Security Health Plan Clinical Guidelines

Medical Prior Auth and Claims Edits

Abraxane J9264
(paclitaxel protein-bound particles)

Actemra J3262
(tocilizumab)

Acthar J0800
(corticotropin, ACTH)

Adcetris J9042
(brentuximab)

Alimta J9305
(pemetrexed)

Aloxi J2469
(palonosetron)

Aranesp J0881
(darbepoetin alfa)

Arzerra J9302
(ofatumumab)

Avastin J9035
(bevacizumab)

Beleodaq J9032
(belinostat)

Bendeka J9034 
(bendamustine hcl)

Benlysta J0490
(belimumab)

Berinert J0597
(C1 Esterase Inhibitor Human)

Blincyto J9039
(blinatumomab)

Cimzia J0717
(certolizumab pegol)

Cinqair J2786
(reslizumab)

Cinryze J0598
(C1 Esterase Inhibitor Human)

Cyramza J9308
(ramucirumab)

Darzalex J9145
(daratumumab)

Empliciti J9176
(elotuzumab)

Entyvio J3380
(vedolizumab)

Erbitux J9055
(cetuximab)

Firazyr J1744
(icatibant)

Fusilev J0641
(levoleucovorin)

Gazyva J9301
(obinutuzumab)

Halaven J9179
(eribulin)

Herceptin J9355
(trastuzumab)

Inflectra Q5102
(infliximab-dyyb)

IVIG (immune globulin):
(Bivigam J1556,
Carimune NF J1566,
Flebogamma/Flebogamma DIF J1572,
Gammaplex J1557,
Gamunex-C J1561,
Gammaked J1561,
Gammagard S/D J1566,
Gammagard Liquid J1569,
Octagam J1568,
Privigen J1459)

Jevtana J9043
(cabazitaxel)

Kadcyla J9354
(ado-trastuzumab emtansine)

Kalbitor J1290
(ecallantide)

Keytruda J9271
(pembrolizumab)

Krystexxa J2507
(pegloticase)

Kyprolis J9047
(carfilzomib)

Lemtrada J0202
(alemtuzumab)

Marqibo J9371
(vincristine sulfate liposomal)

Neupogen J1442
(filgrastim)

Nplate J2796
(romiplostim)

Nucala J2182
(mepolizumab)

Onivyde J9205
(irinotecan liposome injection)

Opdivo J9299
(nivolumab)

Orencia J0129
(abatacept)

Perjeta J9306
(pertuzumab)

Portrazza J9295
(necitumumab)

Procrit/Epogen J0885
(epoetin alfa)

Prolia/Xgeva J0897
(denosumab)

Provenge Q2043
(sipuleucel-T)

Remicade J1745
(infliximab)

Renflexis Q5102
(infliximab-abda)

Rituxan J9310
(rituximab)

Ruconest J0596
(C1 Esterase Inhibitor [recombinant])

Sandostatin LAR J2353
(octreotide)

SCIG (immune globulin SQ):
(Cuvitru J3590,
Hizentra J1559,
Gammagard Liquid J1569,
Gamunex-C J1561,
Gammaked J1561,
Hyqvia J1575)

Simponi ARIA J1602
(golimumab)

Soliris J1300
(eculizumab)

Stelara J3357
(ustekinumab)

Stelara IV Q9989
(ustekinumab)

Sylvant J2860
(siltuximab)

Synribo J9262
(omacetaxine)

Treanda J9033
(bendamustine)

Tysabri J2323
(natalizumab)

Vectibix J9303
(panitumumab)

Xolair J2357
(omalizumab)

Yervoy J9228
(ipilimumab)

Yondelis J9352
(trabectedin)

Zaltrap J9400
(ziv-aflibercept)

 

 

View the Security Health Plan post service claim edit policies.