Pharmacy

Harvard Pilgrim only covers compounded medications that are medically necessary for your adult patient’s care.

How do I request coverage for a compounded medication?
You may submit a Medication Request Form for coverage of a compounded medication on behalf of your patient. CT, MA and NH: Decisions are made within 2 business days of receipt of the request; ME: Decisions are made within 72 hours or two business days (whichever is less) of receipt of the request. Completed Medication Request forms should be submitted to:

OptumRx
Fax: 844-403-1029
Phone: 855-258-1561

What happens if my request is denied by Harvard Pilgrim?
If Harvard Pilgrim denies your request for coverage of a compounded medication, your patient may file an appeal. We provide a detailed description of member appeal rights in your patient’s Benefit Handbook. Your patient may also call Harvard Pilgrim Member Services for information on how to file an appeal.

Questions?
If you have any questions about Harvard Pilgrim’s coverage for compounded medications, please call Harvard Pilgrim Pharmacy Services at 617-509-9060.

• Physicians for Responsible Opioid Prescribing (PROP) – PROP’s mission is to reduce opioid-related morbidity and mortality by promoting cautious and responsible prescribing practices. This site provides information about opioid risks and benefits for providers and consumers.
• Overdose Prevention kit – SAMHSA – This site provides information to prescribers, first responders, and family members about preventing overdose and the role of naloxone.
• Opioid risk evaluation tool – The Opioid Risk Tool (ORT) is a self-report screening tool that can be administered and scored in less than one minute, designed for use in primary care settings to assess risk for opioid abuse among adult patients prescribed opioids for treatment of chronic pain.
• MED Calculator – This site is connected to an online tool to calculate Morphine Equivalent dose of all opioids to support MED limits in guidelines. This calculator should NOT be used to determine doses when converting a patient from one opioid to another.
• Mass Medical Society – Offers information for physicians/prescribers as well as patients and families, including information on opioid overdose and naloxone, preventing prescription drug misuse, and safe storage and disposal information of opioids.
• CDC Website – The CDC Guideline for Prescribing Opioids for Chronic Pain provides recommendations about the appropriate prescribing of opioid pain relievers and other treatment options to improve pain management and patient safety.

Harvard Pilgrim’s Pharmacy & Therapeutics (P&T) Committee is an advisory group comprised of Harvard Pilgrim clinical staff, as well as physician specialists, independent physicians, and pharmacy specialists who work together to promote clinically sound, cost-effective pharmaceutical care. The Committee makes recommendations for tier placement of drugs and limitations on drug coverage and provides guidance on clinical criteria.

The P&T Committee meets four times per year. The schedule is subject to change.

2021 Meeting Schedule