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.

 

Acthar HP (corticotropin)

Akynzeo (fosnetupitant/palonosetron)

Avastin (bevacizumab)

Bavencio (avelumab) 

Botox (onabotulinum toxin a)

Cinqair (reslizumab)

Gazyva (obintuzumab)

HA Derivatives 

Imfinzi (durvalumab)

Imlygic (talimogene laherparepvec)

Kadcyla (ado-trastuzumab emtansine)

Keytruda (pembrolizumab)

Kymriah (tisagenlecleucel)

Nucala (mepolizumab)

Opdivo (nivolumab)

Prolia/Xgeva (denosumab)

Rituxan Hyclea (rituximab)

Soliris (eculizumab)

Spinraza (nusinersen)

Sustol (granisetron extended‐release)

Synagis (palivizumab)

Tecentriq (atezolizumab)

Tysabri (natalizumab)

Xolair (omalizumab)

Yervoy (ipilimumab)

Yescarta (axicabtagene ciloleucel)

Zaltrap (ziv-aflibercept)

 

 View Mayo Medical Plan List of Drugs Excluded from Coverage (PDF)

 

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