Prior authorization for care

Prior authorization is a process that requires either your provider or you to obtain approval from Harvard Pilgrim before receiving specific items and services. 

The specific benefits subject to prior authorization may vary by product and/or employer group. Please reference the appropriate member materials (e.g., Benefit Handbook, Certificate of Coverage) for member-specific benefit information.

Who is responsible?

The following outlines who is responsible for obtaining prior authorizations:

  • If you have an HMO plan and see an in-network provider (doctor or clinician), the provider is responsible for obtaining prior authorization for select items and services noted in the following section.
  • If you have a POS or PPO product (including Access America) and you see an in-network provider (doctor or clinician) in the service area (as defined in your Benefit Handbook), the provider is responsible for obtaining prior authorization for select items and services noted in the following section.
  • If you have a POS or PPO product (including Access America) and your provider is out of network for your plan or is an in-network provider outside of the service area (as defined in your Benefit Handbook), your provider or you are responsible for obtaining prior authorization.

 

To obtain a prior authorization, you or your provider should call ...

Prior authorization needed

Under most Harvard Pilgrim plans, prior authorization is required for the following. For members enrolled in Harvard Pilgrim’s HMO products, prior authorization is required for any elective referral to a non-contracted provider.

See the criteria used to review prior authorization requests

  • Implantable neurostimulators
  • Interventional pain management, including: 1
    • Epidural injections
    • Facet joint injections
    • Facet neurolysis
  • Out-of-network outpatient services
  • BHCA services
  • Outpatient diagnostic imaging services, including:
    • Computerized tomography and computerized tomography angiography (CT/CTA)
    • Magnetic resonance imaging and magnetic resonance angiography (MRI/MRA)
    • Nuclear cardiology
    • Positron emission tomography (PET)
    • Diagnostic CT colonoscopy (virtual colonoscopy, CT colonography)
  • Sleep diagnostics, including:
    • Home or attended sleep studies
  • Molecular diagnostic management
  • For Gaucher disease
  • For hereditary breast and/or ovarian cancer
  • Pre-implantation genetic testing (PGT)
  • E.g., visiting nurse, home infusion
  • Collection, storage and cryopreservation (freezing) of eggs, sperm or embryos
  • Donor oocyte
  • Donor sperm
  • Gamete intra-fallopian transfer (GIFT)
  • Intra-cytoplasmic sperm injection (ICSI)
  • Intra-uterine insemination (IUI) 
  • In-vitro fertilization (IVF) 
  • Embryo transfer and frozen embryo transfer (FET)
  • Microsurgical epididymal sperm aspiration (MESA)
  • Testicular sperm extraction (TESE) 
  • Zygote intra-fallopian transfer (ZIFT)
  • Immune globulin (IVIg)
  • Intravenous antibiotics for treatment of Lyme disease/tick-borne diseases

Selected medical benefit drugs and biologicals including:1

  • Abraxane (paclitaxel protein-bound)
  • Actemra (tocilizumab)
  • Acthar HP (repository corticotropin injection)
  • Adagen (pegademase bovine)
  • Adcetris (brentuximab vedotin)
  • Advate (factor VIII (antihemophilic factor, recombinant)
  • Adynovate (factor VIII (antihemophilic factor, recombinant)
  • Afstyla (factor VIII (antihemophilic factor, recombinant)
  • Aldurazyme (laronidase)
  • Alimta (pemetrexed)
  • Aloxi (palonosetron HCI)
  • Alphanate/VWF Complex/Human (factor VIII [antihemophilic factor, recombinant])
  • AlphaNine SD (factor IX (antihemophilic factor, purified, non-recombinant)
  • Alprolix (factor IX (antihemophilic factor, recombinant)
  • Anzemet (dolasetron mesylate)
  • Aralast NP (alpha-1 proteinase inhibitor)
  • Aranesp (darbepoetin alfa)
  • Arzerra (ofatumumab)
  • Avastin (bevacizumab)
  • Aveed (testosterone undecanoate)
  • Azacitidine (azacitidine)
  • Bavencio (avelumab)
  • Bebulin (factor IX, complex)
  • Beleodaq (belinostat)
  • Bendeka (bendamustine HCI)
  • BeneFIX (factor IX (antihemophilic factor, recombinant)
  • Benlysta (belimumab)
  • Berinert (c-1 esterase inhibitor [human])
  • Bivigam (immune globulin)
  • Blincyto (blinatumomab)
  • Botox (onabotulinumtoxina)
  • Carimune NF (immune globulin)
  • Cerezyme (imiglucerase)
  • Cinryze (c-1 esterase inhibitor [human])
  • Cimzia (certolizumab)
  • Cyramza (ramucirumab)
  • Dacogen (decitabine)
  • Darzalex (daratumumab)
  • Decitabine (decitabine)
  • Deferoxamine Mesylate (deferoxamine mesylate)
  • Desferal (deferoxamine mesylate)
  • Docefrez (docetaxel)
  • Docetaxel (docetaxel)
  • Doxil (doxorubicin hydrochloride, liposomal)
  • DOXOrubicin HCl Liposomal (doxorubicin hydrochloride, liposomal)
  • Dysport (abobotulinumtoxina)
  • Elaprase (idursulfase)
  • Elelyso (taliglucerace alfa)
  • Eligard (leuprolide acetate (for depot suspension)
  • Eloctate (factor VIII (antihemophilic factor, recombinant)
  • Eloxatin (oxaliplatin)
  • Emend (fosaprepitant)
  • Empliciti (elotuzumab)
  • Entyvio (vedolizumab)
  • Epogen (epoetin alfa)
  • Epoprostenol Sodium (epoprostenol)
  • Erbitux (cetuximab)
  • Erwinaze (asparaginase)
  • Eteplirsen (Exondys 51™ Injection)
  • Euflexxa (1% sodium hyaluronate)
  • Eylea (aflibercept)
  • Fabrazyme (agalsidase beta)
  • Factor IX NOC (factor IX (antihemophilic factor, recombinant)
  • Feiba (anti-inhibitor coagulant complex)
  • Firmagon (degarelix)
  • Flebogamma DIF (immune globulin)
  • Flolan (epoprostenol)
  • Folotyn (pralatrexate)
  • Fusilev (levoleucovorin calcium)
  • GamaSTAN S/D (gamma globulin)
  • Gammagard (immune globulin)
  • Gammaked (immune globulin)
  • Gammaplex (immune globulin)
  • Gamunex-C (immune globulin)
  • Gazyva (obinutuzumab)
  • Gemcitabine HCl (gemcitabine hydrochloride)
  • Gemzar (gemcitabine hydrochloride)
  • Genvisc 850 (hyaluronan or derivative)
  • Glassia (alpha-1 proteinase inhibitor)
  • Granix (tbo-filgrastim)
  • Halaven (eribulin mesylate)
  • Helixate FS (factor VIII (antihemophilic factor, recombinant)
  • Hemofil M (factor VIII (antihemophilic factor, recombinant)
  • Herceptin (trastuzumab)
  • Hizentra (immune globulin)
  • Humate-P (factor VIII (antihemophilic factor, recombinant)
  • Hyalgan (hyaluronan or derivative)
  • Hyqvia (immune globulin infusion 10% [human] recombinant human hyaluronidase)
  • Ilaris (canakinumab)
  • Inflectra (infliximab)
  • Istodax (romidepsin)
  • Ixempra Kit (ixabepilone)
  • Ixinity (factor IX [antihemophilic factor, recombinan])
  • Jevtana (cabazitaxel)
  • Kadcyla (ado-trastuzumab emtansine)
  • Kalbitor (ecallantide)
  • Kanuma (sebelipase alfa)
  • Keytruda (pembrolizumab)
  • Koate-DVI (factor VIII [antihemophilic factor, recombinant])
  • Kogenate FS/Kogenate FS Bio-Set (factor VIII [antihemophilic factor, recombinant])
  • Kovaltry (factor VIII [antihemophilic factor, recombinant])
  • Krystexxa (pegloticase)
  • Kyprolis (carfilzomib)
  • Lemtrada (alemtuzumab)
  • Leukine (sargramostim [gm-csf])
  • Levoleucovorin Calcium (levoleucovorin calcium)
  • Lucentis (ranibizumab)
  • Lumizyme (alglucosidase alfa)
  • Lupron Depot (leuprolide acetate)
  • Lupron Depot - PED (leuprolide acetate)
  • Lupron Depot - Prostate Cancer (leuprolide acetate)
  • Makena (hydroxyprogesterone caproate)
  • Mircera (epoetin beta/methoxy polyethylene glycol)
  • Mitoxantrone HCl (mitoxantrone hydrochloride)
  • Monoclate-P (factor VIII [antihemophilic factor, recombinant])
  • Mononine (factor IX (antihemophilic factor, purified, non-recombinant)
  • Monovisc (hyaluronan or derivative)
  • Mozobil (plerixafor injection)
  • Myobloc (rimabotulinumtoxinb)
  • Naglazyme (galsulfase)
  • Neulasta/Neulasta Onpro (pegfilgrastim)
  • Neupogen (filgrastim)
  • Novoeight (factor VIII [antihemophilic factor, recombinant])
  • NovoSeven RT (factor VIIa [antihemophilic factor, recombinan])
  • Nplate (romiplostim)
  • Nucala (mepolizumab)
  • Nuwiq (factor VIII [antihemophilic factor, recombinant])
  • Obizur (factor VIII [antihemophilic factor, recombinant])
  • Ocrevus (ocrelizumab)
  • Octagam (immune globulin)
  • Octreotide Acetate (octreotide, non-depot form for subcutaneous or intravenous injection)
  • Oncaspar (pegaspargase)
  • Opdivo (nivolumab)
  • Orencia/Orencia Clickject (abatacept)
  • Orthovisc (hyaluronan or derivative)
  • Oxaliplatin (oxaliplatin)
  • Perjeta (pertuzumab)
  • Portrazza (necitumumab)
  • Privigen (immune globulin)
  • Procrit (epoetin alfa)
  • Profilnine/Profilnine SD (factor IX, complex)
  • Prolastin-C (alpha-1 proteinase inhibitor)
  • Proleukin (aldesleukin)
  • Prolia (denosumab)
  • Radicava (edaravone)
  • Reclast (zoledronic acid)
  • Recombinate (factor VIII [antihemophilic factor, recombinant])
  • Remicade (infliximab)
  • Remodulin (treprostinil)
  • Rituxan - Oncology (rituximab)
  • Rituxan - RA (rituximab)
  • Rixubis (factor IX [antihemophilic factor, recombinant])
  • Ruconest (c1 esterase inhibitor [recombinant])
  • Sandostatin (octreotide)
  • Sandostatin LAR Depot (octreotide depot)
  • Signifor LAR (pasireotide)
  • Simponi Aria (golimumab)
  • Soliris (eculizumab)
  • Somatuline Depot (lanreotide)
  • Spinraza (nusinersen)
  • Stelara (ustekinumab)
  • Supartz/Supartz FX (hyaluronan or derivative)
  • Supprelin LA (histrelin acetate)
  • Sylvant (siltuximab)
  • Synagis (palivizumab)
  • Synribo (omacetaxine mepesuccinate)
  • Synvisc/Synvisc One (hylan G-F 20)
  • Taxotere (docetaxel)
  • Temodar (temozolomide)
  • Torisel (temsirolimus)
  • Treanda (bendamustine HCI)
  • Trelstar/Terlstar Mixject (triptorelin pamoate)
  • Tysabri (natalizumab)
  • Vantas (histrelin acetate)
  • Vectibix (panitumumab)
  • Velcade (bortezomib)
  • Veletri (epoprostenol)
  • Vidaza (azacitidine)
  • Vimizim (elosulfase alfa)
  • Vpriv (velaglucerase alfa)
  • Wilate (von Willebrand factor complex [human])
  • Xeomin (incobotulinumtoxinA)
  • Xgeva (denosumab)
  • Xolair (omalizumab)
  • Xyntha/Xyntha Solofuse (factor VIII [antihemophilic factor, recombinant])
  • Yervoy (ipilimumab)
  • Zaltrap (ziv-aflibercept)
  • Zarxio (filgrastim-sndz)
  • Zemaira (alpha-1 proteinase inhibitor)
  • Zoladex (goserelin acetate)
  • Zoledronic Acid (zoledronic acid)
  • Zometa (zoledronic acid)
  • Continuous glucose monitoring systems
  • Prosthetic devices for upper and lower limbs
  • Outpatient diagnostic imaging services including:
    • Computerized tomography and computerized tomography Angiography (CT/CTA)
    • Magnetic resonance imaging and magnetic resonance angiography (MRI/MRA)
    • Nuclear cardiology
    • Positron emission tomography (PET) 
    • Diagnostic CT colonoscopy (virtual colonoscopy, CT colonography)
  • Outpatient pulmonary rehabilitation
  • Outpatient speech/language therapy (MA only) 
    • Physical and/or occupational therapy services require prior authorization if services are expected to exceed the member’s benefit limit. 
  •  Admissions
  • Bariatric
  • Breast reduction and reconstruction
  • Cholecystectomy
  • Cosmetic/reconstructive, including:
    • Blepharoplasty
    • Destruction of vascular cutaneous lesions
    • Excision/surgical planing of rhinophyma
    • Panniculectomy/removal of excess tissue 
    • Ptosis repair
    • Removal of breast implants
    • Repair of congenital chest wall deformities
    • Rhinoplasty
    • Scar revision
    • Septoplasty
  • Dental or oral surgery services performed in inpatient or SDC settings
  • Gender reassignment
  • Gynecomastia
  • Hip arthroplasty/hip replacement1
  • Hysterectomy
  • Knee arthroplasty/knee replacement1
  • Shoulder arthroscopy1
  • Sinus
  • Spine surgeries, including:1
    • Artificial cervical disc
    • Lumbar decompression
    • Lumbar fusion (single and multiple level)
    • Lumbar microdiscectomy
  • Surgical treatment of obstructive sleep apnea (MMO or UPPP)
  • Urinary incontinence surgeries
  • Formulas and enteral nutrition
  • Hospice services 
  • New technologies not assessed and incorporated into Harvard Pilgrim benefits
  • Non-emergency medical transportation
  • Out-of-network referrals
  • Physical and/or occupational therapy services
  • Varicose vein treatments

Contracted vendors

Vendor Services
Carelon Medical Benefits Management (formerly AIM Specialty Health) Genetic and Molecular
Diagnostic Testing
National Imaging Associates (NIA)     Cardiac Diagnostic Tests/Interventional Procedures
Diagnostic Imaging Services
Hip/Knee/Shoulder Surgeries
Sleep Studies
Spine Services (Lumbar Spine Surgery, Interventional Spine Pain Management Services, and Cervical Spine Surgery)
OncoHealth (formerly Oncology Analytics)     Outpatient chemotherapy (infused and/or injected)
Radiation therapy
Optum/United Behavioral Health Behavioral Health
Progeny Health Non-routine newborn care (Level II-IV) and all neonatal intensive care unit (NICU) admissions

Questions about Harvard Pilgrim’s prior authorization process?

Call Member Services at (888) 888-4742 (TTY: 711).

Initial inquiries are referred to Member Services for review and response where appropriate. Routine inquiries regarding specific cases are triaged by Member Services and referred to appropriate Utilization Management (UM) staff. UM staff are available Monday-Friday, 8:30 a.m. - 5 p.m. Inquiries received outside normal business hours are recorded on voicemail and returned within one business day of receipt.

 

Disclosures

1 Must get prior authorization from Harvard Pilgrim’s list of contracted vendors.