Harvard Pilgrim Health Care and OncoHealth, our vendor for medical necessity and utilization review for certain oncology medical drugs, are implementing a step therapy/preferred product strategy for a number of drug classes, effective for dates of service beginning April 1, 2023 for Harvard Pilgrim Commercial members. This implementation has been delayed from an initial Jan. 1, 2023 date.
Beginning April 1, 2023, members will be required to have first tried and failed, or have a documented contraindication, or intolerance to a preferred product prior to approval of a non-preferred product for the drugs noted below. This is similar to the step therapy requirement already in place for Harvard Pilgrim’s StrideSM (HMO)/(HMO-POS) Medicare Advantage plans.
As part of this change, Harvard Pilgrim Health Care and OncoHealth removed the prior authorization requirement for the following medications for Commercial members, effective Jan. 1, 2023: Zarxio (Q5101), Mvasi (Q5107), Zirabev (Q5118), Ogivri (Q5114), Kanjinti (Q5117), and Trazimera (Q5116).
The following preferred product strategy will be put in place on April 1:
- Bevacizumab products – Mvasi (Q5107) and Zirabev (Q5118) will be preferred products and will not require prior authorization, while Avastin (J9035) Almysys (Q5126), and Vegzelma (J3590) will be non-preferred and will continue to require prior authorization.
- Long-Acting Colony Stimulating Factor products – Neulasta (J2506), Neulasta Onpro (J2506), and Fulphila (Q5108) will be preferred products, while Flynetra (J3590), Udenyca (Q5111), Nyvepria (Q5122), and Ziextenzo (Q5120) will be non-preferred. All Long-Acting Colony Stimulating Factor agents will continue to require prior authorization.
- Rituximab products – Truxima (Q5115) and Ruxience (Q5119) will be preferred, while Rituxan (J9312), Rituxan Hycela (J9311), and Riabni (Q5123) will be non-preferred. All Rituximab agents will continue to require prior authorization.
- Short Acting Colony Stimulating Factor products – Zarxio (Q5101) will be preferred and does not require prior authorization, while Neupogen (J1442), Granix (J1447), Leukine (J2820), Releuko (Q5125), and Nivestym (Q5110) will be non-preferred and will continue to require prior authorization.
- Trastuzumab products – Ogivri (Q5115), Kanjinti (Q5117), and Trazimera (Q5116) will be preferred products and do not require prior authorization, while Herceptin (J9355), Herceptin Hylecta (J9356), Ontruzant (Q5112), and Herzuma (Q5113) will be non-preferred and will continue to require prior authorization.
For more information, visit the Harvard Pilgrim OncoHealth page.
Director, Provider Relations & Communications
Senior Manager, Provider Communications
Joseph O’Riordan, Jesse Salvato, Stephen Wong