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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.

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Eric H. Schultz,
President and Chief Executive Officer

Robert Farias,
Vice President, Network Services

Annmarie Dadoly,

Joseph O'Riordan,

Kristin Edmonston,
Production Coordinator