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

August 2014

Prior Authorization Required for BRCA Testing 

For dates of service beginning Nov. 1, 2014, Harvard Pilgrim is requiring prior authorization for all BRCA testing for members of our HMO, POS, and PPO products. Harvard Pilgrim covers medically necessary BRCA1, BRCA2, multi-site BRCA3, or single-site BRCA1 or BRCA2 testing for members at high risk for breast cancer.

In creating the medical criteria for BRCA testing, Harvard Pilgrim drew on the best clinical evidence from respected medical societies, clinical journals, and government organizations, such as the U.S. Preventive Services Task Force and the National Comprehensive Cancer Network. For detailed information on the medical criteria that members must meet for BRCA testing to be covered, please refer to the Genetic Testing for Hereditary Breast and/or Ovarian Cancer Medical Review Criteria.

To obtain authorization, clinicians must submit documentation showing that the member meets the criteria, the member obtained genetic counseling from a qualified clinician, and any BRCA test results will affect the member’s medical management. To request prior authorization, please fax a completed Hereditary Breast/Ovarian Cancers Genetic Testing Prior Authorization Request Form to Harvard Pilgrim at

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A Note on Genetic Testing from Michael Sherman, M.D, Chief Medical Officer

Prior Authorization Required for BRCA Testing

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President and Chief Executive Officer

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Senior Vice President, Provider Network

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