Beginning October 1, 2015, Harvard Pilgrim will require prior authorization for coverage of the combination non-steroidal anti-inflammatory drugs (NSAIDs) and acid-reducing therapies Duexis (ibuprofen/famotidine) and Vimovo (esomeprazole/naproxen) on the Premium formularies. These medications are not covered on the Value formularies.
On August 1, 2015, Harvard Pilgrim sent letters to members who have filled prescriptions for either of these agents in the past three months notifying them of the change. Harvard Pilgrim's NSAID-GI Combination Agents Clinical Coverage Criteria detail the requirements that must be met in order to obtain prior authorization, including:
- Diagnosis of rheumatoid arthritis, osteoarthritis, or ankylosing spondylitis
- Patient has at least one of the following risk factors for GI toxicity:
- Is over age 65
- Has a history of gastrointestinal (GI) event, including peptic ulcer, GI bleed, GI obstruction or GI perforation
- Is on high-dose NSAID therapy
- Is concurrently using aspirin (including low dose), corticosteroids, anticoagulants, selective serotonin reuptake inhibitors (SSRIs), or bisphosphonates
- Patient has tried and failed therapy with simultaneous use of a NSAID or COX-2 inhibitor AND PPI or misoprostol.
Approvals will be valid for 12 months. To request prior authorization, please complete the NSAID-GI Combination Agents Medication Request Form and fax it to MedImpact Healthcare Systems at 888-807-6643.
For more information, please refer to the Pharmacy section of Harvard Pilgrim's provider website.