Independent Health Clinical Guidelines
Please Note: Criteria may differ by line of business. Review the appropriate policy for specific criteria or refer to the Part D or Part B Step Therapy criteria for Medicare members.
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Medical Prior Auth and Claims Edits
Abraxane
(paclitaxel protein-bound particles)
Actemra
(tocilizumab)
Acthar
(corticotropin, ACTH)
Adakveo
(crizanlizumab-tmca)
Adcetris
(brentuximab)
Akynzeo
(fosnetupitant/palonosetron)
Aldurazyme
(laronidase)
Aliqopa
(copanlisib)
Alpha-1-Proteinase Inhibitors
Aralast NP
Glassia
Prolastin-C
Zemaira
Aranesp
(darbepoetin alfa)
Bavencio
(avelumab)
Beleodaq
(belinostat)
Bendamustine
(bendamustine hcl):
Belrapzo
Bendeka
Treanda
bendamustine (Apotex)
bendamustine (Baxter)
Benlysta
(belimumab)
Beovu
(brolucizumab-dbll)
Besponsa
(inotuzumab ozogamicin)
Berinert
(C1 Esterase Inhibitor Human)
Bevacizumab
Alymsys
Avastin
Mvasi
Vegzelma
Zirabev
Blenrep
(belantamab mafodotin-blmf)
Blincyto
(blinatumomab)
Bortezomib
Bortezomib (Hospira, Fresenius, Dr. Reddy's)
Velcade
Cerezyme
(imiglucerase)
Cimzia
(certolizumab pegol)
Cinryze
(C1 Esterase Inhibitor Human)
Cosela
(trilaciclib)
Crysvita
(burosumab-twza)
Cyramza
(ramucirumab)
Danyelza
(naxitamab-gqgk)
Darzalex
(daratumumab)
Darzalex Faspro
(daratumumab and hyaluronidase-fihj)
Elelyso
(taliglucerase alfa)
Elzonris
(tagraxofusp-erzs)
Empaveli
(pegcetacoplan)
Empliciti
(elotuzumab)
Enhertu
(fam-trastuzumab deruxtecan-nxki)
Entyvio
(vedolizumab)
Epoetin Alfa *Non-Dialysis*
Epogen
Procrit
Retacrit
Erbitux
(cetuximab)
Evenity
(romosozumab-aqqg)
Eylea
(aflibercept)
Fabrazyme
(agalsidase beta)
Fasenra
(benralizumab)
Filgrastims (Colony Stimulating Factors):
Granix
Neupogen
Nivestym
Releuko
Fulvestrant
Faslodex
Fulvestrant (Teva, Fresenius Kabi)
Fyarro
(sirolimus albumin‐bound)
Gamifant
(emapalumab-lzsg)
Gazyva
(obinutuzumab)
Givlaari
(givosiran)
Halaven
(eribulin)
Herceptin Hylecta
(trastuzumab and hyaluronidase-oysk)
Hyaluronic Acid:
Euflexxa
Durolane
Gel-One
Gel-Syn
GenVisc 850
Hylagan
Hymovis
Monovisc
Orthovisc
Supartz/Supartz FX
Synojoynt, Synvisc
Synvisc-One
Triluron, TriVisc
Visco-3
Hycamtin Oral
(topotecan)
Ilaris
(canakinumab)
Ilumya
(tildrakizumab-asmn)
Imfinzi
(durvalumab)
Imlygic
(talimogene laherparepvec)
Infliximab
Avsola (infliximab-axxq)
Inflectra (infliximab-dyyb)
Remicade (infliximab)
Renflexis (infliximab-abda)
IVIG
(immune globulin):
Asceniv
Bivigam
Flebogamma/Flebogamma DIF
Gammaplex
Gamunex-C
Gammaked
Gammagard S/D
Gammagard Liquid
Octagam
Panzyga
Privigen
Ixempra
(ixabepilone)
Jelmyto
(mitomycin)
Jemperli
(dostarlimab-gxly)
Jevtana
(cabazitaxel)
Kadcyla
(ado-trastuzumab emtansine)
Kalbitor
(ecallantide)
Kanuma
(sebelipase alfa)
Keytruda
(pembrolizumab)
Kyprolis
(carfilzomib)
Lemtrada
(alemtuzumab)
Leukine
(sargramostim)
Leuprolide
Lupron Depot
Lupron Depot-Ped
Eligard
Fensolvi
Camcevi
Levoleucovorin
(Intravenous):
Fusilev
Khapzory
Libtayo
(cemiplimab-rwlc)
Lumizyme
(alglucosidase alfa)
Lumoxiti
(moxetumomab pasudotox-tdfk)
Margenza
(margetuximab-cmkb)
Mepsevii
(vestronidase alfa-vjbk)
Mircera
(methoxy polyethylene glycol-epoetin beta)
Monjuvi
(tafasitamab-cxix)
Mozobil
(plerixafor)
Mylotarg
(gemtuzumab ozogamicin)
Naglazyme
(galsulfase)
Nexviazyme
(avalglucosidase alfa‐ngpt)
Nplate
(romiplostim)
Nulibry
(fosdenopterin)
Ocrevus
(ocrelizumab)
Onivyde
(irinotecan liposome injection)
Onpattro
(patisiran lipid complex)
Opdivo
(nivolumab)
Orencia
(abatacept)
Oxlumo
(lumasiran)
Paclitaxel Albumin-Bound
(paclitaxel protein-bound particles)
Padcev
(enfortumab vedotin-ejfv)
Pegfilgrastim
Fulphila
Fylnetra
Neulasta
Nyvepria
Stimufend
Udenyca
Ziextenxo
Pemetrexed
Alimta
Pemfexy
Pemetrexed (Teva, Hospira, Accord, Sandoz, Bluepoint)
Pemetrexed Ditromethamine
Perjeta
(pertuzumab)
Phesgo
(pertuzumab, trastuzumab and hyaluronidase-zzxf)
Polivy
(polatuzumab vedotin-piiq)
Portrazza
(necitumumab)
Poteligeo
(mogamulizumab-kpkc)
Prolia/Xgeva
(denosumab)
Provenge
(sipuleucel-T)
Purified Cortrophin Gel
(corticotropin, ACTH)
Ranibizumab:
Byooviz
Cimerli
Lucentis
Reblozyl
(luspatercept-aamt)
Revcovi
(elapegademase-lvlr)
Rituximab
Riabni
Rituxan
Ruxience
Truxima
Rituxan Hycela
(rituxumab hyaluronidase)
Rolvedon
(eflapegrastim-xnst)
Ruconest
(C1 Esterase Inhibitor [recombinant])
Rybrevant
(amivantamab‐vmjw)
Ryplazim
(plasminogen, human‐tvmh)
Sandostatin LAR
(octreotide)
Saphnelo
(anifrolumab‐fnia)
Sarclisa
(isatuximab-irfc)
SCIG
(immune globulin SQ):
Cutaquig
Cuvitru
Gammagard Liquid
Gammaked
Gamunex-C
Hizentra
Hyqvia
Xembify
Simponi ARIA
(golimumab)
Soliris
(eculizumab)
Spinraza
(nusineren)
Stelara
(ustekinumab)
Sustol
(granisetron)
Sylvant
(siltuximab)
Synribo
(omacetaxine)
Tecentriq
(atezolizumab)
Tepezza
(teprotumumab-trbw)
Tivdak
(tisotumab vedotin-tftv)
Trastuzumab
Herceptin
Herzuma
Kanjinti
Ogivri
Ontruzant
Trazimera
Trodelvy
(sacituzumab govitecan-hziy)
Tysabri
(natalizumab)
Ultomiris
(ravulizumab-cwvz)
Unituxin
(dinutuximab)
Uplizna
(inebilizumab-cdon)
Vabysmo
(faricimab-svoa)
Vectibix
(panitumumab)
Vimizim
(elosulfase alfa)
VPRIV
(velaglucerase alfa)
Vyvgart
(efgartigimod alfa-fcab)
Vyxeos
(cytarabine and daunorubicin liposomal)
Xipere
(triamcinolone acetonide)
Yervoy
(ipilimumab)
Yondelis
(trabectedin)
Zaltrap
(ziv-aflibercept)
Zepzelca
(lurbinectedin)
Zoledronic Acid
Zometa
Reclast
Zynlonta
(loncastuximab tesirine-lpyl)
Pharmacy Prior Auth
Abiraterone
Yonsa
Actemra SQ
(tocilizumab)
Alecensa
(alectinib)
Alpha-1-Proteinase Inhibitors
Aralast NP
Glassia
Prolastin-C
Zemaira
Alunbrig
(brigatinib)
Aranesp
(darbepoetin alfa)
Ayvakit
(avapritinib)
Balversa
(erdafitinib)
Benlysta SQ
(belimumab)
Berinert
(C1 Esterase Inhibitor Human)
Braftovi
(encorafenib)
Brukinsa
(zanubrutinib)
Bosulif
(bosutinib)
Cabozantinib
Cabometyx
Cometriq
Calquence
(acalabrutinib)
Caprelsa
(vandetanib)
Cimzia
(certolizumab pegol)
Copiktra
(duvelisib)
Cosentyx
(secukinumab)
Cotellic
(cobimetinib)
Daurismo
(glasdegib)
Doptelet
(avatrombopag)
Empaveli
(pegcetacoplan)
Enspryng
(satralizumab-mwge)
Epoetin Alfa *Non-Dialysis*
Epogen
Procrit
Retacrit
Erleada
(apalutamide)
Erivedge
(vismodegib)
Evrysdi
(risdiplam)
Exkivity
(mobocertinib)
Fasenra
(benralizumab)
Filgrastims (Colony Stimulating Factors):
Neupogen
Nivestym
Fotivda
(tivozanib)
Galafold
(migalastat)
Gavreto
(pralsetinib)
Gilotrif
(afatinib)
Haegarda
(C1 esterase inhibitor)
Hycamtin Oral
(topotecan)
Ibrance
(palbociclib)
Iclusig
(ponatinib)
Idhifa
(enasidenib)
Imbruvica
(ibrutinib)
Inlyta
(axitinib)
Inqovi
(decitabine and cedazuridine)
Inrebic
(fedratinib)
IVIG
(immune globulin):
Bivigam
Flebogamma
Gammaplex
Gamunex-C
Gammaked
Gammagard S/D
Gammagard Liquid
Octagam
Privigen
Jakafi
(ruxolitinib)
Kisqali
(ribociclib)
Koselugo
(selumetinib)
Lenvima
(lenvatinib)
Leukine
(sargramostim)
Leuprolide
Camcevi
Eligard
Lupron
Lonsurf
(trifluridine and tipiracil)
Lorbrena
(lorlatinib)
Lumakras
(sotorasib)
Lynparza
(olaparib)
Mekinist
(trametinib)
Mektovi
(binimetinib)
Mulpleta
(lusutrombopag)
Nerlynx
(neratinib)
Ninlaro
(ixazomib)
Nubeqa
(daroltamide)
Odomzo
(sonidegib)
Onureg
(azacitidine)
Orencia
(abatacept)
Orgovyx
(relugolix)
Orladeyo
(berotralstat)
Oxbryta
(voxelotor)
Pegfilgrastim
Fulphila
Neulasta
Udenyca
Pemazyre
(pemigatinib)
Piqray
(alpelisb)
Pomalyst
(pomalidomide)
Prolia/Xgeva
(denosumab)
Promacta
(eltrombopag)
Purified Cortrophin Gel
(corticotropin, ACTH)
Qinlock
(ripretinib)
Retevmo
(selpercatinib)
Revlimid
(lenalidomide)
Rezurock
(belumosudil)
Rozlytrek
(entrectinib)
Rubraca
(rucaparib)
Ruconest
(C1 Esterase Inhibitor [recombinant])
Rydapt
(midostaurin)
Scemblix
(asciminib)
SCIG
(immune globulin SQ):
Cuvitru
Gammagard
Gammaked
Gamunex-C
Hizentra
Sprycel
(dasatinib)
Stelara
(ustekinumab)
Stivarga
(regorafenib)
Synribo
(omacetaxine)
Tabrecta
(capmatinib)
Tafamidis -
(Vyndamax,
Vyndaqel)
Tafinlar
(dabrafenib)
Tagrisso
(osimertinib
Takhzyro
(lanadelumab-flyo)
Talzenna
(talazoparib)
Tasigna
(nilotinib)
Tavalisse
(fostamatinib disodium hexahydrate)
Tazverik
(tazemetostat)
Tegsedi
(inotersen)
Tepmetko
(tepotinib)
Tibsovo
(ivosidenib)
Tukysa
(tucatinib)
Turalio
(pexidartinib)
Ukoniq
(umbralisib)
Venclexta
(venetoclax)
Verzenio
(abemaciclib)
Vitrakvi
(larotrectinib)
Vizimpro
(dacomitinib)
Votrient
(pazopanib)
Welireg
(belzutifan)
Xalkori
(crizotinib)
Xermelo
(telotristat ethyl)
Xospata
(gilteritinib)
Xtandi
(enzalutamide)
Zejula
(niraparib)
Zelboraf
(vemurafenib)
Zolinza
(vorinostat)
Zydelig
(idelalisib)
Zykadia
(ceritinib)
Hemophilia Program
Anti-Inhibitor Coagulant Complex (Feiba NF)
Anti-Inhibitor Antibody: Hemlibra (emicizumab-kxwh)
Factor VIIa
Novoseven RT
Sevenfact
Factor VIII
(Advate
Adynovate
Afstyla
Altuviiio
Eloctate
Esperoct
Hemofil M
Jivi
Koate DVI
Kogenate FS
Kovaltry
Novoeight
Nuwiq
Obizur
Recombinate
Xyntha)
Factor IX
(Alphanine SD,
Alprolix,
BeneFIX,
Idelvion,
Ixinity,
Mononine,
Profilnine,
Rebinyn,
Rixubis)
Factor X (Coagadex)
Factor XIII (Corifact)
Coagulation Factor XIII A-subunit (Tretten)
von Willebrand Factor (Vonvendi)
Factor VIII/VWF Complex
(Alphanate,
Humate-P,
Wilate)