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

May 2020

Khapzory Prior Authorization: Coding Update


Harvard Pilgrim currently requires prior authorization for Khapzory for members of our commercial plan. We have updated this policy to require prior authorization for HCPCS code J0642 (Injection, levoleucovorin [khapzory], 0.5 mg). Please use this code when billing for Khapzory, which is used to prevent the harmful effects of chemotherapy in certain individuals.

You can find the complete list of covered indications and coverage criteria on Harvard Pilgrim’s updated commercial Fusilev and Khapzory Medical Policy.

As a reminder, to request authorization, please contact CVS Health–NovoLogix via phone (844-387- 1435) or fax (844-851-0882).

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