Oxlumo Covered With Prior Authorization

Harvard Pilgrim now covers Oxlumo (HCPCS code J0224: Injection, lumasiran, 0.5 mg), with prior authorization, for members of our commercial plans.

Oxlumo is indicated for the treatment of primary hyperoxaluria type 1 to lower urinary oxalate levels in children and adults.

To request authorization, please contact CVS Health–NovoLogix via phone (844-387-1435) or fax (844-851-0882). For complete coverage criteria and other information, including FDA-approved maximum dosage and frequency limits, refer to Harvard Pilgrim’s commercial Oxlumo Medical Policy.

Publication Information

Helen Connaughton,
Director, Network Operations

Annmarie Dadoly,

Joseph O’Riordan,

Kristin Edmonston,
Production Coordinator