Coverage decisions
If your drug is not on our formulary or is on our formulary with restrictions, there are three things you can do:
- Get a temporary supply (only members in certain situations can get a temporary supply). To find out more, visit our page about Transition of Care. This will give you and your provider time to change to another drug or to file a request to have it covered
- Change to another drug on our formulary
- Request a coverage decision (exception) and ask us to cover your drug or remove its restrictions
- If we cover your drug on our formulary at a tier that makes your cost more expensive than you think it should be, you can change to another drug or ask us for a coverage decision (exception)
To ask for a standard or expedited coverage decision by fax or mail, you or your representative can contact us at the phone number below, or submit your written request by fax or mail.
Phone: 888-609-0692 (TTY 711)
Fax: 617-673-0956
Mailing Address:
Harvard Pilgrim Health Care
Attn: Pharmacy Utilization Management Department
1 Wellness Way
Canton, MA 02021
Medicare Prescription Drug Determination Request Form (pdf)
Appeals
If you would like us to review and change a coverage decision we have made, you can file an appeal. To start an appeal, you, your provider, or your representative must contact us:
Phone: (888) 609-0692
Fax: (617) 509-4232
Mailing address:
Harvard Pilgrim Health Care
Appeals & Grievances
P.O. Box 328
Canton, MA 02021
Medicare Prescription Drug Redetermination Request Form (pdf)
Level 2 Appeals
If we have denied your prescription drug appeal, the next step is to request a reconsideration by an Independent Review Organization. The following form contains the information you will need to make this request:
Medicare Part D Reconsideration Form (pdf)
Links on this page may take you away from the Harvard Pilgrim Health Care website.
H6750_24007 Last updated: 10/03/2023