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

February 2016

Prior Authorization Required for Pennsaid


Effective April 1, Harvard Pilgrim will require prior authorization for coverage of the medication Pennsaid on the commercial Premium formularies. Pennsaid is not covered on the Value formularies. Pennsaid is a 2% topical formulation of diclofenac sodium used to treat osteoarthritis of the knee.

To obtain prior authorization, providers must meet the requirements of the Pennsaid Clinical Criteria, which state that the patient has a diagnosis of osteoarthritis of the knee and has tried and failed therapy with, or has a contraindication to all of the following:

  • 2 oral prescription-strength nonsteroidal anti-inflammatory drugs (NSAIDs)
  • Generic diclofenac 1.5% topical solution
  • One additional topical NSAID, eg., Flector patch, Voltaren gel

Approvals will be valid for 12 months. To request prior authorization, please complete the Pennsaid Medication Request Form and fax it to MedImpact Healthcare Systems at 888-807-6643. For more information, please refer to the Pharmacy page on Harvard Pilgrim's provider website.

 

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