Harvard Pilgrim Health Care Home
  Learn more.
  Sign up for HPHConnect.
Medical Management
For Your Patient
News Center
Network Matters
Newsletter Archives
Newsletter Registration
Office Support
Provider Manual
Medicare Advantage
Research & Teaching
Resources & Links
Print    Text Size

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

May 2014

Prior Authorization and Quantity Limits for Testosterone Therapy 

Harvard Pilgrim will be requiring prior authorization and setting quantity limits on testosterone therapy in a phased-in approach as follows:

  • May 15, 2014 — Effective date for members age 18 and older who are beginning testosterone therapy
  • Sept. 1, 2014 —Effective date for members age 18 and older  currently receiving testosterone therapy

Please refer to our Testosterone Clinical Criteria for details on quantity limits and prior authorization requirements. Harvard Pilgrim covers medically necessary testosterone therapy for:

  • Male members with low testosterone levels that are confirmed by laboratory values (either total serum testosterone < 200ng/dL or low testosterone level as indicated by a lab result with a reference range) obtained in the last 90 days AND meet one of the following criteria:
    • Have been diagnosed with hypogonadism and are symptomatic
    • Have been diagnosed with HIV
    • Are being treated with high-dose glucocorticoids

      (Prior authorization approvals will be valid for one year.)
  • Female members with a diagnosis of metastatic breast cancer. (Prior authorization approvals will be open-ended.)
  • Transgendered members. (Prior authorization approvals will be open-ended.)

To obtain prior authorization for testosterone therapy new starts, please complete the appropriate Medication Request Form and fax it back to MedImpact Healthcare Systems at 888-807-6643.

Email this article to a colleague   

Receive Network Matters by e-mail

Network Matters Archives

Download printer-friendly version


Harvard Pilgrim Health Care Institute Receives National Clinical Award

ICD-10 Testing Continues

Spine Management and Prior Authorization: Sign Up for a Webinar

Harvard Pilgrim Enters Connecticut

Video Presentation: ACA and Risk Adjustment


Comprehensive Approach to Disease Management

Prior Authorization Required for Shoulder Arthroscopy

Expanded Coverage: Capsule Endoscopy of the Small Bowel

Expanded Coverage: Stereotactic Body Radiation Therapy

Hetlioz Now Covered with Prior Authorization

Update: Outpatient Rehabilitative Therapies Authorization

Prior Authorization and Quantity Limits for Testosterone Therapy

South Asian Community Organization Hosts Mental Health Symposium

Complex Case Management

Medication-Assisted Treatment for Opioid Abuse


Reminder: Unlisted Billing Guidelines

CMS 1500 (08/05) Form Rejected After June 15

Reminder for EFT Users with Clearinghouses

2014 Update of the Home Care Seasonal Flu Vaccine Fee Schedule

Reminder: CPT Code for Administering Immunizations


Eric H. Schultz,
President and Chief Executive Officer

Richard Weisblatt PhD,
Senior Vice President, Provider Network

Annmarie Dadoly,

Kristin Edmonston,
Production Coordinator