Request an Exception
If your provider believes you need 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 your plan’s formulary (prescription drug list). We will grant exceptions only for clinical reasons.
To start the exception process, your prescriber can complete a formulary exception request form and fax it to our pharmacy benefits manager, MedImpact, at (888) 807-6643. They can also call MedImpact customer service at (800) 788-2949. MedImpact will need a statement from your prescriber explaining why an exception is medically necessary, including why a covered drug is not as effective as the requested drug. We will act on an exception request within two days of receiving your prescribing provider’s statement. For a faster decision, your provider must provide the necessary medical information with the initial request for an exception.
Your prescriber may request an expedited exception when you could seriously jeopardize your life, health or ability to regain maximum function if there is a delay in treatment, or if you are 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.
Your exception request will be considered by pharmacists and other clinicians as appropriate. If we deny your request, we will let you know why and explain how you can request an appeal of our decision. You may be eligible for an expedited external review at the same time you pursue your appeal with Harvard Pilgrim.
Download a Formulary Exception Request Form (pdf) .