Policies to ensure safe and effective medication use

Harvard Pilgrim wants you to have access to certain high-cost medications when you need them. We have adopted prior authorization, quantity limits and step therapy policies to help make sure medications are prescribed and used safely, effectively and appropriately.

Prior authorization

Harvard Pilgrim requires prior authorization for certain medications. This process helps us ensure that you are using the most effective and safe medications for your health conditions.

Drugs that require prior authorization may include high-cost drugs, drugs that are no more effective than another lower-cost drug, drugs that may be used for non-medical purposes, brand-name drugs that are available as generics, drugs that can be misused or abused, and drugs that have dangerous side effects.

Your prescriber must request prior authorization by faxing a completed Medication Request Form to OptumRx, Harvard Pilgrim’s pharmacy benefits manager. Once they receive all the information they need, OptumRx will let you and your provider know within two business days whether the request was approved or denied. If OptumRx needs more information to make a decision, they will contact your prescriber within one business day of receiving the request.  The request will be denied if OptumRx does not receive the additional information they need to make a decision.

Quantity limits

Harvard Pilgrim may limit the quantity of some drugs we cover. For example, you may be able to receive only a certain number of pills or doses. This helps ensure appropriate usage and minimize potential waste of expensive medications.

Step therapy

In some cases, Harvard Pilgrim may require that you first try one drug for a medical condition before we cover another drug for that condition.

For example, if Drug A and Drug B both treat the same medical condition, we may require you to try Drug A first. If Drug A does not work, then we will cover Drug B. If you did not try Drug A first, then prior authorization would be required for Drug B.