If 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.
Start the exception process by completing this Exception Request Form (login required).
Providers can start the exception process by completing a formulary exception request form and faxing it to our pharmacy benefits manager, OptumRx, at 844-403-1029. They can also call OptumRx customer service at 855-258-1561. OptumRx will need a statement from your provider explaining why an exception is medically necessary, including why a covered drug is not as effective as the requested drug. In CT, MA & NH decisions will be made within two days of receiving your provider’s statement, in ME, a decision will be made within 72 hours or two business days (whichever is less) of receipt. For a faster decision, your provider must provide the necessary medical information with the initial request for an exception.
Your provider 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.
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