Medica Clinical Guidelines
These policies apply Medica's Commercial, Individual & Family, Minnesota Health Care Programs and Medica Health Plan Solutions plans. Medica's Medicare Advantage, Dual Solutions and AccessAbility Solutions Enhanced plans are excluded from Hemophilia Prior Authorization. For Mayo Medical Plan, please reference plan specific clinical guidelines.
PLEASE NOTE: These policies do not apply to the SUBCUTANEOUS formulations of Actemra, Cimzia, and Orencia, which are handled by the pharmacy benefit.
Abraxane (paclitaxel protein bound)
Actemra (tocilizumab) Intravenous (IV) only
Adcetris (brentuximab)
Akynzeo (fosnetupitant/palonosetron)
Aldurazyme (laronidase)
Alimta (pemetrexed)
Aliqopa (copanlisib)
Aloxi (palonosetron)
Aranesp (darbepoetin alfa)
Avastin (bevacizumab) - For Oncology Indications
Azedra (iobenguane)
Bavencio (avelumab)
Beleodaq (belinostat)
Belrapzo (Bendamustine)
Bendamustine (bendamustine hcl):
Bendeka
Treanda
Benlysta IV (belimumab)
Berinert (C1 esterase inhibitor human)
Besponsa (inotuzumab ozogamicin)
Blincyto (blinatumomab)
Bortezomib Intravenous (IV) only
Brineura (cerliponase alfa)
Cerezyme (imiglucerase)
Cimzia (certolizumab pegol) - Lyophilized powder only
Cinqair (reslizumab)
Cinryze (C1 esterase inhibitor human)
Crysvita (burosumab-twza)
Cyramza (ramucirumab)
Darzalex (daratumumab)
Elaprase (idursulfase)
Elelyso (taliglucerase alfa)
Elzonris (tagraxofusp-erzs)
Empliciti (elotuzumab)
Entyvio (vedolizumab)
Erbitux (cetuximab)
Evenity (romosozumab-aqqg)
Exondys-51 (eteplirsen)
Eylea (aflibercept)
Fabrazyme (agalsidase beta)
Fasenra (benralizumab)
Firazyr (icatibant)
Fulphila (pegfilgrastim-jmdb)
Gamifant (emapalumab-lzsg)
Gazyva (obinutuzumab)
Granix (tbo-filgrastim)
Herceptin (trastuzumab)
Herceptin Hylecta (trastuzumab and hyaluronidase-oysk)
Herzuma (trastuzumab-pkrb)
Ilumya (tildrakizumab-asmn)
Imfinzi (durvalumab)
Imlygic (talimogene laherparepvec)
Inflectra (infliximab-dyyb)
Intravenous Immune Globulin (IVIG)
Asceniv
Bivigam
Carimune NF
Flebogamma 10% DIF
Flebogamma 5% DIF
Gamunex-C
Gammagard Liquid
Gammagard S/D
Gammaked
Gammaplex
Octagam 10%
Octagam 5%
Privigen
Panzyga
Jevtana (cabazitaxel)
Kadcyla (ado-trastuzumab emtansine)
Kalbitor (ecallantide)
Kanjinti (trastuzumab-anns)
Kanuma (sebelipase alfa)
Keytruda (pembrolizumab)
Khapzory (levoleucovorin)
Krystexxa (pegloticase)
Kymriah (tisagenlecleucel)
Lartruvo (olaratumab)
Lemtrada (alemtuzumab)
Libtayo (cemiplimab-rwlc)
Lucentis (Ranibizumab)
Lumizyme (alglucosidase alfa)
Lumoxiti (moxetumomab pasudotox-tdfk)
Lutathera (lutetium Lu 177 dotatate)
Luxturna (voretigene neparvovec-rzyl)
Macugen (pegaptanib)
Marqibo (vincristine sulfate liposomal)
Mepsevii (vestronidase alfa-vjbk)
Mvasi (bevacizumab-awwb)
Mylotarg (gemtuzumab ozogamicin)
Naglazyme (galsulfase)
Neulasta (pegfilgrastim)
Neupogen (filgrastim)
Nivestym (filgrastim-aafi)
NPlate (romiplostim)
Nucala (mepolizumab)
Ocrevus (ocrelizumab)
Ogivri (trastuzumab-dkst)
Onivyde (irinotecan liposome injection)
Onpattro (patisiran lipid complex)
Ontruzant (trastuzumab-dttb)
Opdivo (nivolumab)
Orencia (abatacept) Intravenous IV only
Polivy (polatuzumab vedotin-piiq)
Perjeta (pertuzumab)
Portrazza (necitumumab)
Poteligeo (mogamulizumab-kpkc)
Procrit/Epogen (erythropoiesis stimulating agents (ESAs)
Provenge (sipuleucel-T)
Radicava (edaravone)
Remicade (infliximab)
Renflexis (infliximab-abda)
Retacrit (epoetin alfa-epbx)
Revcovi (elapegademase-lvlr)
Rituxan IV (rituximab)
Rituxan Hycela (rituximab and hyaluronidase human)
Ruconest (C1 Esterase Inhibitor [recombinant])
Ruxience (rituximab-pvvr)
Subcutaneous Immune Globulin (SCIG)
Hizentra
Gamunex-C
Gammaked
Gammagard liquid
HyQvia
Cuvitru
Cutaquig
Xembify
Simponi ARIA (golimumab)
Soliris (eculizumab)
Spinraza (nusinersen)
Stelara (ustekinumab)
Sustol (granisetron extended‐release)
Sylvant (siltuximab)
Synagis (palivizumab)
Tecentriq (atezolizumab)
Trazimera (trastuzumab-qyyp)
Trogarzo (ibalizumab-uiyk)
Truxima (rituximab-abbs)
Tysabri (natalizumab)
Udenyca (pegfilgrastim-cbqv)
Ultomiris (ravulizumab-cwvz)
Vectibix (panitumumab)
Velcade (bortezomib)
Vimizim (elosulfase alfa)
VPRIV (velaglucerase alfa)
Vyxeos (daunorubicin and cytarabine)
Xolair (omalizumab)
Yervoy (ipilimumab)
Yescarta (axicabtagene ciloleucel)
Yondelis (trabectedin)
Zirabev (bevacizumab-bvzr)
Zolgensma (onasemnogene abeparvovec-xioi)