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

Adakveo (crizanlizumab-tmca)

Adcetris (brentuximab)

Akynzeo (fosnetupitant/palonosetron)

Aldurazyme (laronidase)

Alimta (pemetrexed)

Aliqopa (copanlisib)

Aloxi (palonosetron)

Aranesp (darbepoetin alfa)

Avsola (infliximab-axxq)

Azedra (iobenguane)

Bavencio (avelumab)

Beleodaq (belinostat)

Bendamustine (bendamustine hcl):

Belrapzo

Bendeka

Treanda

Benlysta IV (belimumab)

Beovu (brolucizumab-dbll)

Berinert (C1 esterase inhibitor human)

Besponsa (inotuzumab ozogamicin)

Bevacizumab

Avastin 

Mvasi

Zirabev

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)

Darzalex Faspro (daratumumab and hyaluronidase- fihi)

Elaprase (idursulfase)

Elelyso (taliglucerase alfa)

Elzonris (tagraxofusp-erzs)

Empliciti (elotuzumab)

Enhertu (fam-trastuzumab deruxtecan-nxki)

Entyvio (vedolizumab)

Epoetin (erythropoiesis stimulating agents (ESAs)

Procrit

Epogen

Retacrit

Erbitux (cetuximab)

Evenity (romosozumab-aqqg)

Exondys-51 (eteplirsen)

Eylea (aflibercept)

Fabrazyme (agalsidase beta)

Fasenra (benralizumab)

Filgrastim

Granix

Neupogen

Nivestym

Firazyr (icatibant)

Gamifant (emapalumab-lzsg)

Gazyva (obinutuzumab)

Givlaari (givosiran)

Herceptin Hylecta (trastuzumab and hyaluronidase-oysk)

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

Jelmyto (mitomycin)

Jevtana (cabazitaxel)

Kadcyla (ado-trastuzumab emtansine)

Kalbitor (ecallantide)

Kanuma (sebelipase alfa)

Keytruda (pembrolizumab)

Krystexxa (pegloticase)

Kymriah (tisagenlecleucel)

Lartruvo (olaratumab)

Lemtrada (alemtuzumab)

Levoleucovorin

Fusilev 

Khapzory

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)

Mylotarg (gemtuzumab ozogamicin)

Naglazyme (galsulfase)

NPlate (romiplostim)

Nucala (mepolizumab)

Ocrevus (ocrelizumab)

Onivyde (irinotecan liposome injection)

Onpattro (patisiran lipid complex)

Opdivo (nivolumab)

Orencia (abatacept) Intravenous IV only

Padcev (enfortumab vedotin-ejfv)

Pegfilgrastim

Neulasta

Fulphila

Udenyca

Ziextenzo

Perjeta (pertuzumab)

Polivy (polatuzumab vedotin-piiq)

Portrazza (necitumumab)

Poteligeo (mogamulizumab-kpkc)

Provenge (sipuleucel-T)

Radicava (edaravone)

Reblozyl (luspatercept-aamt)

Remicade (infliximab)

Renflexis (infliximab-abda)

Revcovi (elapegademase-lvlr)

Rituximab

Rituxan

Truxima

Ruxience

Rituxan Hycela (rituximab and hyaluronidase human)

Ruconest (C1 Esterase Inhibitor [recombinant])

Sarclisa (isatuximab irfc)

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)

Tepezza (teprotumumab-trbw)

Trastuzumab

Herceptin

Herzuma

Kanjinti

Ogivri

Ontruzant

Trazimera

Trodelvy (sacituzumab govitecan-hziy)

Trogarzo (ibalizumab-uiyk)

Truxima (rituximab-abbs)

Tysabri (natalizumab)

Ultomiris (ravulizumab-cwvz)

Vectibix (panitumumab)

Velcade (bortezomib)

Vimizim (elosulfase alfa)

VPRIV (velaglucerase alfa)

Vyepti (eptinezumab-jjmr)

Vyondys 53 (golodirsen)

Vyxeos (daunorubicin and cytarabine)

Xolair (omalizumab)

Yervoy (ipilimumab)

Yescarta (axicabtagene ciloleucel)

Yondelis (trabectedin)

Zolgensma (onasemnogene abeparvovec-xioi)