DMBA Clinical Guidelines

Medical Prior Authorization

Abraxane J9264 (paclitaxel protein-bound particles)

Actemra J3262 (tocilizumab)

Acthar J0800 (corticotropin, ACTH)

Adcetris J9042 (brentuximab)

Aldurazyme J1931 (laronidase)

Alimta J9305 (pemetrexed)

Aloxi J2469 (palonosetron)

Alpha-1PI (proteinase inhibitor):
(Aralast J1556,
 Glassia J0257,
 Prolastin J0256,
 Zemaira J0256)

Aranesp J0881 (darbepoetin alfa)

Arzerra J9302 (ofatumumab)

Avastin J9035 (bevacizumab)

Bavencio J9023 (avelumab)

Beleodaq J9032 (belinostat)

Bendeka J9034 (bendamustine)

Benlysta J0490 (belimumab)

Blincyto J9039 (blinatumomab)

Cerezyme J1786 (imiglucerase)

Cimzia J0717 (certolizumab pegol)

Cinqair J2786 (reslizumab)

Cyramza J9308 (ramucirumab)

Darzalex J9145 (daratumumab)

Elaprase J1743 (idursulfase)

Elelyso J3060 (taliglucerase alfa)

Empliciti J9176 (elotuzumab)

Entyvio J3380 (vedolizumab)

Erbitux J9055 (cetuximab)

Erwinaze J9019 (asparainase)

Fabrazyme J0180 (agalsidase beta)

Folotyn J9307 (pralatrexate)

Fusilev J0641 (levoleucovorin calcium)

Gazyva J9301 (obinutuzumab)

Halaven J9179 (eribulin)

Herceptin J9355 (trastuzumab)

Ilaris J0638 (canakinumab)

Imfinzi J9999 (durvalumab)

Imlygic J9325 (tamlimogene laherparepvec)

Inflectra Q5103 (infliximab-dyyb)

IVIG (immune globulin):
(Bivigam J1556,
Carimune NF J1566,
Flebogamma/Flebogamma DIF J1572,
Gammaplex J1557,
Gamunex-C J1561,
Gammaked J1561,
Gammagard S/D J1566,
Gammagard Liquid J1569,
Octagam J1568,
Privigen J1459)

Istodax J9315 (romidepsin)

Jevtana J9043 (cabazitaxel)

Kadcyla J9354 (ado-trastuzumab emtansine)

Kalbitor J1290 (ecallantide)

Kanuma J2840 (sebelipase alfa)

Keytruda J9271 (pembrolizumab)

Krystexxa J2507 (pegloticase)

Kyprolis J9047 (carfilzomib)

Kymriah Q2040 (tisagenlecleucel)

Lemtrada J0202 (alemtuzumab)

Lumizyme J0221 (alglucosidase alfa)

Marqibo J9371 (vincristine liposomal)

Mircera J0888 (methoxy polyethylene glycol-epoetin beta (non-esrd))

Mozobil J2562 (plerixafor)

Mylotarg J9203 (gemtuzumab ozogamicin)

Naglazyme J1458 (galsulfase)

Neulasta J2505 (pegfilgrastim)

Nplate J2796 (romiplostim)

Nucala J2182 (mepolizumab)

Ocrevus J2350 (ocrelizumab)

Oncaspar J9266 (pegaspargase)

Onivyde J9205 (irinotecan liposome)

Opdivo J9299 (nivolumab)

Orencia J0129 (abatacept)

Perjeta J9306 (pertuzumab)

Procrit/Epogen J0885 (epoetin alfa)

Prolia / Xgeva J0897 (denosumab)

Provenge Q2043 (sipuleucel-t)

Remicade J1745 (infliximab)

Renflexis Q5104 (infliximab-abda)

Retacrit Q5106 (epoetin alfa-epbx)

Rituxan J9310 (rituximab)

Rituxan Hycela J9999 (rituximab and hyaluronidase human)

Sandostatin J2353 (octreotide depot)

Simponi J1602 (golimumab)

Soliris J1300 (eculizumab)

Stelara J3358 (ustekinumab)

Sustol J1627 (granisetron extended-release)

Sylvant J2860 (siltuximab)

Synribo J9262 (omacetaxine)

Tecentriq J9022 (atezolizumab0

Torisel J9330 (temsirolimus)

Treanda J9033 (bendamustine)

Tysabri J2323 (natalizumab)

Vectibix J9303 (panitumumab)

Velcade J9041 (bortezomib)

Vimizim J1322 (elosulfase alfa)

Vpriv J3385 (velaglucerase alfa)

Xolair J2357 (omalizumab)

Yervoy J9228 (ipilimumab)

Yescarta Q2041 (axicabtagene ciloleucel)

Yondelis J9352 (trabectedin)

Zaltrap J9400 (ziv-aflibercept)

 

Medical Pharmacy Claims Edit Policies

Botox J0585 (onabotulinumtoxina)

Doxorubicin Liposomal (Doxil Q2050, Lipodox Q2049) (doxorubicin))

Dysport J0586 (abobotulinumtoxina)

Eloxatin J9263 (oxaliplatin)

Emend J1453 (fosaprepitant)

Eylea J0178 (aflibercept)

Faslodex J9395 (fulvestrant)

Granix J1447 (tbo-filgrastim)

Hyaluronic Acid Derivatives:
(Euflexxa J7323, Synvisc/Synvisc-One J7325) 

Hycamtin J9351 (topotecan)

Iluvien J7313 (fluocinolone acetonide intravitreal implant)

Jetrea J7316 (ocriplasmin)

Leukine J2820 (sargramostim)

Lucentis J2778 (ranibizumab)

Lupron Depot (J1950, J9217, Eligard J9217) (leuprolide acetate (for depot suspension))

Macugen J2503 (pegaptanib sodium)

Myobloc J0587 (rimabotulinumtoxinb)

Neupogen J1442 (filgrastim)

Retisert J7311 (Fluocinolone acetonide intravitreal implant)

Taxotere /Docefrez J9171 (docetaxel)

Trelstar J3315 (triptorelin pamoate)

Vantas J9225 (histrelin acetate)

Xeomin J0588 (incobotulinumtoxina)

Zarxio Q5101 (filgrastim-sndz)

Zoladex J9202 (goserelin acetate implant)