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Back to Prior Authorization

Medical Benefit Drugs: Medical Necessity Guidelines

Beginning Jan. 1, 2023, Harvard Pilgrim will manage prior authorization requests for certain medical benefit drugs directly (CVS-Novologix will no longer accept authorization requests for Harvard Pilgrim members). Our new Medical Drug Medical Necessity Guidelines offer details on coverage criteria and product applicability. Submit your prior authorization requests via PromptPA (via HPHConnect) or fax.

If you are utilizing a medical drug for oncology, prior authorization is necessary through OncoHealth (formerly Oncology Analytics). For more information, please refer to these resources: the OncoHealth link on the Medical/Clinical Policies webpage and the vendor programs resource page.

Please note that there may be two policies for a given drug: a Commercial policy (visually noted with a blue symbol) and a Medicare Advantage policy (visually noted with a red symbol)

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Documents in this collection

Abecma (idecabtagene vicleucel)
Abecma (idecabtagene vicleucel)
Actemra (tocilizumab)
Acthar (corticotropin)
Adakveo (crizanlizumab-tmca)
Aduhelm (aducanumab-avwa)
Ajovy (fremanezumab-vfrm)
Alpha1-Proteinase Inhibitors
ARALAST NP (alpha1-proteinase inhibitor [human]), GLASSIA (alpha1-proteinase inhibitor [human]), PROLASTIN-C (alpha1-proteinase inhibitor [human]), ZEMAIRA (alpha1-proteinase inhibitor [human])
Amondys 45 (casimersen)
Amondys45 (casimersen)
Amyloidosis Therapies
Amvuttra (vutrisiran), Onpattro (patisiran)
Amyloidosis Therapies
ONPATTRO (patisiran), Amvuttra (vutrisiran)
Anti-inflammatory Agents
Actemra (tocilizumab), Avsola (infliximab-axxq), Entyvio (vedolizumab), Ilumya (tildrakizumab-asmn), Inflectra (infliximab-dyyb), Infliximab (infliximab), Orencia (abatacept), Remicade (infliximab), Renflexis (infliximab-abda), Simponi Aria (golimumab, Stelara (ustekinumab)
Antihemophilic Factor IX Products
BeneFIX (antihemophilic factor IX, [recombinant]), Ixinity (coagulation factor IX [recombinant)]), Rixubis (coagulation factor IX [recombinant]), Alprolix (coagulation factor IX [recombinant], Fc fusion protein), Idelvion (coagulation factor IX [recombinant], albumin fusion protein), Rebinyn (coagulation factor IX [recombinant] glycopegylated), Alphanine-SD (coagulation factor IX [human]), Profilnine (factor IX Complex, solvent detergent treated)
Antihemophilic factor VIII
Advate [Antihemophilic Factor (Recombinant)], Adynovate [Antihemophilic Factor (Recombinant), PEGylated], Afstyla [Antihemophilic Factor (Recombinant), Single Chain], Alphanate (Antihemophilic Factor/Von Willebrand Factor Complex [Human]), Eloctate [Antihemophilic factor (recombinant), Fc fusion protein], Esperoct [Antihemophilic Factor (Recombinant), glycopegylated-exei], Hemofil-M [Antihemophilic Factor (Human), method m, monoclonal purified] nano-filtered], Humate-P [Antihemophilic Factor/von Willebrand Factor Complex (Human)], Jivi [Antihemophilic Factor (recombinant), PEGylated-aucl], Koate [Antihemophilic Factor (Human)], Koate-DVI [Antihemophilic Factor (Human)], Kovaltry [Antihemophilic Factor (Recombinant)], Novoeight [Antihemophilic Factor (Recombinant)], Nuwiq [Antihemophilic Factor (Recombinant)], Obizur R [Antihemophilic Factor (Recombinant), Porcine Sequence], Recombinate [Antihemophilic Factor (Recombinant)], Wilate [von Willebrand Factor/Coagulation Factor VIII Complex (Human)], Xyntha (Antihemophilic Factor [Recombinant]), Xyntha Solofuse (Antihemophilic Factor [Recombinant])
Apretude (cabotegravir)
Avastin for ophthalmic conditions ONLY
bevacizumab
Benlysta (belimumab)
Benlysta (belimumab)
BEOVU (brolucizumab)-dbll)
BOTOX (onabotulinumtoxin A)
Botulinum Toxins
Botox (onabotulinumtoxin A), Dysport (abobotulinumtoxin A), Myobloc (rimabotulinumtoxin B), Xeomin (incobotulinumtoxinA)
Breyanzi (lisocabtagene maraleucel)
Breyanzi (lisocabtagene maraleucel)
Brineura (cerliponase alfa)
Byooviz (ranibizumab-nuna)
Carvykti (ciltacabtagene autoleucel)
CARVYKTI (ciltacabtagene autoleucel)
Cerezyme (imiglucerase)
Cerezyme (imiglucerase), Eleyso (taliglucerase alfa), Vpriv (taliglucerase alfa)

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