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Medical Drug Prior Authorization (CVS Health—NovoLogix)

Harvard Pilgrim is partnering with CVS Health—NovoLogix to oversee our prior authorization program for medical drugs. For detailed information, please refer to our Prior Authorization for Select Medical Drugs FAQ. For the following medical drugs, CVS Health—NovoLogix will perform medical necessity and utilization review on behalf of Harvard Pilgrim.

Important Note: For some of the following drugs, Harvard Pilgrim does not reimburse for dosages and/or frequency above limits in accordance with FDA-approved labeling, accepted compendia, and/or evidence-based practice guidelines. Prior authorization applies for the clinical criteria only, not dosing, frequency, or route of administration; claims edits may be applied at the time of reimbursement. For more information, please refer to the Drug Dosage and Frequency Medical Policy, this list of medical drugs for which claims edits apply, and the February 2018 Network Matters article (which includes details on where to find a list of the maximum dosages).

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Medical Drug

Prior Authorization Policy and Forms

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])
Besponsa
(inotuzumab ozogamicin)
Bivigam
(immune globulin )
Blincyto
(blinatumomab)
Botox
(onabotulinumtoxina)
Brineura
(cerliponase alfa)
Carimune NF
(immune globulin)
Cerezyme
(imiglucerase)
Cinqair
(reslizumab)
Cinryze
(c-1 esterase inhibitor [human])

Cinvanti
(aprepitant)

Cimzia
(certolizumab)
Coagadex
(coagulation factor X)
Crysvita
(burosumab-twza)
Cutaquig
(immune globulin)
Cuvitru
(Subcutaneous Immune Globulin (SCIG))
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)

Durolane
(hyaluronan or derivative)

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)

Euflexxa
(1% sodium hyaluronate)

Eteplirsen (Exondys 51™ Injection)

Eylea
(aflibercept)
Fabrazyme
(agalsidase beta)
Factor IX NOC
(factor IX (antihemophilic factor, recombinant))
Fasenra
(benralizumab)
Feiba
(anti-inhibitor coagulant complex)
Firmagon
(degarelix)
Flebogamma DIF
(immune globulin)
Flolan
(epoprostenol)
Folotyn
(pralatrexate)
Fulphila
(pegfilgrastim-jmdp)
Fusilev
(levoleucovorin calcium)
GamaSTAN S/D
(gamma globulin)
Gammagard
(immune globulin)
Gammaked
(immune globulin)
Gammaplex
(immune globulin)
Gamunex-C
(immune globulin)
Gazyva
(obinutuzumab)

Gel-One
(hyaluronan or derivative)

Gelsyn-3
(hyaluronan or derivative)

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))

Hemlibra
(emicizumab-kxwh)

Hemofil M
(factor VIII (antihemophilic factor, recombinant))

Herceptin
(trastuzumab)
Hizentra
(immune globulin)

Humate-P
(factor VIII (antihemophilic factor, recombinant))

Hyalgan
(hyaluronan or derivative)

Hymovis
(hyaluronan or derivative)

Hyqvia
(immune globulin infusion 10% [human] recombinant human hyaluronidase)
Idelvion
(coagulation factor IX [recombinant], albumin fusion protein)
Ilaris
(canakinumab)
Ilumya
(tildrakizumab-asmn)
Imfinzi
(durvalumab)
Imlygic
(talimogene laherparepvec)

Inflectra
(infliximab)

Istodax
(romidepsin)

Ixempra Kit
(ixabepilone)

Ixinity
(factor IX (antihemophilic factor, recombinant))
Jevtana
(cabazitaxel)
Jivi
(antihemophilic factor [recombinant])
Kadcyla
(ado-trastuzumab emtansine)
Kalbitor
(ecallantide)
Kanuma
(sebelipase alfa)
Keytruda
(pembrolizumab)
Khapzory
(levoleucovorin calcium)

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)
Kymriah
(tisagenlecleucel)
Lemtrada
(alemtuzumab)
Leukine
(sargramostim (gm-csf))
Levoleucovorin Calcium
(levoleucovorin calcium)
Libtayo
(cemiplimab-rwlc)
Lucentis
(ranibizumab)
Lumizyme
(alglucosidase alfa)
Lumoxiti
(moxetumomab pasudotox-tdfk)
Lupron Depot
(leuprolide acetate)
Lupron Depot - PED
(leuprolide acetate)
Lupron Depot - Prostate Cancer
(leuprolide acetate)
Lutathera
(lutetium Lu 177 dotatate)
Luxturna
(Voretigene neparvovec-rzyl)
Makena
(hydroxyprogesterone caproate)
Mepsevii
(vestronidase alfa-vjbk)
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)
Mvasi
(bevacizumab-awwb)
Mylotarg
(gemtuzumab ozogamicin)
Myobloc
(rimabotulinumtoxinb)
Naglazyme
(galsulfase)
Neulasta/Neulasta Onpro
(pegfilgrastim)
Neupogen
(filgrastim)
Nivestym
(filgrastim-aafi)

Novoeight
(factor VIII (antihemophilic factor, recombinant))

NovoSeven RT
(factor VIIa (antihemophilic factor, recombinant))
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)

Onpattro
(patisiran)
Opdivo
(nivolumab)

Orencia/Orencia Clickject(abatacept)

Orthovisc
(hyaluronan or derivative)

Oxaliplatin
(oxaliplatin)
Perjeta
(pertuzumab)
Poteligeo
(mogamulizumab-kpkc)
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)
Rebinyn
(factor IX (antihemophilic factor, recombinant))
Reclast
(zoledronic acid)

Recombinate
(factor VIII (antihemophilic factor, recombinant))

Remicade
(infliximab)

Remodulin
(treprostinil)

Renflexis
(infliximab)

Retacrit
(epoetin alfa)

Rituxan - Oncology
(rituximab)

Rituxan - RA
(rituximab)

Rituxan Hycela
(rituximab and hyaluronidase human)

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)

Sustol
(granisetron)

Sylvant
(siltuximab)
Synagis
(palivizumab)
Synribo
(omacetaxine mepesuccinate)

Synvisc/Synvisc One
(hylan G-F 20)

Taxotere
(docetaxel)

Tecentriq
(atezolizumab)

Temodar
(temozolomide)
Torisel
(temsirolimus)
Treanda
(bendamustine HCI)
Trelstar/Terlstar Mixject
(triptorelin pamoate)
TriVisc
(sodium hyaluronate)

Tysabri
(natalizumab)

Vantas
(histrelin acetate)
Udenyca

Varubi
(rolapitant)

Vectibix
(panitumumab)
Velcade
(bortezomib)
Veletri
(epoprostenol)
Vidaza
(azacitidine)
Vimizim
(elosulfase alfa)
Visco-3
(sodium hyaluronate)
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)

Yescarta
(axicabtagene ciloleucel)

Zaltrap
(ziv-aflibercept)
Zarxio
(filgrastim-sndz)

Zemaira
(alpha-1 proteinase inhibitor)

Zoladex
(goserelin acetate)
Zoledronic Acid
(zoledronic acid)
Zometa
(zoledronic acid)

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