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

March 2018

New Preferred Biologics Drugs for Step Therapy

Harvard Pilgrim is updating our step therapy criteria for certain biologic drugs covered with prior authorization under our medical or pharmacy benefits to treat conditions such as rheumatoid arthritis, psoriatic arthritis, Crohn’s disease, ulcerative colitis, and relapsing multiple sclerosis, among others, for dates of service beginning April 1, 2018.

With these updates, our preferred biologic drugs under our pharmacy benefit will expand to include Stelara (ustekinumab) and Xeljanz (tofacitinib), in addition to the current preferred agents, Humira (adalimumab) and Enbrel (etanercept)*. Under the medical benefit, Remicade (infliximab) and Simponi Aria (golimumab) will become the preferred biologic drugs used in step therapy.

The updates detailed below are effective beginning April 1, and apply for new requests for prior authorization. These changes will not affect members who have previously received authorization and are currently utilizing one of these drugs.
Medical prior authorization criteria being updated

Harvard Pilgrim is updating the prior authorization criteria for the following injectable/infusible medications covered under the medical benefit to reflect that Remicade and Simponi Aria will replace Humira and Enbrel as preferred agents: 

  • Actemra (tocilizumab)
  • Cimzia (certolizumab)
  • Entyvio (vedolizumab)
  • Orencia (abatacept)
  • Remicade (infliximab)
  • Rituxan (rituximab)
  • Simponi Aria (golimumab)
  • Stelara (ustekinumab)
  • Tysabri (natalizumab)
These medications, which are obtained and dispensed by clinicians, require prior authorization through CVS Health–Novologix. You may submit your request to CVS Health–NovoLogix via phone (844-387-1435) or fax (844-851-0882). For complete details, including criteria and the prior authorization request forms, please visit the Medical Drug Prior Authorization page on Harvard Pilgrim’s provider website.

Pharmacy clinical criteria updates

In addition, Harvard Pilgrim is updating the prior authorization criteria for the following biologic drugs covered under the pharmacy benefit (when dispensed to members and self-administered) to reflect that Stelara (ustekinumab) and Xeljanz (tofacitinib) are preferred agents along with Humira (adalimumab) and Enbrel (etanercept)*:  

  • Actemra (tocilizumab)
  • Cimzia (certolizumab pegol)
  • Cosentyx (secukinumab)
  • Enbrel (etanercept)
  • Humira (adalimumab)
  • Kineret (anakinra)
  • Orencia (abatacept)
  • Otezla (apremilast)
  • Simponi (golimumab)
  • Stelara (ustekinumab)
  • Taltz (ixekizumab)
  • Xeljanz (tofacitinib citrate)
These medications require prior authorization through MedImpact Healthcare Systems. Updated criteria and medication request forms will be posted in the Pharmacy section of our provider website on April 1, 2018. To request coverage for these medications, please complete the appropriate medication request form and fax it to MedImpact at 888-807-6643.
A note on Stelara

When Stelara was originally introduced, a physician had to administer it, but that has changed over time and it can now be self-administered. For dates of service beginning April 1, 2018, Stelara will be processed under the pharmacy benefit. Pharmacy copayments and cost-sharing will now be applied for members currently taking the drug as well as members who are new to the drug.

*The number of preferred agents may vary by indication

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