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

September 2018

GIC Plans: Express Scripts Manages Certain Medical Drugs


As you are aware, Express Scripts administers the pharmacy prescription drug benefit for Harvard Pilgrim’s active/non-Medicare Group Insurance Commission (GIC) plans — Primary Choice HMO and Independence Plan POS. In addition, medications that can be self-administered by the patient are also covered by Express Scripts, including when administered by a clinician in certain settings, and their policies and procedures for obtaining these medications will apply.

Beginning Nov. 1, 2018, for our GIC plans only, clinicians who plan to administer any of the following medications in the office (place of service 11), home (12), off-campus outpatient hospital (19), or at an on-campus outpatient hospital (22) must first contact Express Scripts at 800-922-8279 for prior authorization:

Actimmune (J9216)

Ganirelix acetate (S0132)

Nutropin [all forms] (J2941)

Afinitor (J7527)

Genotropin (J2941)

Omnitrope (J2941)

Apokyn (J0364)

Glatopa (J1595)

Pegasys (S0145)

Arcalyst (J2793)

Gleevec (S0088)

Peg-intron [all forms] (S0148)

Avonex (J1826)  

Humatrope (J2941)

Rebif (Q3028)

Avonex (Q3027)  

Humira [all forms] (J0135) 

Saizen (J2941)

Betaseron (J1830)

Hycamtin oral (J8705)

Serostim (J2941)

Copaxone (J1595)

Imatinib mesylate (S0088)

Stelara [SQ]* (J3357)

Duopa (J7340)

Increlex (J2170)

Temodar/temozolomide [oral] (J8700)

Enbrel [all forms] (J1438) 

Infergen (J9212)

Tremfya (C9029)

Extavia (J1830)

Iressa (J8565)

Zomacton (J2941)

Forteo (J3110)

Norditropin [all forms] (J2941) 

Zorbtive (J2941)

For our GIC plans, claims for these medications — when either self-administered by the patient or administered by a clinician in the outpatient settings noted — should be directed to Express Scripts. Any claims submitted to Harvard Pilgrim for these drugs for GIC plan members when they are administered by a clinician in places of service 11, 12, or 22 will be denied. Harvard Pilgrim will continue to manage coverage of these medications in all other settings.

Currently, for our commercial plans, Harvard Pilgrim requires prior authorization for the medical drug Stelara through CVS-Novologix. This will not apply for our GIC plans; you need only contact Express Scripts. However, for all other Harvard Pilgrim members, if you are planning to administer Stelara in an outpatient setting, please continue to contact CVS-Novologix for prior authorization.

You can recognize members of Harvard Pilgrim’s GIC plans by their member ID cards (shown below), which identify the GIC plan they belong to and include contact information for Express Scripts.

Updated 12.4.18

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