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

June 2019

Update: Maximum Dosages for Medical Drugs


As you may know, Harvard Pilgrim applies industry standard claims edits and does not reimburse for drug dosages above limits in accordance with FDA-approved labeling, accepted compendia, and/or evidence-based practice guidelines for certain medical drugs for our commercial members. Periodically, we review and update the list of medical drugs for which this applies. As a result, effective for dates of service beginning August 1, 2019, Harvard Pilgrim will be applying these dosage and frequency limits for the medications listed below.

Brand Name (Procedure Code)

Avastin

Exondys 51

Opdivo

Carimune NF

Glassia

Perjeta

Cimzia

Granix

Renflexis

Cinqair

Herceptin

Rituxan

Docetaxel/Docefrez

Inflectra

Somatuline Depot

Dysport

Keytruda

Velcade

Elelyso

Lemtrada

Venofer

Eligard

Myobloc

Xeomin

Elelyso

Lemtrada

Venofer

Entyvio

Nucala

Xgeva

Erbitux

Ocrevus

Yervoy

Erwinaze

Oncaspar

A full list of the medical drugs for which the maximum dose policy applies is available on our provider website and a more detailed list that includes the maximum dosages is available in HPHConnect, Harvard Pilgrim’s secure web-based transaction tool. You’ll find that list in the “Office Management” section of HPHConnect. If you are currently not a user of HPHConnect, it’s quick and easy to register online.

Harvard Pilgrim reserves the right to conduct post-payment review and audit of claims submitted for drugs and may recover payments made for amounts in excess of the FDA labelling. For more information, please refer to the Drug Dosage and Frequency Medical Policy.

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Robert Farias,
Senior Vice President, Corporate Network Strategy

Annmarie Dadoly,
Editor

Joseph O'Riordan,
Writer

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Production Coordinator