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Network Matters
News and Information for the
Harvard Pilgrim Health Care Network

March 2017

Stelara Coverage and Prior Authorization Criteria Updated

Effective for dates of service on or after April 15, 2017, Harvard Pilgrim is updating our Stelara commercial and StrideSM (HMO) Medicare Advantage prior authorization policies to include additional criteria for the use of Stelara to treat plaque psoriasis and psoriatic arthritis and to add Crohn’s disease as a covered indication.

Harvard Pilgrim covers Stelara for the treatment of certain adults with moderate-to-severe plaque psoriasis or psoriatic arthritis with prior authorization. Effective April 15, coverage criteria will include the following:

  • Previous treatment failure, inadequate response, contraindication (per FDA label), intolerance, or not a candidate for anti-tumor necrosis factor (TNF) biologic therapy with adalimumab (Humira™) or etanercept (Enbrel®)

In addition, Harvard Pilgrim will begin covering Stelara to treat severely active Crohn’s disease when the treatment is reasonable and medically necessary and all prior authorization criteria have been met.

To request prior authorization, please fax one of the following to 800-232-0816: a completed Massachusetts Standard Form for Medication Prior Authorization Requests if you are a Massachusetts provider or a completed Immune Modulating Drugs Prior Authorization Request form if you practice in state.

For complete information, refer to the updated commercial Stelara Medical Review Criteria and StrideSM (HMO) Medicare Advantage Stelara Medical Review Criteria.
Stelara is also offered through Harvard Pilgrim’s pharmacy benefit, and the associated Stelara Clinical Coverage Criteria have been updated to reflect these changes, effective April 15, 2017. When requesting authorization through the pharmacy benefit, providers in Massachusetts should complete the Massachusetts Standard Form for Medication Prior Authorization Requests, including any supplementary information that may be useful in the “Additional information pertinent to this request” section, and fax it to MedImpact Healthcare Systems at 888-807-6643. Providers in all other states should complete the updated Stelara Medication Request Form and fax it to MedImpact Healthcare Systems at 888-807-6643.

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