Medicare Advantage: Prior Authorization for Riabni and Avsola

Harvard Pilgrim currently requires prior authorization for the medications Riabni (HCPCS code Q5123) and Avsola (HCPCS code Q5121) for commercial members — and effective for dates of service beginning Jan. 1, 2021, this prior authorization requirement will also apply to members of our StrideSM (HMO) Medicare Advantage plans.

Riabni is a biosimilar of the drug Rituxan and Avsola is a biosimilar of Remicade. Harvard Pilgrim currently requires prior authorization for Rituxan and Remicade and their other biosimilars for both commercial and StrideSM (HMO) Medicare Advantage plans. The respective medical policies outline the criteria that must be met for authorization.

To request authorization for these medications for non-oncology purposes for members of StrideSM (HMO) Medicare Advantage plans, please contact the Medicare Advantage Provider Service Center at 888-609-0692.

As a reminder, when Riabni and Avsola are requested for oncology purposes, prior authorization review is conducted by OncoHealth (formerly Oncology Analytics). You can view prior authorization criteria for oncology drugs, as well as any recent coding updates, on the OncoHealth website and may request authorization for oncology purposes by contacting OncoHealth by fax (800-264-6128) or phone (877-222-2021), or online via HPHConnect.

For more information, please refer to the updated StrideSM (HMO) Medicare Advantage medical policies for Rituxan and Remicade.


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