Harvard Pilgrim regularly reviews our clinical medical policies, clinical literature, and utilization trends, and updates policies and procedures as appropriate. Based on these ongoing reviews, Harvard Pilgrim is making the following changes, effective for dates of service beginning October 1, 2016.
Retiring medical policies
Previously, Harvard Pilgrim had clinical medical policies in place for the injectable and infusible medications listed below. In these cases, Harvard Pilgrim provided reimbursement for the injectable and infusible drugs when billed with the diagnosis codes and dose referenced in the appropriate policy. After a review, Harvard Pilgrim is expanding coverage by retiring the policies and the corresponding diagnosis-based claims edits for the following medications:
- Abraxane (paclitaxel protein bound)
- Alimta (pemetrexed injection)
- Doxil (doxorubicin injection 10 mg/imported lipodox injection)
- Eloxatin (oxaliplatin)
- Gemzar (gemcitabine HCL injection)
- Hycamtin (topotecan injection)
- Taxotere (docetaxel injection)
- Vectibix (panitumumab injection)
- Zoladex (goserelin acetate implant)
In addition, Harvard Pilgrim is updating the clinical medical policies for the injectable and infusible drugs listed below to include additional covered indications. For details on these changes, please refer to the linked clinical medical policies for the following medications:
Change in coverage for Trelstar Depot LA
- Avastin (bevacizumab injection) — updated to include coverage for multiple additional indications
- Erbitux (cetuximab injection) — updated to include coverage for anal cancer and penile cancer
- Herceptin (trastuzumab injection) — updated to include coverage for esophageal and gastoesophagel cancer
- Lupron (Leuprolide acetate 3.75 mg/leuprolide acetate suspension) and Eligard — updated to include coverage for infertility and gender dysphoria
- Velcade (bortezomib injection) — updated to include coverage for cutaneous or peripheral T-cell lymphoma and multicentric Castleman disease
Harvard Pilgrim found that the current clinical literature did not support the use of Trelstar Depot LA for endometriosis and will be updating our clinical medical policy and coverage accordingly. For further information, please refer to the Trelstar Depot LA (triptorelin pamoate) Clinical Medical Policy.
New Prior Authorization Policy for Sandostatin
Also effective for dates of service beginning October 1, 2016, Harvard Pilgrim is requiring prior authorization for Sandostatin (octreotide depot). Harvard Pilgrim is continuing to offer coverage of Sandostatin for the same conditions going forward, but this clinical review will allow for greater individual consideration and flexibility.
Harvard Pilgrim authorizes medically necessary use of Sandostatin LAR Depot for the treatment of the conditions listed below, provided the criteria outlined in the policy are met:
- Bleeding gastroesophageal varices associated with liver disease
- Carcinoid tumors
- Chemotherapy/radiation-induced diarrhea
- CNS cancers (e.g. meningiomas)
- HIV/AIDS-related refractory diarrhea
- Neuroendocrine tumors (e.g. pituitary adenoma, insulinoma, glucagonoma, vasoactive intestinal polypeptidoma, or VIPoma)
- Pancreatic endocrine tumors (Islet cell tumors)
- Thymic cancer and thymomas
For more information, please refer to the Sandostatin Prior Authorization Medical Review Criteria.