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)
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)
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)
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)
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)
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)
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)