Mayo Medical Plan Clinical Guidelines and Exclusions
(effective 1/1/2019)
PLEASE NOTE: This list of policies only applies to Mayo Medical Plan for Mayo Clinic employees.
MAYO CLINIC PROVIDERS - Coverage for Spinraza administered at Mayo Clinic is provided exclusively through the PHARMACY BENEFIT. Please submit prior authorization requests through Mayo Clinic Pharmacy Benefit Solutions. For more information visit https://pharmacybenefits.mayoclinic.org/providers
Acthar HP (corticotropin)
Akynzeo (fosnetupitant/palonosetron)
Avastin (bevacizumab)
Bavencio (avelumab)
Botox (onabotulinum toxin a)
Cinqair (reslizumab)
Imfinzi (durvalumab)
Imlygic (talimogene laherparepvec)
Kadcyla (ado-trastuzumab emtansine)
Keytruda (pembrolizumab)
Kymriah (tisagenlecleucel)
Marqibo (vincristine sulfate liposomal)
Nucala (mepolizumab)
Opdivo (nivolumab)
Prolia/Xgeva (denosumab)
Rituxan Hyclea (rituximab)
Soliris (eculizumab)
Spinraza (nusinersen)
Sustol (granisetron extended‐release)
Synagis (palivizumab)
Tecentriq (atezolizumab)
Tysabri (natalizumab)
Ultomiris (ravulizumab-cwvz)
Xolair (omalizumab)
Yervoy (ipilimumab)
Yescarta (axicabtagene ciloleucel)
Zaltrap (ziv-aflibercept)
View Mayo Medical Plan List of Drugs Excluded from Coverage (PDF)