Effective immediately, Harvard Pilgrim is covering the new medication Briviact on the Premium formularies only, at the highest tier (i.e., Tier 3 on the 3-Tier and Tier 4 on the 4-Tier) with prior authorization. Approvals are valid for a 12-month period.
In February, the U.S. Food and Drug Administration approved Briviact for use along with other medications to treat partial onset seizures in patients ages 16 and older with epilepsy.
Harvard Pilgrim’s Briviact Clinical Review Criteria detail the requirements that must be met in order to obtain prior authorization. To request prior authorization, please complete the Briviact Medication Request Form and fax it to MedImpact Healthcare Systems at 888-807-6643. For more information, refer to the Pharmacy section of Harvard Pilgrim’s provider website.