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)