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May 2017
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Highlights
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Medical Drug Prior Authorization Program with CVS Health—NovoLogix
Harvard Pilgrim has selected CVS Health–NovoLogix to oversee and expand our prior authorization program for medical drugs to optimize treatment outcomes and promote the safe and cost-effective use of these medications.
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 Reminder: CVS Specialty is New Preferred Specialty Pharmacy
As we announced in last month’s issue of Network Matters, Harvard Pilgrim has selected CVS Specialty as our preferred specialty pharmacy, effective July 1, 2017.
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Update to Infliximab Medical Review Criteria
Effective for dates of service beginning May 26, 2017, Harvard Pilgrim is updating our commercial and StrideSM (HMO) Medicare Advantage medical review criteria for the medication infliximab (Remicade/Inflectra) to allow coverage for the CPT code Q5102 (Injection, infliximab, biosimilar, 10 mg).
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ACA Risk Adjustment Data Validation: Medical Chart Requests
The U.S. Department of Health and Human Services and Massachusetts Health Connector (the federal and state agencies administering the Affordable Care Act’s risk adjustment program) are required to annually validate the accuracy of claims data submitted by health insurance companies for risk adjustment-covered-plans through the validation of members’ medical records.
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2017 Home Care Seasonal Flu Vaccine Fee Schedule
Updates to Harvard Pilgrim’s standard home care seasonal influenza vaccine fee schedule will take effect on August 1, 2017.
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