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)

Aldurazyme J1931
(laronidase)

Alimta J9305
(pemetrexed)

Aloxi J2469
(palonosetron)

Aranesp J0881
(darbepoetin alfa)

Arzerra J9302
(ofatumumab)

Avastin J9035
(bevacizumab)

Bavencio J9023
(avelumab)

Beleodaq J9032
(belinostat)

Bendeka J9034 
(bendamustine hcl)

Benlysta J0490
(belimumab)

Berinert J0597
(C1 Esterase Inhibitor Human)

Blincyto J9039
(blinatumomab)

Cerezyme J1786
(imiglucerase)

Cimzia J0717
(certolizumab pegol)

Cinqair J2786
(reslizumab)

Cinryze J0598
(C1 Esterase Inhibitor Human)

Cyramza J9308
(ramucirumab)

Darzalex J9145
(daratumumab)

Elaprase J1743
(idursulfase)

Elelyso J3060
(taliglucerase alfa)

Empliciti J9176
(elotuzumab)

Entyvio J3380
(vedolizumab)

Erbitux J9055
(cetuximab)

Fabrazyme J0180
(agalsidase beta)

Firazyr J1744
(icatibant)

Fulphila Q5108
(pegefilgrastim-jmdb)

Fusilev J0641
(levoleucovorin)

Gazyva J9301
(obinutuzumab)

Halaven J9179
(eribulin)

Herceptin J9355
(trastuzumab)

Inflectra Q5103
(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)

Lumizyme J0221
(alglucosidase alfa)

Marqibo J9371
(vincristine sulfate liposomal)

Naglazyme J1458
(galsulfase)

Neulasta J2505
(pegfilgrastim)

Neupogen J1442
(filgrastim)

Nplate J2796
(romiplostim)

Nucala J2182
(mepolizumab)

Ocrevus J2350
(ocrelizumab)

Oncaspar J9266
(pegaspargase)

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 J1555,
Hizentra J1559,
Gammagard Liquid J1569,
Gamunex-C J1561,
Gammaked J1561,
Hyqvia J1575)

Simponi ARIA J1602
(golimumab)

Soliris J1300
(eculizumab)

Stelara J3357, Q9989 
(ustekinumab)

Sustol J1627
(granisetron extended-release)

Sylvant J2860
(siltuximab)

Synribo J9262
(omacetaxine)

Tecentriq J9022
(atezolizumab)

Treanda J9033
(bendamustine)

Tysabri J2323
(natalizumab)

Vectibix J9303
(panitumumab)

Vpriv J3385
(velaglucerase alfa)

Xolair J2357
(omalizumab)

Yervoy J9228
(ipilimumab)

Yondelis J9352
(trabectedin)

Zaltrap J9400
(ziv-aflibercept)

 

 

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