Common Ground Healthcare Cooperative Prior Authorization Guidelines
Medical Prior Auth
Abraxane (paclitaxel protein-bound particles)
Actemra (tocilizumab)
Acthar Gel (corticotropin, ACTH)
Adakveo (crizanlizumab-tmca)
Adcetris (brentuximab)
Akynzeo IV (netupiant and palonosetron)
Aldurazyme (laronidase)
Alpha-1-Proteinase Inhibitors:
Aralast NP
Glassia
Prolastin-C
Zemaira
Aranesp (darbepoetin alfa)
Arzerra (ofatumumab)
Asparlas (calaspargase pegol-mknl)
Bavencio (avelumab)
Beleodaq (belinostat)
Bendamustine :
Belrapzo RTD
Bendeka
Treanda
Benlysta IV (belimumab)
Berinert (C1 Esterase Inhibitor Human)
Bevacizumab:
Avastin
Mvasi
Zirabev
Blenrep (belantamab mafodotin-blmf)
Blincyto (blinatumomab)
Brineura (cerliponase alfa)
Cerezyme (imiglucerase)
Cimzia (certolizumab pegol)
Cinqair (reslizumab)
Cinryze (C1 Esterase Inhibitor Human)
Crysvita (burosumab-twza)
Cyramza (ramucirumab)
Darzalex (daratumumab)
Darzalex Faspro (daratumumab and hyaluronidase-fihj)
Elaprase (idursulfase)
Elelyso (taliglucerase alfa)
Elzonris (tagraxofusp-resz)
Emend (fosaprepitant dimeglumine)
Empliciti (elotuzumab)
Entyvio (vedolizumab)
Epotein Alfa (Non Dialysis)
Epogen
Procrit
Retacrit
Erbitux (cetuximab)
Evenity (romozozumab-aqqg)
Exondys-51 (eteplirse)
Fabrazyme (agalsidase beta)
Fasenra (benralizumab)
Faslodex (fulvestrant)
Filgrastims:
Granix (Tbo-Filgrastim)
Neupogen (Filgrastim)
Nivestym (Filgrastim-aafi)
Firazyr (icatibant)
Gamifant (emapalumab-lzsg)
Gazyva (obinutuzumab)
Givlaar (givosiran)
Haegarda (C1 Esterase Inhibitor (Human))
Halaven (eribulin)
Imfinzi (durvalumab)
Infliximab:
Avsola
Inflectra
Remicade
Renflexis
Infugem (gemcitabine)
IVIG (immune globulin):
Asceniv
Bivigam
Carimune NF
Flebogamma/Flebogamma DIF
Gammaplex
Gamunex-C
Gammaked
Gammagard S/D
Gammagard Liquid
Octagam
Panzyga
Privigen
Jevtana (cabazitaxel)
Kadcyla (ado-trastuzumab emtansine)
Kalbitor (ecallantide)
Kanuma (sebelipase alfa)
Keytruda (pembrolizumab)
Krystexxa (pegloticase)
Kyprolis (carfilzomib)
Lemtrada (alemtuzumab)
Leukine (sargramostim)
Leuprolide Suspension:
Eligard
Fensolvi
Lupron Depot
Lupron Depot-Ped
Libtayo (cemiplimab-rwlc)
Lumizyme (alglucosidase alfa)
Lumoxiti (moxetumomabpasudotox-tdfk)
Lutathera (lutetium Lu 177 dotatate)
Marqibo (vincristine sulfate liposomal)
Mepsevii (vestronidase alfa-vjbk)
Monjuvi (tafasitamab-cxix)
Mozobil (plerixafor)
Naglazyme (galsulfase)
Nplate (romiplostim)
Nucala (mepolizumab)
Oncaspar (pegaspargase)
Onivyde (irinotecan liposome injection)
Onpattro (patisiran)
Opdivo (nivolumab)
Orencia (abatacept)
Pulmonary Arterial Hypertension:
Flolan/Veletri (epoprostenol)
Remodulin (treprostinil)
Revatio (sildenafil)
Pegfilgrastim:
Neulasta
Fulphila
Udenyca
Pemetrexed:
Alimta
Pemfexy
Perjeta (pertuzumab)
Polivy (polatuzumab vedotinpiiq)
Portrazza (necitumumab)
Poteligeo (mogamulizumab-kpkc)
Prolia/Xgeva (denosumab)
Provenge (sipuleucel-T)
Radicava (edaravone)
Reblozyl (luspatercept-aamt)
Revcovi (elapegademase-lvlr)
Rituxan IV (rituximab)
Rituxan Hycela (rituximab and hyaluonidase human)
Ruconest (C1 Esterase Inhibitor [recombinant])
Sandostatin LAR (octreotide)
Sarclisa (isatuximab-irfc)
SCIG (immune globulin SQ):
Cuvitru
Hizentra
Gammagard Liquid
Gamunex-C
Gammaked
Hyqvia
Simponi ARIA (golimumab)
Soliris (eculizumab)
Somatuline Depot (lanreotide)
Spinraza (nusinersen)
Stelara (ustekinumab)
Sylvant (siltuximab)
Synagis (Palivizumab)
Synribo (omacetaxine)
Takhzyro (Lanadelumab-flyo)
Tecentriq (atezolizumab)
Tepezza (teprotumumab-trbw)
Trastuzumab:
Herceptin
Herzuma
Kanjinti
Ogivri
Ontruzant
Trazimera
trastuzumab and hyaluronidase-oysk (Herceptin Hylecta)
Trelstar (triptorelin)
Trodelvy (sacituzumab govitecan-hziy)
Tysabri (natalizumab)
Ultomiris (ravulizumab-cwvz)
Uplizna (inebilizumab-cdon)
Vantas (histrelin acetate)
Vectibix (panitumumab)
Velcade (bortezomib)
Vidaza (Azacitidine)
Vilteps (viltolarsen)
VPRIV (velaglucerase alfa)
Vyepti (eptinezumab-jjmr)
Xolair (omalizumab)
Yervoy (ipilimumab)
Yondelis (trabectedin)
Zaltrap (ziv-aflibercept)
Zoladex (goserelin acetate)