Harvard Pilgrim Health Care Home
  HPHConnect
 
  Learn more.
  Sign up for HPHConnect.
Medical Management
E-Transactions
HPHConnect
Pharmacy
For Your Patient
News Center
Network Matters
Newsletter Archives
Newsletter Registration
Newsroom
Office Support
Products
Provider Manual
Medicare Advantage
Research & Teaching
Resources & Links
 
Print    Text Size

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

December 2015

PCSK9 Inhibitors: Prior Authorizations and Innovative Contract for Repatha


Harvard Pilgrim offers coverage of Repatha and Praluent, which are part of a new class of biotechnology medicines known as PCSK9 inhibitors, with prior authorization. These medications are used to treat elevated LDL cholesterol levels in patients whose levels are not adequately controlled by other treatment options and are given by injection every 2-4 weeks.

As our preferred PCSK9, Repatha is offered to members at a lower cost share. Repatha is covered on our Premium and Value formularies (Tier 2 in the Premium 3-tier; tier 3 in Premium 4-tier; tier 3 in Value 4-tier; tier 4 in Value 5-tier), while Praluent is covered on the Premium formularies only, at the highest tier (Tier 3 on the Premium 3-tier and Tier 4 on the Premium 4-tier).

Contract allows for member cost-saving

Harvard Pilgrim Health Care and Amgen Inc., the maker of Repatha, have negotiated an agreement that will help to slow the growth of escalating health care costs and improve care for patients.

This innovative contract contains a pay for performance guarantee through which Amgen is taking financial risk by providing the health plan with an enhanced discount if the reduction in LDL levels for Harvard Pilgrim members is less than what was observed during clinical trials. In addition to this guarantee, the agreement also provides for additional discounts if utilization of the drug exceeds certain levels. This enables those patients who can most benefit from the drug to receive it while continuing to encourage utilization of lower cost statins for the majority of patients.

“As the health care delivery system has moved away from paying fee-for-service toward paying for appropriate outcomes, the pharmaceutical segment has remained primarily in a traditional ‘pay for pill’ model,” said Harvard Pilgrim Chief Medical Officer Michael Sherman. “Agreeing to pricing models that align payment with appropriate outcomes is critical if we are to better manage increasing drug costs.”

Obtaining prior authorization

To learn more about Harvard Pilgrim’s clinical criteria for the usage of these medications, please refer to the PCSK9 inhibitors medication request guidelines. To obtain authorization, please complete the PCSK9 Inhibitors Medication Request Form and fax it to MedImpact Healthcare Systems at 888-807-6643.

These medications will be offered through Accredo as part of Harvard Pilgrim’s Specialty Pharmacy program. For more information, please refer to the Specialty Pharmacy Program section of our provider website.

Email this article to a colleague   


Network Matters Archives

Download printer-friendly version

HPHCURRENT EVENTS

Harvard Pilgrim Welcomes New Employer Accounts and Products for 2016

CLINICIAN CORNER

PCSK9 Inhibitors: Prior Authorizations and Innovative Contract for Repatha

Pharmacy Updates: 90-day Supplies at Retail and Controlled Substance Limitations

Reminder: Referral Procedure Change for Massachusetts Providers

Reminder: Prior Authorizations for Medicare Advantage via NIA

Administration of Zostavax by Pharmacists

CMS Requirement: Enrolling as a Participating Medicare Provider

Substance Abuse Screening and Referral for Treatment

Reminder: Mandate on Inpatient Care Related to Breast Cancer

OFFICE ASSISTANT

Professional Claim Submission Available on HPHConnect

Improvements in Provider Claims Reporting Tools

Urgent Care Network Requirements

PUBLICATION INFORMATION

Eric H. Schultz,
President and Chief Executive Officer

Robert Farias,
Vice President, Network Services

Annmarie Dadoly,
Editor

Joseph O'Riordan,
Writer

Kristin Edmonston,
Production Coordinator