Beginning next year, Harvard Pilgrim will require prior authorization on a select number of opioid analgesics used to manage moderate to severe chronic pain. Because there is a risk of addiction, abuse, and misuse with these medications, careful management is necessary. Given the heightened awareness of opioid abuse at the state level, Harvard Pilgrim is implementing these prior authorization requirements as an addition to our opioid management program.
Harvard Pilgrim is not requiring any members currently taking these medications who have a presumed cancer diagnosis (as determined by ICD-9 code or medication history) to obtain prior authorization.
However, any members beginning treatment with opioid analgesics or members currently taking these medications who have not been diagnosed with cancer will require prior authorization beginning next year. Earlier this month, Harvard Pilgrim mailed letters to the few members who had filled prescriptions for these medications within the last 6 months who do not have a cancer diagnosis to notify them of the new prior authorization requirements.
Effective Jan. 1, 2015, Zohydro ER, a long-acting hydrocodone product that is not formulated with abuse-deterrent mechanisms, will require a prior authorization on the Harvard Pilgrim’s Premium (open) formulary. Zohydro ER is not covered on our Value (closed) formulary or the 2015 Medicare Advantage formulary.
Transmucosal immediate-release fentanyl products
Also beginning on Jan. 1, 2015, Harvard Pilgrim will require prior authorization on all transmucosal immediate-release fentanyl products (for example, fentanyl citrate lozenges, Fentora, and Subsys) for all formularies (Value, Premium, and Medicare Advantage). These products are used to manage breakthrough pain in patients with cancer who are 18 years of age and older and are already receiving, and are tolerant to, around-the-clock opioid therapy for their underlying, persistent cancer pain.
Requesting prior authorization
To request prior authorization for any of the medications listed above, please review the clinical criteria and submit the appropriate Medication Request Form by fax to MedImpact Healthcare Systems at 888-807-6643. The clinical criteria and medication request form will be available on the prior authorization section of our Pharmacy webpage by Dec. 15.