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

February 2016

Clinical Policy and Prior Authorization Updates for May 1


Harvard Pilgrim regularly reviews clinical literature, best practices, and our existing clinical policies, and creates new policies and updates existing ones based on this information. The chart below summarizes policy and procedure changes, based on this ongoing review. All of the following policies are effective for dates of service beginning May 1, 2016.

Harvard Pilgrim welcomes your feedback related to the research and development of our medical policies and clinical utilization management guidelines, and encourages you to send your comments and questions to medical_policy_team@harvardpilgrim.org. All other inquiries — on claims, referrals, billing practices, etc. — should continue to be directed to our Provider Service Center at 800-708-4414.

    Clinical Policy and Prior Authorization Updates — Effective May 1, 2016

    Policy/procedure Description Additional resources

    New medical policies created.

    Botulinum A and B toxins

    Harvard Pilgrim has created a new medical policy to ensure the appropriate, medically necessary use of Botulinum A and B. This policy lists numerous conditions for which Botulinum A or B is medically appropriate and will be reimbursed, as well as conditions for which the use of these medications is not covered. Harvard Pilgrim worked with practicing clinicians in developing and vetting this policy.

    Prior authorization is not required for the physician buy and bill option. If you choose to receive this medication through our Specialty Pharmacy program, however, prior authorization is necessary.

    Eylea (aflibercept)

    Harvard Pilgrim considers intravitreal injections with Eylea (aflibercept) medically necessary as treatment for the following:
    • Diabetic macular edema
    • Diabetic retinopathy with diabetic macular edema
    • Established neovascular "wet" age-related macular degeneration
    • Macular edema from retinal vein occlusion
    Prior authorization is not required for the physician buy and bill option. If you choose to receive this medication through our Specialty Pharmacy program, however, prior authorization is necessary.

    New coding established. Existing prior authorization requirements for HMO, POS, and PPO members apply.

    BRCA testing —
    CPT 81162
    The CPT code 81162 was recently established for BRCA1/BRCA 2 testing, and has been added to our BRCA (Genetic) Testing for Hereditary Breast and Ovarian Cancer Medical Review Criteria.
    Hyaluronate Injections for Osteoarthritis —
    J7328 & Q9980
    Gel-syn and GenVisc, two newer hyaluronate injections for osteoarthritis, now have J and Q codes for billing:
    • J7328 (Gel-syn)
    • Q9980 (GenVisc)
    Immune Globulin —Hyqvia A HCPCS code is now available for the subcutaneous immune globulin product Hyqvia:
    • J1575 (Injection, immune globulin/hyaluronidase, Hyqvia, 100 mg injection)
    Please use this code when requesting reimbursement for Hyqvia.

    New prior authorization requirements.

    Coverage is for reasonable, medically necessary, clinically appropriate care that is supported by evidence-based literature. In all cases, prior authorization is required for HMO, POS, and PPO members. The attached policies detail the medical criteria that must be met and documented to obtain authorization. Initial authorizations may be for up to 12 months, and reauthorizations may be for up to 12 months.

    The links below apply for the physician buy and bill program. Alternatively, you may choose to receive the following medications through Harvard Pilgrim’s Specialty Pharmacy program. Our pharmacy benefits manager, MedImpact Healthcare Systems, will begin accepting prior authorization requests for these medications on May 1, 2016. To request Specialty Pharmacy authorization, please complete the appropriate medication review request form (to be posted here prior to May 1st) and fax it to MedImpact at 888-807-6643.

    Alpha 1-Proteinase Inhibitors —
    Aralast NP, Glassia, Prolastin-C, and Zemaira
    Coverage of Aralast NP, Glassia, Prolastin-C and Zemaira to treat panacinar emphysema due to alpha-1 antitrypsin deficiency.
    Enzyme Replacement Therapy for Gaucher Disease —
    Cerezyme, Elelyso, VPRIV
    Coverage of Cerezyme, Elelyso, or VPRIV for the treatment of adults and children with Type 1 or Type 3 Gaucher disease.
    Lumizyme and Myozyme (alglucosidase alfa) for Pompe disease Coverage of Lumizyme and Myozyme for the treatment of Pompe disease (also known as acid maltase deficiency).

    Nplate (romiplostim) Coverage of Nplate (romiplostim) to treat members age 18 and over with immune thrombocytopenia purpura (ITP).
    Prolia and Xgeva
    (denosumab)

    Coverage of Prolia and Xgeva (denosumab) in members 18 and over.

    Prolia is covered for the following indications:

    • Treatment of osteoporosis in post-menopausal women at high risk for fracture
    • Prevention of osteoporosis in women taking aromatase inhibitors for breast cancer treatment
    • To increase bone mass in men at high risk for fracture due to osteoporosis, or androgen deprivation therapy related to non-metastatic prostate cancer
    Xgeva is covered for the following indications:
    • Bone metastases from solid tumors or giant cell tumor of the bone
    • Hypercalcemia of malignancy

    Soliris Coverage of Soliris (eculizumab) for the treatment of adults and children with Paroxysmal Nocturnal Hemoglobinuria (PNH) or atypical Hemolytic Uremic Syndrome. Prescribing physicians must be enrolled in the FDA-required Risk Evaluation and Mitigation and Strategy program for Soliris (eculizumab).

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