Exception Process for Medical Drugs Requiring Authorization

Harvard Pilgrim has developed a commercial Custom Prior Authorization Exception Criteria Policy to handle requests for certain dosing regimens for medical drugs requiring authorization — specifically for dosages outside FDA-approved product labeling, as well as requests for newly FDA-covered indications, doses and frequencies not yet reflected in our medical drug policies.

As a reminder, CVS-Health NovoLogix conducts utilization management for specific medical drugs for Harvard Pilgrim Health Care.

The criteria outlined on the policy may be applied in situations where criteria updates are pending development and configuration. For example, if the FDA has approved a new indication requiring a higher dose of a given drug but the approved indication and dose are not yet reflected in Harvard Pilgrim’s CVS-Health NovoLogix policy for that drug, the authorization request may be approved if the patient who meets the criteria listed on the Custom Prior Authorization Exception Criteria Policy.

Please refer to the policy for further details.

Publication Information

Annmarie Dadoly,

Joseph O’Riordan,

Kristin Edmonston,
Production Coordinator