Medication Center

Medical Prior Auth 

Abecma
(Idecabtagene vicleucel)

Actemra
(tocilizumab)

Adakveo
(crizanlizumab-tmca)

Adbry
(tralokinumab-ldrm)

Adcetris
(brentuximab)

Adstiladrin
(nadofaragene firadenovec-vncg)

Akynzeo IV
(netupiant and palonosetron)

Aldurazyme
(laronidase)

Amondys-45
(casimersen)

Amvuttra
(vutrisiran)

Aranesp
(darbepoetin alfa)

Arzerra
(ofatumumab)

Asparlas
(calaspargase pegol-mknl)

Bavencio
(avelumab)

Beleodaq
(belinostat)

Bendamustine:
Belrapzo RTD
Bendeka
Treanda
Vivimusta

Benlysta IV
(belimumab)

Beovu
(brolucizumab-dbll)

Berinert
(C1 Esterase Inhibitor Human)

Bevacizumab:
Avastin
Mvasi
Zirabev
Alymsys
Vegzelma

Blenrep
(belantamab mafodotin-blmf)

Blincyto
(blinatumomab)

Borezomib
Velcade

Breyanzi
(lisocabtagene maraleucel)

Brineura
(cerliponase alfa)

Briumvi
(ublituximab-xiiy)

Carvykt
(ciltacabtagene autoleucel)

Cerezyme
(imiglucerase)

Cimzia
(certolizumab pegol)

Cinqair
(reslizumab)

Cinryze
(C1 Esterase Inhibitor Human)

Corticotropin‐ACTH:
Acthar Gel (repository corticotropin injection)
Cortrophin Gel (repository corticotropin injection)

Cosela
(trilaciclib)

Cosentyx
(secukinumab)

Crysvita
(burosumab-twza)

Cyramza
(ramucirumab)

Danyelza
(naxitamab-gqgk)

Darzalex
(daratumumab)

Darzalex Faspro
(daratumumab and hyaluronidase-fihj)

Elahere
(mirvetuximab soravtansine‐gynx)

Elaprase
(idursulfase)

Elelyso
(taliglucerase alfa)

Elzonris
(tagraxofusp-resz)

Empliciti
(elotuzumab)

Enhertu
(fam-trastuzumab deruxtecan-nxki)

Enjaymo
(sutimlimab-jome)

Enspryng
(satralizumab-mwge)

Entyvio
(vedolizumab)

Epotein Alfa (Non Dialysis)
Epogen
Procrit
Retacrit

Erbitux
(cetuximab)

Evenity
(romozozumab-aqqg)

Evkeeza
(evinacumab-dgnb)

Exondys-51
(eteplirse)

Eylea
(aflibercept)

Fabrazyme
(agalsidase beta)

Fasenra
(benralizumab)

Feraheme
(ferumoxytol)

Firazyr
(icatibant)

Fyarro
(sirolimus albumin-bound nanoparticles)

Gamifant
(emapalumab-lzsg)

Gazyva
(obinutuzumab)

Givlaar
(givosiran)

HA derivatives
Durolane
Euflexxa
Gel-One
Gelsyn-3
GenVisc 850
Hyalgan/Supartz/Supartz Fx
Hymovis
Monovisc
Synojoynt/sodium hyaluronate
Synvisc/Synvisc One
Triluron
Trivisc
Visco-3

Haegarda
(C1 Esterase Inhibitor (Human))

Halaven
(eribulin)

Hemgenix
(etranacogene dezaparvovec‐drlb)

Ilumya
(tildrakizumab-asmn)

Imfinzi
(durvalumab)

Imjudo
(tremelimumab‐actl)

Imlygic
(talimogene laherparepvec)

Infliximab:
Avsola
Inflectra
Remicade
Renflexis

Infugem
(gemcitabine)

Injectafer
(ferric carboxymaltose injection)

IVIG
(immune globulin):
Asceniv
Bivigam
Carimune NF
Flebogamma/Flebogamma DIF
Gammaplex
Gamunex-C
Gammaked
Gammagard S/D
Gammagard Liquid
Octagam
Panzyga
Privigen

Jemperli
(dostarlimab‐gxly)

Jevtana
(cabazitaxel)

Kadcyla
(ado-trastuzumab emtansine)

Kalbitor
(ecallantide)

Kanuma
(sebelipase alfa)

Keytruda
(pembrolizumab)

Kimmtrak
(tebentafusp-tebn)

Krystexxa
(pegloticase)

Kymriah
(tisagenlecleucel)

Kyprolis
(carfilzomib)

Lamzede
(velmanase alfa-tycv)

Lemtrada
(alemtuzumab)

Leqembi
(lecanemab-irmb)

Leqvio
(inclisiran)

Leuprolide Suspension:
Lupron
Lupron Depot-Ped
Eligard
Fensolvi
Camcevi

Libtayo
(cemiplimab-rwlc)

Lumizyme
(alglucosidase alfa)

Lumoxiti
(moxetumomabpasudotox-tdfk)

Lunsumio
(mosunetuzumab-axgb)

Lutathera
(lutetium Lu 177 dotatate)

Luxturna
(voretigene neparvovec-rzyl)

Marqibo
(vincristine sulfate liposomal)

Mepsevii
(vestronidase alfa-vjbk)

Mircera
(methoxy polyethylene glycol-epoetin beta)

Monjuvi
(tafasitamab-cxix)

Monoferric
(ferric derisomaltose)

Mozobil
(plerixafor)

Naglazyme
(galsulfase)

Nexviazyme
(avalglucosidase alfa‐ngpt)

Nplate
(romiplostim)

Ocrevus
ocrelizumab

Oncaspar
(pegaspargase)

Onivyde
(irinotecan liposome injection)

Onpattro
(patisiran)

Opdivo
(nivolumab)

Opdualag
(nivolumab/relatlimab-rmbw)

Orencia
(abatacept)

Oxlumo
(lumasiran)

Paclitaxel protein-bound particles:
Abraxane
Paclitaxel Albumin-Bound Ψ

Pemetrexed:
Alimta
Pemfexy

Perjeta
(pertuzumab)

Pluvicto
(lutetium Lu 177 vipivotide tetraxetan)

Polivy
(polatuzumab vedotinpiiq)

Portrazza
(necitumumab)

Poteligeo
(mogamulizumab-kpkc)

Prolia/Xgeva
(denosumab)

Provenge
(sipuleucel-T)

Radicava
(edaravone)

Ranibizumb
Byooviz
Cimerli
Lucentis

Reblozyl
(luspatercept-aamt)

Revcovi
(elapegademase-lvlr)

Rituximab
(rituximab)
Riabni
Ruxience
Truxima

Rituxan Hycela
(rituximab and hyaluonidase human)

Rolvedon
(eflapegrastim‐xnst)

Ruconest
(C1 Esterase Inhibitor [recombinant])

Rybrevant
(amivantamab‐vmjw)

Rylaze
(asparaginase Erwinia chrysanthemi (recombinant)‐rywn)

Ryplazim
(plasminogen, human-tvmh)

Sandostatin LAR
(octreotide)

Saphnelo
(anifrolumab‐fnia)

Sarclisa
(isatuximab-irfc)

Scenesse
(afamelanotide)

SCIG
(immune globulin SQ):
Cutaquig
Cuvitru
Gammagard Liquid
Gamunex-C
Gammaked
Hizentra
Hyqvia
Zembify

Signifor LAR
(pasireotide)

Simponi ARIA
(golimumab)

Skyrizi IV
(risankizumab‐rzaa)

Skysona
(elivaldogene autotemcel)

Soliris
(eculizumab)

Somatuline Depot
(lanreotide)

Spevigo
(spesolimab)

Spinraza
(nusinersen)

Stelara
(ustekinumab)

Susvimo
(ranibizumab)

Syfovre
pegcetacoplan

Sylvant
(siltuximab)

Synagis
(Palivizumab)

Synribo
(omacetaxine)

Takhzyro
(Lanadelumab-flyo)

Tecartus
(brexucabtagene autoleucel)

Tecentriq
(atezolizumab)

Tecvayli
(teclistamab‐cqyv)

Tepezza
(teprotumumab-trbw)

Tezspire
(tezepelumab-ekko)

Tivdak
(tisotumab vedotin-tftv)

Trastuzumab:
Herceptin
Herzuma
Kanjinti
Ogivri
Ontruzant
Trazimera

Trastuzumab and hyaluronidase-oysk
(Herceptin Hylecta)

Trodelvy
(sacituzumab govitecan-hziy)

Tysabri
(natalizumab)

Tzield
(teplizumab‐mzwv)

Ultomiris
(ravulizumab-cwvz)

Uplizna
(inebilizumab-cdon)

Vabysmo
(faricimab‐svoa)

Vectibix
(panitumumab)

Vidaza
(Azacitidine)

Viltepso
(viltolarsen)

VPRIV
(velaglucerase alfa)

Vyepti
(eptinezumab-jjmr)

Vyondys-53
(golodirsen)

Vyvgart
(efgartigimod alfa-fcab)

Xenpozyme
(olipudase alfa)

Xipere
(triamcinolone acetonide)

Yervoy
(ipilimumab)

Yescarta
(axicabtagene ciloleucel)

Yondelis
(trabectedin)

Zaltrap
(ziv-aflibercept)

Zolgensma
(onasemnogene abeparvovec-xioi)

Zynlonta
(loncastuximab tesirine‐lpyl)

Zynteglo
(betibeglogene autotemcel)

Zynyz
(retifanlimab-dlwr)