Currentharvard pilgrim health carePolicy N/A

Pharmacy formulary management and utilization management programs (prior authorization, step therapy, quantity limits, specialty pharmacy, mail-order/retail90) coverage criteria

Defines Harvard Pilgrim's pharmacy formulary management, utilization management programs (prior authorization, step therapy, quantity limits, specialty pharmacy, mail-order/retail90), and the processes for exceptions and new-to-market drug evaluation; applies to providers submitting pharmacy coverage requests for Harvard Pilgrim members.

Policy Summary

Payerharvard pilgrim health care

PolicyPharmacy formulary management and utilization management programs coverage criteria

Policy CodePolicy N/A

Change TypeRevised New-to-Market evaluation process

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests or exception documentation using the Medication Request Form or electronic portals (PromptPA/ePA) when required.

SourceLink

POLICY UPDATE CHANGES

Updated New-to-Market Drug Evaluation Process content to reflect business process change.

Removed detailed formulary information and directed readers to website for further details.

P&T CommitteeGovernance body

PA, ST, QL, SPUM programs

30 daysTransition fill (MA)

84-90dMail/Retail90

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Coverage Criteria and Exceptions

Exception / Medical Necessity

Covered when medical necessity is demonstrated and utilization management criteria (if any) are satisfied.

General exception approval: An exception will be granted only for clinical reasons with a statement explaining why formulary drugs are not as effective as the requested drug.N/A

Provider must supply clinical justification via the Medication Request Form or electronically through PromptPA/ePA, fax, or mail to Pharmacy Utilization Management.

New-to-Market Drug Coverage

New-to-market drugs are excluded from coverage until reviewed; exceptions possible for urgent medical need.

New-to-market evaluation: New drug products are excluded from coverage until reviewed by the Plan's Pharmacy and Therapeutics Committee and a coverage determination is made.Excluded until completion of review (no later than Dec. 31 of the following calendar year or as required by law)

Physicians may request an exception for members with medical need; approved exceptions will be assigned the highest cost share tier.

Compound Drugs

Compound drugs are covered only under specific conditions or with prior approval.

Compound drug coverage: Compound drugs are covered if all active ingredients are FDA‑approved prescription drugs, are covered on the Plan formulary, cost less than $500, and the patient is under 18.Cost < $500 and patient < 18 years

If these conditions are not met, prior approval is required for coverage.

New-to-market drug products are excluded from coverage until the Plan's Pharmacy and Therapeutics Committee completes its review and issues a coverage determination. This temporary exclusion remains in effect until the earlier of Dec. 31 of the following calendar year or as required by law. Providers may request an exception if a physician determines a member has a medical need; approved exceptions will be assigned the highest cost-share tier. For questions about a drug's coverage status, contact Provider Services at the number listed in the policy.

Non-formulary drugs are generally considered non-covered when safe, comparably effective, less expensive alternatives are available. If a member has a documented medical need to continue or receive a non-formulary drug, the provider should submit a request for an exception to coverage describing why formulary alternatives are not appropriate for that patient.

Supply Lengths, Monetary Thresholds, and Coding Notes

Transition fill length — 30-day supply

Transition fill lengthOne-time transition fill allowed for Massachusetts members up to a 30-day supply while an exception is reviewed.

ApplicabilityApplies when a Massachusetts member is already prescribed and stable on a drug subject to step therapy requirements.

How to requestContact Provider Services at 800-708-4414 to request the one-time transition fill.

Mail/Retail90 supply length — 84-90 day supply

Supply lengthMail-order and Retail90 options provide an 84-90 day supply for maintenance medications.

Mail-order programAdministered exclusively by OptumRx Home Delivery for 84-90 day supplies.

Prior Authorization, Step Therapy, and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior Authorization Required for selected drugs. The prior authorization program applies to selected drug products that have specific indications, high cost, or safety concerns. These medications have clinical guidelines and require prior approval for coverage through the Utilization Review Process. Providers must submit requests using the Medication Request Form or electronically (PromptPA or electronic prior authorization/ePA). See www.point32health.org/provider/policies/pharmacy/requesting-authorizationpharmacy-and-medical-drugs and Point32Health.PromptPA.com for forms and submission portals. Fax and mailing address for the Pharmacy Utilization Management Department are available for non-electronic submissions.

Medication Request Form or electronic portals (PromptPA, ePA)
Fax: 617-673-0988
Mail: Harvard Pilgrim Health Care, Attn: Pharmacy Utilization Management Department, 1 Wellness Way, Canton, MA 02021-1166

Step Therapy

Step Therapy Denial (Point of Sale)

Step therapy prior authorization is enforced at the point of sale. If a member does not meet the initial step therapy criteria, the prescription will deny at point of sale with a message indicating that prior authorization or step requirement applies. Step therapy protocols are automated and based on claims history, clinical guidelines, FDA labeling, and cost. Providers may submit prior approval requests through the Utilization Review process.

Key Program Definitions

Step therapy prior authorization (STPA)

DefinitionAn automated prior authorization process that uses claims history at the point of sale to encourage use of first-line, cost-effective therapies.

PurposeDesigned so the most therapeutically appropriate and cost-effective agents are used first before other treatments are covered.

OperationApprovals are determined using claims history at point of sale; members currently on a stepped drug may be allowed fills automatically.

Prior authorization (PA)

DefinitionA utilization management requirement for selected drug products that require clinical review prior to coverage due to safety, cost, or indication concerns.

Selection criteriaDrugs may be placed in PA if they are expensive, have safety concerns, are not first-line therapy, or have potential off-label use.

Step Therapy Operations and Transition Rules

Program	Policy
Step therapy prior authorization (STPA)	Automated evaluation using claims history at point of sale to approve a drug or product when step therapy criteria are met.
Transition fill for members already stable on therapy (Massachusetts only)	A one-time transition fill of up to a 30-day supply is allowed for Massachusetts members who are already prescribed and stable on a drug subject to step therapy while an exception is reviewed; providers may contact Provider Services at 800-708-4414 to request this fill.

Quantity Limits and Affected Products

Selected drugs — Plan-specific limits apply

Selected drugsPlan-specific quantity limits apply to selected drugs; limits are defined by the health plan for quality and safety reasons.

Exception processPhysicians may request an exception if a quantity in excess of the plan limit is medically necessary using the Medication Request Form.

PurposeQuantity limits encourage appropriate drug use and help reduce drug benefit costs.

Specialty Pharmacy and Mail/Retail Options

Billing Rule

Use designated specialty pharmacies for certain specialty drugs; 30‑day mail supply available

Designated specialty pharmacies supply select specialty drugs; members may obtain up to a 30‑day supply by mail from these specialty pharmacies.

For questions or to identify designated specialty pharmacies, refer to the Plan's online formularies or contact Provider Services at 800-708-4414.

Billing Rule

Mail-order and Retail90 provide 84–90 day supplies for maintenance medications

Mail-order (OptumRx Home Delivery) and Retail90 (OptumRx Retail90) options allow members to obtain an 84–90 day supply of maintenance medications when appropriate.

Prescriptions must be written for an 84–90 day supply to use Retail90; members are responsible for three times their applicable cost-sharing for a 90‑day retail supply.

Program Governance and P&T Committee Role

The Plan's Pharmacy and Therapeutics (P&T) Committee evaluates drug safety, clinical effectiveness, and cost-effectiveness to determine formulary placement and utilization management programs. The Committee's review informs decisions such as placement of new products on the formulary or exclusion until review is complete, and the use of prior authorization, step therapy, and other management tools to promote safe, effective, and cost-conscious prescribing.