Harvard Pilgrim Health Care Home
  HPHConnect
 
  Learn more.
  Sign up for HPHConnect.
Medical Management
E-Transactions
HPHConnect
Pharmacy
For Your Patient
News Center
Network Matters
Newsletter Archives
Newsletter Registration
Press Releases
Office Support
Products
Provider Manual
Medicare Advantage
Research & Teaching
Resources & Links
 
Print    Text Size

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

May 2017

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).

With prior authorization, Harvard Pilgrim covers the medically necessary use of infliximab for members with any of the following:

  • Moderately to severely active rheumatoid arthritis or active psoriatic arthritis
  • Moderately to severely active Crohn’s Disease
  • Fistulizing Crohn’s disease
  • Moderately to severely active pediatric Crohn’s disease
  • Moderately to severely active ulcerative colitis
  • Moderately to severely active pediatric ulcerative colitis
  • Active ankylosing spondylitis
  • Severe plaque psoriasis (i.e., extensive and/or disabling)
  • Non-infectious uveitis (chronic, recurrent, refractory, OR vision-threatening)

To obtain prior authorization for infliximab, providers must meet the criteria as specified in the updated commercial Infliximab (Remicade®/Inflectra) Medical Review Criteria or the StrideSM (HMO) Medicare Advantage Infliximab (Remicade®/Inflectra) Medical Review Criteria. In addition, please complete the Immune Modulating Drugs Prior Authorization request form (for non-Massachusetts providers) or the Massachusetts Standard Form for Medication Prior Authorization Requests (Massachusetts providers only) and submit the necessary information.

Email this article to a colleague   


Network Matters Archives

Download printer-friendly version

HPHCURRENT EVENTS

GIC Product Updates Effective July 1

CLINICIAN CORNER

Medical Drug Prior Authorization Program with CVS Health–NovoLogix

Reminder: CVS Specialty is New Preferred Specialty Pharmacy

Update to ExMI Therapy for Urinary Incontinence Medical Policy

Update to Infliximab Medical Review Criteria

Fecal Microbiota Transplantation Medical Policy Updated

Reducing Preventable Readmissions in the Medicare Advantage Population

Non-Medication Alternative Treatments for Chronic Pain

ACA Risk Adjustment Data Validation: Medical Chart Requests

Robust Discussion at Massachusetts Medical Directors’ Meeting

OFFICE ASSISTANT

2017 Home Care Seasonal Flu Vaccine Fee Schedule

PUBLICATION INFORMATION

Eric H. Schultz,
President and Chief Executive Officer

Robert Farias,
Vice President, Network Services

Annmarie Dadoly,
Editor

Joseph O'Riordan,
Writer

Kristin Edmonston,
Production Coordinator