Medical Drug Utilization Management

As a reminder, Point32Health will be streamlining the utilization management for pharmacy and medical drugs — including managing the intake of and conducting review of pharmacy and medical drug prior authorization requests in-house.

Effective Jan. 1, 2023, providers should submit requests for authorization for pharmacy and medical benefit drugs directly to Harvard Pilgrim Health Care.

Currently, CVS Health-NovoLogix manages the utilization management of medical drugs for Harvard Pilgrim Health Care.  As of Jan. 1, CVS Health-NovoLogix will no longer accept medical drug prior authorization requests for Harvard Pilgrim members.

Please be aware of the following:

  • Point32Health, the parent company of Harvard Pilgrim Health Care and Tufts Health Plan, has developed the medical necessity guidelines for medical benefit drugs. These guidelines are aligned within lines of business (for example, medical drug policies for Harvard Pilgrim and Tufts Health Plan Commercial members are consistent).
  • The Medical Benefit Drug Medical Necessity Guidelines and Pharmacy Medical Necessity Guidelines that are effective beginning Jan. 1, 2023 are available on our provider websites.
  • While as a whole, the medical drugs requiring prior authorization largely remain the same, and in some cases prior authorization will not be required, other articles in this issue of the provider newsletter and our What’s Ahead at Point32Health FAQ detail changes of note.
  • Dose/frequency limits will continue to be applied. Please note that, beginning on Jan. 1, these limits will be applied during claims processing; when receiving prior authorization for a medical benefit drug, the authorization will not note the dose/frequency limitation.
  • Open authorizations for medical benefit drugs will remain active through the end date of the authorization. For existing Harvard Pilgrim members, any authorizations that are reviewed and approved by CVS Health-NovoLogix will be uploaded into Harvard Pilgrim Health Care’s systems and will be honored. For members moving from Tufts Health Plan Commercial plans to Harvard Pilgrim Health Care Commercial plans, any medical drug benefit authorizations approved by Tufts Health Plan will also continue to be valid through the end date identified on the authorization.

To request pharmacy or medical drug prior authorizations beginning Jan 1., we encourage you to submit your requests through our new online prior authorization tool, PromptPA. You will be able to access PromptPA through our provider portal or directly through a dedicated website. Alternatively, you may request authorization via the FAX number noted on the medical necessity guideline (617-673-0988 for Commercial members and 617-673-0956 for Medicare Advantage members).

For more information on our medical drug program, please refer to our What’s Ahead at Point32Health FAQ.

Audrey Kleinberg,
Director, Provider Relations & Communications

Annmarie Dadoly,
Senior Manager, Provider Communications

Joseph O’Riordan,

Kristin Edmonston,
Production Coordinator