For our commercial members, Harvard Pilgrim requires prior authorization for certain high cost medical drugs through our vendor partner, CVS-Novologix, which evaluates these requests against FDA label clinical indications, dose, and frequency, as well as compendia indications. Beginning Sept. 1, 2020, this prior authorization review will provide feedback not only on requested clinical indication, but also on the requested dose —as well as frequency.
Clarity on allowable dose/frequency at time of authorization
Previously, the prior authorization determination only addressed the clinical indication; dosing editing, when applicable, was applied via claim edits at the time of reimbursement. With this Sept. 1 change, dose and frequency guidelines will be applied at the time of the authorization determination.
Incorporating dose/frequency into the authorization provides greater efficiency and reimbursement clarity. Authorization approvals from CVS-Novologix will clearly note the amount and frequency of administration of the medical drug for which the patient is approved. In addition, the CVS-Novologix medical drug policies have been updated to include details on the dosing/frequency guidelines.
When loading dose is required
In some cases, treatment requires a loading dose that will vary from the maintenance dose. In this circumstance, providers must obtain two separate authorizations —one for the initial loading dose and another for the maintenance dose.
Please keep in mind that, for dates of service beginning Sept. 1, some medical drugs that previously required authorization from CVS-Novologix will require prior authorization from Oncology Analytics instead — when used for oncology purposes. (See the article on the new Oncology Analytics program for details.) However, if the drug is being used to treat other conditions for our commercial members, it will still require authorization from CVS-Novologix.
New online option for submitting prior authorization
Beginning Sept. 1, CVS-Novologix will also be offering another option for submitting your prior authorization request —via a new online portal. You can choose among the following ways to request authorization:
- Portal: Submit requests online to CVS-Novologix via HPHConnect’s single sign on feature. Starting Sept. 1, you’ll be able to access the single sign on link by logging into hphcprovider.healthtrio.com and selecting the “CVSNovologix” link in the Office Management drop down.
- Phone: 844-851-1435
- Fax: 844-851-0882
To help providers get started with the portal, CVS-Novologix is offering trainings in August. To register click on the session of your choice(additional sessions will be added in September, too):
In addition, refer to their portal training guide for instructions on how to use the site.
Additional informationFor additional information, please refer to the Medical Drug Dose and Frequency Medical Policy. For a list of medical drugs requiring prior authorization from CVS-Novologix, with links to criteria and request forms, please refer to the Medical Drug Prior Authorization page.
Director, Network Operations