Security Health Plan Clinical Guidelines

 

Effective April 1st 2019 - The following drugs will require Prior Authorization; Crysvita, Haegarda, Radicava, Akynzeo IV, Imfinzi, Fasenra, and Vidaza. The prior authorization request window for these drugs will open Friday, March 15th, 2019.”

Effective May 1st 2019 - Step Therapy requirements for Medicare outpatient (Part B) medications

Medical Prior Auth and Claims Edits

Abraxane 
(paclitaxel protein-bound particles)

Actemra
(tocilizumab)

Acthar Gel
(corticotropin, ACTH)

Adcetris
(brentuximab)

Akynzeo IV
(netupiant and palonosetron)

Aldurazyme
(laronidase)

Alimta 
(pemetrexed)

Aloxi 
(palonosetron)

Aranesp
(darbepoetin alfa)

Arzerra
(ofatumumab)

Avastin
(bevacizumab)

Bavencio
(avelumab)

Beleodaq
(belinostat)

Bendamustine (bendamustine hcl):
Bendeka
Treanda

Benlysta IV 
(belimumab)

Berinert
(C1 Esterase Inhibitor Human)

Blincyto
(blinatumomab)

Cerezyme
(imiglucerase)

Cimzia
(certolizumab pegol)

Cinqair
(reslizumab)

Cinryze 
(C1 Esterase Inhibitor Human)

Crysvita
(burosumab-twza)

Cyramza
(ramucirumab)

Darzalex
(daratumumab)

Elaprase
(idursulfase)

Elelyso
(taliglucerase alfa)

Empliciti
(elotuzumab)

Entyvio 
(vedolizumab)

Erbitux
(cetuximab)

Exondys-51
(eteplirse)

Eylea
(aflibercept)

Fabrazyme 
(agalsidase beta)

Fasenra 
(benralizumab)

Firazyr
(icatibant)

Fulphila
(pegefilgrastim-jmdb)

Fusilev
(levoleucovorin)

Gazyva
(obinutuzumab)

Haegarda
(C1 Esterase Inhibitor (Human))

Halaven
(eribulin)

Herceptin
(trastuzumab)

Imfinzi 
(durvalumab)

Inflectra
(infliximab-dyyb)

IVIG (immune globulin):
(Bivigam,
Carimune NF,
Flebogamma/Flebogamma DIF,
Gammaplex,
Gamunex-C,
Gammaked,
Gammagard S/D,
Gammagard Liquid,
Octagam,
Privigen)

Jevtana 
(cabazitaxel)

Kadcyla
(ado-trastuzumab emtansine)

Kalbitor
(ecallantide)

Keytruda
(pembrolizumab)

Krystexxa 
(pegloticase)

Kyprolis
(carfilzomib)

Lemtrada 
(alemtuzumab)

Lucentis
(Ranibizumab)

Lumizyme 
(alglucosidase alfa)

Macugen
(pegaptanib)

Marqibo 
(vincristine sulfate liposomal)

Mozobil
(plerixafor)

Naglazyme 
(galsulfase)

Neulasta 
(pegfilgrastim)

Neupogen 
(filgrastim)

Nplate
(romiplostim)

Nucala
(mepolizumab)

Ocrevus 
(ocrelizumab)

Oncaspar 
(pegaspargase)

Onivyde 
(irinotecan liposome injection)

Opdivo
(nivolumab)

Orencia
(abatacept)

Perjeta
(pertuzumab)

Portrazza
(necitumumab)

Procrit/Epogen
(epoetin alfa)

Prolia/Xgeva
(denosumab)

Provenge
(sipuleucel-T)

Radicava
(edaravone)

Remicade
(infliximab)

Renflexis
(infliximab-abda)

Rituxan IV
(rituximab)

Ruconest
(C1 Esterase Inhibitor [recombinant])

Sandostatin LAR
(octreotide)

SCIG (immune globulin SQ):
(Cuvitru,
Hizentra,
Gammagard Liquid,
Gamunex-C,
Gammaked,
Hyqvia)

Simponi ARIA 
(golimumab)

Soliris
(eculizumab)

Spinraza
(nusinersen)

Stelara
(ustekinumab)

Sustol
(graniestron extended-release)

Sylvant
(siltuximab)

Synagis
(Palivizumab)

Synribo
(omacetaxine)

Tecentriq
(atezolizumab)

Tysabri
(natalizumab)

Vectibix
(panitumumab)

Vidaza
(Azacitidine)

VPRIV
(velaglucerase alfa)

Xolair
(omalizumab)

Yervoy
(ipilimumab)

Yondelis
(trabectedin)

Zaltrap 
(ziv-aflibercept)

View the Security Health Plan post service claim edit policies.