Harvard Pilgrim Health Care Prior Authorization Lookup
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Latest Harvard Pilgrim Health Care prior authorization updates25
- Prior AuthClinical/Medical PolicyEff. 2026-08-11Akynzeo (netupitant/palonosetron) prior authorizationPrior authorization criteria for coverage of Akynzeo (netupitant/palonosetron) for prevention of chemotherapy-induced nausea and vomiting in adult members of Harvard Pilgrim and Tufts commercial products.All harvard pilgrim health care updates
- Prior AuthClinical/Medical PolicyEff. 2026-08-11Medical Necessity Guidelines: Acne and Rosacea MedicationsMedical necessity and prior authorization criteria for topical and related medications used to treat acne vulgaris, rosacea, and select dermatologic conditions for Harvard Pilgrim Health Care members (excludes Medicare members). Applies to pharmacy and medical benefits where specified.All harvard pilgrim health care updates
- Prior AuthClinical/Medical PolicyEff. 2026-08-11Onapgo (apomorphine) and Vyalev (foscarbidopa/foslevodopa) - Prior AuthorizationPrior authorization policy for coverage of Onapgo (apomorphine hydrochloride) and Vyalev (foscarbidopa/foslevodopa) for adults with advanced Parkinson's disease under Harvard Pilgrim and affiliated Tufts commercial and specified public products.All harvard pilgrim health care updates
- Prior AuthClinical/Medical PolicyEff. 2026-08-012026 Step Therapy Prior Authorization Medical Necessity GuidelinesStep therapy prior authorization rules for specified drug products (antidepressants, atypical antipsychotics, inhaled corticosteroids, interferons) for Harvard Pilgrim Health Care members; outlines required prior medication fills or documentation to bypass authorization.All harvard pilgrim health care updates
- Prior AuthClinical/Medical PolicyEff. 2026-08-01Prior authorization medical necessity guidelines — formulary product listings (partial)Section of Harvard Pilgrim Health Care's 2026 prior authorization medical necessity guidelines listing pharmacy products and summarizing prior authorization criteria, documentation, step therapy and prescriber restrictions for selected specialty drugs.All harvard pilgrim health care updates
- Prior AuthClinical/Medical PolicyEff. 2026-07-01Adalimumab products — Prior authorization and medical necessityThis guideline governs prior authorization and medical necessity criteria for coverage of adalimumab products (including multiple biosimilars and brands) for Harvard Pilgrim and affiliated commercial products; it applies to prescribers seeking coverage for members under the listed commercial and public plan products.All harvard pilgrim health care updates
- Prior AuthClinical/Medical PolicyEff. 2026-07-01Applied Behavioral Analysis (ABA) therapy coverage — Clinical/Medical Policy (Coverage Criteria)Defines medical necessity, prior authorization, coding, and limits for Applied Behavioral Analysis (ABA) services for applicable Harvard Pilgrim and Tufts commercial products and Tufts Health Direct; includes coverage for ASD and, in Massachusetts products, Down syndrome when criteria are met.All harvard pilgrim health care updates
- Prior AuthClinical/Medical PolicyEff. 2026-07-01Intermittent Skilled Home Health Care — Medical Necessity and Authorization CriteriaMedical necessity and authorization criteria for intermittent skilled home health care services and related billing for Harvard Pilgrim Health Care and affiliated Tufts products. Affects providers delivering home health skilled services and those requesting prior authorization/notification.All harvard pilgrim health care updates
- Prior AuthClinical/Medical PolicyEff. 2026-07-01MassHealth changes to coverage and prior authorization of anti-obesity and GLP-1/GIP medicationsNotifies payers/providers that MassHealth will stop covering drugs used for obesity/overweight effective July 1, 2026, describes which agents are affected, exceptions for certain medically accepted indications, and prior authorization (PA) handling and timelines.All harvard pilgrim health care updates
- Prior AuthClinical/Medical PolicyEff. 2026-07-01Prior Authorization Medical Necessity Guidelines — Partial drug listPortion of Harvard Pilgrim Health Care prior authorization medical necessity guidelines listing specialty and pharmacy drugs, their covered indications, prescriber and prerequisite therapy requirements, and coverage durations for affected products. Affects prescribers requesting PA for the listed drugs and health plan administrators.All harvard pilgrim health care updates
- Prior AuthReimbursement/Payment PolicyEff. 2026-07-01Psychological and Neuropsychological Testing and AssessmentThis policy governs coverage and prior authorization requirements for psychological and neuropsychological testing and assessment services for Harvard Pilgrim Health Care (Tufts-related products listed), defining when testing is considered medically necessary and limitations. It affects providers who perform or bill for these assessments for affected members.All harvard pilgrim health care updates
- Prior AuthClinical/Medical PolicyEff. 2026-07-01Step Therapy Prior Authorization Medical Necessity GuidelinesDefines step therapy requirements and prior authorization conditions for specified formulary drugs (antidepressants, atypical antipsychotics, inhaled corticosteroids, interferons) for Harvard Pilgrim members. Affects prescribers and pharmacy benefit administrators processing prior authorizations and claims.All harvard pilgrim health care updates
- Prior AuthClinical/Medical PolicyEff. 2026-07-01Step therapy and prior authorization requirements for select drugs (Antidepressants, Atypical Antipsychotics, Inhaled Corticosteroids, Interferons)Step therapy and prior authorization requirements for listed antidepressants, atypical antipsychotics, inhaled corticosteroids, and interferons for Tufts Health Plan Senior Care Options (HMO-SNP) members.All harvard pilgrim health care updates
- Prior AuthClinical/Medical PolicyEff. 2026-07-01Tufts Health One Care (HMO D‑SNP) 2026 Prior Authorization Medical Necessity Guidelines — Part 1 (Formulary/Drugs list)Part 1 of the payer's 2026 prior authorization and medical necessity requirements for Tufts Health One Care (HMO D‑SNP) covering multiple Part D drugs and biologics; describes affected products, required medical information, prescriber restrictions, coverage durations, and prerequisite therapy expectations for listed agents.All harvard pilgrim health care updates
- Prior AuthClinical/Medical PolicyEff. 2026-07-01Tufts Medicare Preferred Prior Authorization Medical Necessity Guidelines (partial drug list)Lists products subject to prior authorization with indication-specific medical necessity requirements, prescriber restrictions, coverage durations, and prerequisite therapy notes for covered members and prescribing providers.All harvard pilgrim health care updates
- Prior AuthClinical/Medical PolicyEff. 2026-06-012026 Step Therapy Medical Necessity Guidelines (selected drug classes)Step therapy requirements for select outpatient medications (antidepressants, atypical antipsychotics, inhaled corticosteroids, and multiple sclerosis injectables); defines Step‑1 (no prior authorization) and Step‑2 (requires prior fill history) coverage conditions.All harvard pilgrim health care updates
- Prior AuthClinical/Medical PolicyEff. 2026-06-012026 Step Therapy Prior Authorization for select outpatient drugsDefines Step Therapy requirements for specific outpatient prescription drugs for Tufts Health One Care (HMO D-SNP) members, indicating which products are Step-1 (no prior authorization) vs Step-2 (require previous fill of Step-1/Step-2 agents). Affects providers and pharmacists prescribing or dispensing the listed products.All harvard pilgrim health care updates
- Prior AuthClinical/Medical PolicyEff. 2026-06-01Foot reconstruction procedures: bunionectomy and hallux valgus correction — Medical Necessity GuidelineThis medical necessity guideline governs prior authorization requirements and coverage criteria for foot reconstruction procedures (fifth metatarsal osteotomy, proximal phalanx osteotomy of the first toe, and first MTP joint arthrodesis) for Harvard Pilgrim and affiliated Tufts commercial/public products.All harvard pilgrim health care updates
- Prior AuthClinical/Medical PolicyEff. 2026-06-01Gender‑Affirming Services — Coverage Criteria and Medical NecessityCoverage criteria and medical necessity requirements for gender-affirming medical and surgical services for Harvard Pilgrim Health Care and related Tufts/Point32Health products, including adults and members under 18. Specifies which procedures are considered medically necessary, required documentation, limitations, and prior authorization notes.All harvard pilgrim health care updates
- Prior AuthClinical/Medical PolicyEff. 2026-06-01Prior Authorization Medical Necessity Guidelines — Part 1 (drug-specific PA rules)This document lists prior authorization medical necessity criteria for multiple pharmacy and specialty drug products and defines required documentation, prescriber restrictions, coverage durations, and prerequisite therapy requirements for Harvard Pilgrim Health Care members.All harvard pilgrim health care updates
- Prior AuthClinical/Medical PolicyEff. 2026-06-01Prior Authorization and Notification Requirements for Durable Medical Equipment (DME) and Related ServicesLists DME, prosthetic items, procedures and services that require prior authorization or notification from the Plan and describes applicable clinical references and submission pathways; applies to providers submitting claims for covered members.All harvard pilgrim health care updates
- Prior AuthClinical/Medical PolicyEff. 2026-06-01Prior authorization and notification requirements for DME, prosthetics, procedures and related servicesLists services, durable medical equipment (DME), prosthetic items, and procedure codes that require prior authorization or notification from Point32Health (Harvard Pilgrim), and describes which criteria sources are used for coverage determinations. Affects providers submitting claims or authorization requests for affected members.All harvard pilgrim health care updates
- Prior AuthClinical/Medical PolicyEff. 2026-06-01Prior authorization medical necessity guidelines for Part D drugs (select products)All harvard pilgrim health care updates
- Prior AuthClinical/Medical PolicyEff. 2026-06-01Prior authorization medical necessity guidelines — Part 1 (drug product list excerpt)Portion of the payer's prior authorization and medical necessity guidelines listing Part D drugs, associated indications/requirements, prescriber restrictions, and coverage duration for Tufts Health One Care (HMO D-SNP) and related products; affects providers prescribing the listed specialty and Part D drugs.All harvard pilgrim health care updates
- Prior AuthClinical/Medical PolicyEff. 2026-06-01Prior authorization, notification, and no prior authorization requirements for Tufts Medicare Preferred (HMO and PPO)Governs which services, durable medical equipment (DME), prosthetics, procedures, and drugs require prior authorization or notification for Tufts Medicare Preferred members; applies to providers submitting claims or requesting authorizations.All harvard pilgrim health care updates
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Tool Description
Search Harvard Pilgrim Health Careprior authorization policies by drug name, procedure, or policy title. Results include any policy that mentions prior authorization requirements (drug coverage criteria, imaging guidelines, site-of-service rules) not just documents titled “prior authorization.” Every result links to a full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
Filter by payer, specialty, policy type, or effective year; or search directly for a drug (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee arthroplasty”), or a policy number.
Coverage spans 110+ payers. Jump straight to the busiest prior-auth publishers: UnitedHealthcare, Cigna, Aetna, Anthem, and Centene. You can also browse the full policy updates feed.
Pair a prior-auth search with the billing code lookup to confirm the CPT or J-code on the claim, the payer lookup for plan footprint, and payer profiles for contacts and coverage context.
FAQ
Type a drug name (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee”), or a policy title into the search bar. Filter results by payer, specialty, policy type, or effective year. Open any result for the full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
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