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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.

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PUBLICATION INFORMATION

Eric H. Schultz,
President and Chief Executive Officer

Richard Weisblatt PhD,
Senior Vice President, Provider Network

Annmarie Dadoly,
Editor

Kristin Edmonston,
Production Coordinator