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

July 2014

Prior Authorization Required for Immunobiologic Medications 


For dates of service beginning October 1, 2014, Harvard Pilgrim is requiring prior authorization for infusible and injectable immunobiologic medications. Step therapy guidelines are being applied to immunobiologic drugs to ensure that medications are being used in a clinically appropriate way and that the safest and most cost-effective medications are used first.

Please click the drug names below to be linked to our clinical criteria. These medications are covered under either the medical or pharmacy benefit, which is determined by the method in which the medication is obtained — with the provider purchasing the medication and submitting a claim to Harvard Pilgrim for reimbursement (medical) or ordering the medication through a specialty pharmacy with Harvard Pilgrim billed directly (pharmacy). Because Harvard Pilgrim’s authorization process varies based on whether the drug is available as a medical benefit or through the specialty pharmacy, please refer to the chart below for further details on how to request prior authorization, coding (if applicable), and clinical criteria.

Name and Formulation

(linked to criteria)

Authorization Process

Medical Benefit — Administered by the Health Care Provider
Actemra – IV (J3262)

To request prior authorization, please fax a completed Immune Modulating Drugs Prior Authorization Request Form to Harvard Pilgrim at
800-232-0816.

You may also find it helpful to enter your request in HPHConnect to receive a tracking number and check the status of the request. To aid you in using HPHConnect for this purpose, a Pharmacy Service Transactions User Guide will be posted online prior to the October 1 effective date.

Cimzia – SC powder for reconstitution (J0717)
Ilaris – SC (J0638)
[See below. This medication is also available through our Specialty Pharmacy Program.] 
Orencia – IV (J0129)
Remicade – IV (J1745)
Rituxan – IV (J9310)
Simponi Aria – IV (J1602)
Stelara – SC (J3357)
[See below. This medication is also available through our Specialty Pharmacy Program.]
Tysabri – IV (J2323)
Pharmacy Benefit — Self-administered by the Member (unless otherwise noted)
Actemra – SC To request a prior authorization for these medications, please complete the appropriate Medication Request Form and fax it back to MedImpact Healthcare Systems at 888-807-6643. These medications are available through Accredo. For more information, visit our Specialty Pharmacy website.
Cimzia – SC prefilled syringe
Enbrel – SC
Humira – SC
Ilaris – SC *
(See above. This medication is also available as a medical benefit.)
Kineret – SC
Orencia – SC
Simponi – SC
Stelara – SC **
(See above. This medication is also available as a medical benefit.)

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PUBLICATION INFORMATION

Eric H. Schultz,
President and Chief Executive Officer

Richard Weisblatt PhD,
Senior Vice President, Provider Network

Annmarie Dadoly,
Editor

Kristin Edmonston,
Production Coordinator