Exception Requests

If you are prescribing a medication that Harvard Pilgrim either doesn’t cover or limits, you can ask for an exception. Drugs are excluded from coverage if they are not listed on the plan’s formulary (prescription drug list). We will grant exceptions only for clinical reasons.

Providers can start the exception process by completing a formulary exception request form and faxing it to our pharmacy benefits manager, OptumRx,at 844-403-1029. Providers can also call OptumRx customer service at 855-258-1561. You will need to provide OptumRx with a statement explaining why an exception is medically necessary, including why a covered drug is not as effective as the requested drug.

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. For a faster decision, you must provide the necessary medical information with the initial request for an exception.

Providers may request an expedited exception when a delay could seriously jeopardize a member’s life, health or ability to regain maximum function, or if a member is already undergoing a current course of treatment using a non-covered drug. We will notify you of a decision no later than 24 hours after receiving your expedited request. Exception requests will be considered by pharmacists and other clinicians as appropriate. If we deny a request, we will let you know why and explain how to request an appeal of our decision.