Aimovig
    (erenumab-aooe)

    Criteria

    Ajovy
    (fremanezumab-vfrm)

    Criteria

    Akynzeo3
    (netupitant/ palonosetron)

    Criteria

    Alecensa
    (alectinib hcl)

    Criteria

    Alogliptan benzoate
    (alogliptan benzoate)

    Criteria

    Alunbrig
    (brigatinib)

    Criteria

    Androderm
    (testosterone transdermal)

    Criteria

    Aptensio XR
    (methylphenidate)

    Criteria

    Aranesp
    (darbepoetin)

    Criteria

    Armodafinil
    (armodafinil)

    Criteria

    Austedo
    (deutetrabenazine

    Criteria

    Avita1
    (tretinoin)

    Criteria


    Axert2
    (almotriptan)

    Criteria

    Balversa
    (erdafitinib)

    Criteria

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

    Criteria

    Belsomra
    (suvorexant)

    Criteria

    Belviq/Belviq XR

    Criteria

    Benlysta
    (belimumab)

    Criteria

    Bepreve3
    (bepotastine besilate)

    Criteria

    Bosulif
    (bosutinib)

    Criteria

    Braftovi
    (encorafenib)

    Criteria

    Bydureon2
    (exenatide microspheres)

    Criteria

    Bydureon Bcise
    (exenatide microspheres)

    Criteria

    Byetta2
    (exenatide)

    Criteria

    Cablivi
    (caplacizumab-yhdp)

    Criteria

    Cabometyx
    (cabozantinib s-malate)

    Criteria

    Calquence
    (acalabrutinib)

    Criteria

    Cholbam
    (cholic acid)

    Criteria

    Cialis1
    (tadalafil)

    Criteria

    Cimzia
    (certolizumab pegol)

    Criteria

    Clindamycin/tretinoin
    (clindamycin/tretinoin)

    Criteria

    Cometriq
    (cabozantinib s-malate)

    Criteria

    Compound Exceptions

    Criteria

    Contrave

    Criteria

    Copiktra
    (duvelisib)

    Criteria

    Corlanor
    (ivabradine hcl)

    Criteria

    Cosentyx
    (secukinumab)

    Criteria

    Cotellic
    (cobimetinib fumarate)

    Criteria

    Cresemba3
    (isavuconazonium sulfate)

    Criteria

    Cuprimine
    (penicillamine)

    Criteria

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

    Criteria

    Daytrana
    (methylphenidate)

    Criteria

    Delatestryl
    (testosterone)

    Criteria

    Depen
    (penicillamine)

    Criteria

    Depo-Testosterone
    (testosterone)

    Criteria

    Dermapak Plus
    (tretinoin 0.025%)

    Criteria

    Dexedrine
    (dextroamphetamine sulfate)

    Criteria

    Dexilant3
    (dexlansoprazole)

    Criteria

    dexmethylphenidate Hcl/ er
    (dexmethylphenidate hcl/ er)

    Criteria

    dextroamphetamine/ er
    (dextroamphetamine/ amphetamine)

    Criteria

    dextroamphetamine/ amphetamine
    (dextroamphetamine/ amphetamine)

    Criteria

    Diabetic Test Strips

    Criteria

    Diclofenac sodium

    Criteria

    Doptelet
    (avatrombopag)

    Criteria

    Duavee3
    (conjugated estrogens/ bazedoxifene)

    Criteria

    Dupixent
    (dupilumab)

    Criteria

    Duzallo4
    (lenisurad/allopurinol)

    Criteria

    Dyanavel
    (amphetamine)

    Criteria

    Edluar2
    (zolpidem)

    Criteria

    Egrifta
    (tesamorelin)

    Criteria

    Elidel
    (pimecrolimus)

    Criteria

    Emcyt
    (estramustine phosphate sodium)

    Criteria

    Emflaza
    (deflazacort)

    Criteria

    Emgality
    (galcanezumab-gnlm)

    Criteria

    Enbrel
    (etanercept)

    Criteria

    Epclusa
    (sofosbuvir/ velpatasvir)
  • MRF (Non-MA & Non-NH providers)
  • MA Hepatitis C (MA providers only) 
  • NH Standard PA form  
  • Criteria
  • Epidiolex
    (cannabidiol)

    Criteria

    Epogen
    (epoetin alpha)

    Criteria

    Erivedge
    (vismodegib)

    Criteria

    Erleada
    (apalutamide)

    Criteria

    Eucrisa4
    (crisabarole)

    Criteria

    Evekeo
    (amphetamine sulfate)

    Criteria

    Fabior
    (tazarotene)

    Criteria

    Farydak
    (panobinostat lactate)

    Criteria

    fentora
    (fentanyl citrate)

    Criteria

    Fetzima2
    (levomilnacipran hydrochloride)

    Criteria

    Firazyr
    (icatibant acetate)

    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

    Freestyle Libre
    (Flash Glucose Reader and Sensor)

    Criteria

    Gattex
    (teduglutide)

    Criteria

    Granix
    (tbo-filgrastim)

    Criteria

    Haegarda
    (c1 esterase inhibitor)

    Criteria

    Harvoni
    (ledipasvir/ sofosbuvir)
    Hetlioz
    (tasimelteon)

    Criteria

    Humatrope
    (somatropin)

    Criteria

    Humira
    (adalimumab)

    Criteria

    Ibrance
    (palbociclib)

    Criteria

    Iclusig
    (ponatinib)

    Criteria

    Idhifa
    (enadisenib mesylate)

    Criteria

    Imbruvica
    (ibrutinib)

    Criteria

    Increlex
    (mecasermin recombinant)

    Criteria

    Injectable MRF

    Criteria

    Inlyta
    (axitinib)

    Criteria

    Jakafi
    (ruxolitinib phosphate)

    Criteria

    Kalydeco
    (ivacaftor)

    Criteria

    Kerydin
    (tavaborole)

    Criteria

    Khedezla2
    (desvenlafaxine)

    Criteria

    Kineret
    (anakinra)

    Criteria

    Kisqali
    (ribociclib succinate)

    Criteria

    Kisqali Femara Co-Pack
    (ribociclib succinate/letrozole)

    Criteria

    Lazanda
    (fentanyl citrate)

    Criteria

    Lenvima
    (lenvatinib mesylate)

    Criteria

    Letairis
    (ambrisentan)

    Criteria

    Levitra1
    (vardenafil)

    Criteria

    Lonsurf
    (trifluridine/tipiracil hcl)

    Criteria

    Lucemyra
    (lofexidine hcl)

    Criteria

    Luvox CR2
    (fluvoxamine)

    Criteria

    Luzu3
    (luliconazole)

    Criteria

    Lynparza
    (olaparib)

    Criteria

    Lyrica2
    (pregabalin)

    Criteria

    Mavyret
    (glecaprevir/ pibrentasvir)
    Mektovi
    (binimetinib)

    Criteria

    Mentax3
    (butenafine)

    Criteria

    Metformin ER
    (metformin er gastr-tb)

    Criteria

    methamphetamine
    (methamphetamine hcl)

    Criteria

    methylphenidate er/ cd/la
    (methylphenidate)

    Criteria

    Minitran3
    (nitroglycerin)

    Criteria

    Mircera
    (methoxy peg-epoetin beta)

    Criteria

    Mirvaso3
    (brimonidine tartrate)

    Criteria

    modafinil
    (modafinil)

    Criteria

    Mydayis
    (dextroamphetamine/ amphetamine)

    Criteria

    Mytesi
    (crofelemer)

    Criteria

    Natesto
    (testosterone, nasal gel)

    Criteria

    Neulasta
    (pegfilgrastim)

    Criteria

    Neo-Synalar3
    (neomycin/fluocinolone)

    Criteria

    Nerlynx
    (NERATINIB MALEATE)
    Neupogen
    (filgrastim)

    Criteria

    Ninlaro
    (ixazomib citrate)

    Criteria

    Nityr
    (nitisinone)

    Criteria

    Novolog/Mix 70/30
    (insulin aspart)

    Criteria

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

    Criteria

    Nuplazid
    (pimavanserin tartrate)

    Criteria

    Ocaliva
    (obethicholic acid)

    Criteria

    Odomzo
    (sonidegib phosphate)

    Criteria

    Olysio
    (simeprevir sodium)
    Omnitrope
    (somatropin)

    Criteria

    Onfi
    (clobazam)

    Criteria

    Opsumit
    (macitentan)

    Criteria

    Orencia
    (abatacept)

    Criteria

    Orenitram

    Criteria

    Orfadin
    (nitisinone)

    Criteria

    Orilissa
    (elagolix)

    Criteria

    Orkambi
    (lumacaftor/ ivacaftor)

    Criteria

    Otezla
    (apremilast)

    Criteria

    Ozempic
    (semaglutide)

    Criteria

    Pexeva2
    (paroxetine)

    Criteria

    Phendimetrazine

    Criteria

    Phentermine

    Criteria

    Picato3
    (ingenol mebutate)

    Criteria

    Pomalyst
    (pomalidomide)

    Criteria

    Praluent
    (alirocumab)

    Criteria

    Procrit
    (epoetin alpha)

    Criteria

    Qbrexza
    (glycopyrronium tosylate)

    Criteria

    Quantity Limit Exceptions

    Criteria

    Quillichew ER
    (methylphenidate)

    Criteria

    Quillivant
    (methylphenidate)

    Criteria

    Ravicti
    (glycerol phenylbutyrate)

    Criteria

    Rayaldee
    (calcifediol)

    Criteria

    Relistor
    (methylnaltrexone)

    Criteria

    Repatha
    (evolocumab)

    Criteria

    Revatio
    (sildenafil citrate)
    Revlimid
    (lenalidomide)

    Criteria

    Rexulti
    (brexpiprazole)

    Criteria

    Ritalin LA 10 MG CAP
    (methylphenidate hcl)

    Criteria

    Rozerem2
    (ramelteon)

    Criteria

    Rubraca
    (rucaparib camsylate)

    Criteria

    Rydapt4
    (midostaurin)

    Criteria

    Rytary
    (carbidopa/ levodopa)

    Criteria

    Samsca
    (tolvaptan)

    Criteria

    Sarafem2
    (fluoxetine)
    Savella
    (milnacipran)

    Criteria

    Saxenda

    Criteria

    Serostim
    (somatropin)
    Silenor 2
    (doxepin)

    Criteria

    Simponi
    (golimumab)

    Criteria

    Sirturo3
    (bedaquiline fumarate)

    Criteria

    Soliqua

    Criteria

    Solodyn
    (minocycline)
    Somatuline Depot
    (lanreotide acetate)

    Criteria

    Sovaldi
    (sofosbuvir)
    Sonata2
    (zaleplon)

    Criteria

    Staxyn1
    (vardenafil)

    Criteria

    Stelara
    (ustekinumab)

    Criteria

    Stendra1
    (avanfil)

    Criteria

    Stivarga
    (regorafenib)

    Criteria

    Striant
    (testosterone)

    Criteria

    Subsys
    (fentanyl citrate spray)

    Criteria

    Symdeko
    (tezacaftor/ivacaftor)

    Criteria

    Tagrisso
    (osimertinib mesylate)

    Criteria

    Taltz
    (ixekizumab)

    Criteria

    Tacrolimus ointment
    (tacrolimus)

    Criteria

    Tavalisse
    (fostamatanib)

    Criteria

    Tazorac1
    (tazarotene)
    Thiola
    (tiopronin)
    Tibsovo
    (ivosidenib)

    Criteria

    Tracleer
    (bosentan)

    Criteria

    Tresiba
    (insulin degludec)

    Criteria

    Tresiba Flextouch
    (insulin degludec)

    Criteria

    Tretin-X1
    (tretinoin)

    tretinoin1

    Treximet
    (sumatriptan/
    naproxen)

    Criteria

    trientine
    (trientine)

    Criteria

    Trintellix2
    (vortioxetine hydrobromide)

    Criteria

    Trulicity
    (dulaglutide)

    Criteria

    Tymlos4
    (abaloparatide)

    Criteria

    Uptravi
    (selexipag)

    Criteria

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

    Criteria

    Venclexta
    (venetoclax)

    Criteria

    Venlafaxine ER
    (venlafaxine er)

    Criteria

    Verzenio
    (abemaciclib)

    Criteria

    Viagra 1
    (sildenafil)

    Criteria

    Victoza 2
    (liraglutide)

    Criteria

    Viibryd 2
    (vilazodone)

    Criteria

    Vizimpro
    (dacomitinib)

    Criteria

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

    Criteria

    Vyvanse
    (lisdexamfetamine dimesylate)

    Criteria

    Xalkori
    (crizotinib)

    Criteria

    Xeljanz
    (tofacitinib citrate)

    Criteria

    Xermelo
    (telotristat etiprate)

    Criteria

    Xtampza ER
    (oxycodone myristate)

    Criteria

    Xtandi
    (enzalutamide)

    Criteria

    Xultophy
    (insulin degludec/ liraglutide)

    Criteria

    Xyrem
    (sodium oxybate)

    Criteria

    Yonsa
    (abiraterone acet,submicronized)

    Criteria

    Zarxio
    (filgrastim-sndz)

    Criteria

    Zejula4
    (niraparib tosylate)

    Criteria

    Zenzedi
    (dextroamphetamine)

    Criteria

    Zepatier
    (elbasvir/ grazoprevir)
    Zinbryta
    (daclizumab)

    Criteria

    Zolpimist2
    (zolpidem)

    Criteria

    Zontivity3
    (vorapaxar sulfate)

    Criteria

    Zorbtive
    (somatropin)
    Zurampic
    (lesinurad)

    Criteria

    Zydelig
    (idelalisib)

    Criteria

    Zytiga
    (abiraterone acetate)

    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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