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

October 2016

Update to Formulas and Enteral Nutrition Prior Authorization Policy

This month, Harvard Pilgrim is updating our Formulas and Enteral Nutrition Prior Authorization Policy. Harvard Pilgrim offers coverage of medically necessary special medical formulas and enteral nutrition to ensure that at-risk patients receive the nutritional support needed to prevent clinical deterioration.

Effective for dates of service beginning October 28, 2016, Harvard Pilgrim is also covering the following code with prior authorization:

    B4149 – Enteral formula, manufactured blenderized natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit

When requesting authorization, providers should complete the Pedi/Adult Formula Prior Authorization Request Form and include the following clinical documentation:

  • For infants and pediatric patients: weight for age, weight for height growth charts, and Body Mass Index (BMI) charts (if applicable);
  • For adults, documentation of BMI and/or weight measured over time.

For more information, please refer to the updated Formulas and Enteral Nutrition Medical Review Criteria.

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Update to Formulas and Enteral Nutrition Prior Authorization Policy

Updates to Cardiovascular Disease Risk Tests Policy

Medicare Advantage Blood Glucose Monitoring Supplies

P&T Committee Updates

Specialty Pharmacy Program Updates

Updates to Clinical Medical Policies

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Outpatient Fee Schedule Updates

Assisting our Nurse Case Managers with Requests for Information

Keep Panel Status and Demographic Information Up to Date


Eric H. Schultz,
President and Chief Executive Officer

Robert Farias,
Vice President, Network Services

Annmarie Dadoly,

Joseph O'Riordan,

Kristin Edmonston,
Production Coordinator