Bright Healthcare Clinical Guidelines
Disclaimer: Clinical criteria and medical policies address technology assessment of new and emerging treatments and drugs. These policies are developed to assist in administering plan benefits and do not constitute an offer of coverage nor medical advice. Bright Health medical policies contain only a partial, general description of plan or program benefits and do not constitute a contract. Bright Health does not provide health care services and, therefore, cannot guarantee any results or outcomes. Treating providers are solely responsible for medical advice and treatment of members. Our medical policies may be updated and therefore are subject to change without notice.
Before using this policy, please check the member benefit plan document and any federal or state mandates, if applicable. Policies and practices are compliant with all federal and state requirements, including mental health parity laws.
If there is a difference between this policy and the member specific plan document, the member benefit plan document will govern. For Medicare Advantage members, to ensure consistency with the Medicare National Coverage Determinations (NCD) and Local Coverage Determinations (LCD), all applicable NCDs, LCDs, and Medicare Coverage Articles should be reviewed and applied prior to using the criteria set forth in this medical policy. Refer to the CMS website at http://www.cms.gov for additional information
Medical Pharmacy Prior Authorization
Abraxane
(paclitaxel protein-bound particles)
Actemra IV
(tocilizumab)
Acthar
(corticotropin)
Adcetris
(brentuximab vedotin)
Aduhelm
(aducanumab)
Akynzeo
(fosnetupitant/palonosetron)
Aldurazyme
(laronidase)
Aloxi
(palonosetron)
Amondys-45
(casimersen)
Aranesp
(darbepoetin alfa)
Arzerra
(ofatumumab)
Bavencio
(avelumab)
Bendamustine:
Belrapzo RTD
Bendeka
Treanda
Benlysta IV
(belimumab)
Berinert
(C1 Esterase Inhibitor Human)
Besponsa
(inotuzumab ozogamicin)
Bevacizumab:
Avastin
Mvasi
Zirabev
Blenrep
(belantamab mafodotin-blmf)
Blincyto
(blinatumomab)
Brineura
(cerliponase alfa)
Cerezyme
(imiglucerase)
Cimzia
(certolizumab pegol)
Cinqair
(reslizumab)
Cinryze
(C1 Esterase Inhibitor Human)
Cyramza
(ramucirumab)
Darzalex
(daratumumab)
Darzalex Faspro
(daratumumab and hyaluronidase-fihj)
Denosumab:
Prolia
Xgeva
Elaprase
(idursulfase)
Elelyso
(taliglucerase alfa)
Empliciti
(elotuzumab)
Enhertu
(fam-trastuzumab deruxtecan-nxki)
Enjaymo
(sutimlimab-jome)
Entyvio
(vedolizumab)
Epoetin alfa:
Epogen
Procrit
Retacrit
Erbitux
(cetuximab)
Evenity
(romozozumab-aqqg)
Exondys-51
(eteplirse)
Fabrazyme
(agalsidase beta)
Fasenra
(benralizumab)
Filgrastims:
Granix
Neupogen
Nivestym
Releuko
Zarxio
Gazyva
(obinutuzumab)
Halaven
(eribulin)
Herceptin Hylecta
(trastuzumab-hyaluronidase-oysk)
Ilumya
(tildrakizumab-asmn)
Imfinzi
(durvalumab)
Infliximab:
Remicade
Renflexis
Avsola
Inflectra
IVIG (immune globulin):
Asceniv
Bivigam
Carimune NF
Flebogamma/Flebogamma DIF
Gammaplex
Gamunex-C
Gammaked
Gammagard S/D
Gammagard Liquid
Octagam
Panzyga
Privigen
Jemperli
(dostarlimab‐gxly)
Jevtana
(cabazitaxel)
Kadcyla
(ado-trastuzumab emtansine)
Kalbitor
(ecallantide)
Kanuma
(sebelipase alfa)
Keytruda
(pembrolizumab)
Kimmtrak
(tebentafusp-tebn)
Krystexxa
(pegloticase)
Kyprolis
(carfilzomib)
Lemtrada
(alemtuzumab)
Levoleucovorin:
Fusilev
Khapzory
Libtayo
(cemiplimab-rwlc)
Lumizyme
(alglucosidase alfa)
Luxturna
(voretigene neparvovec-rzyl)
Margenza
(margetuximab-cmkb)
Mepsevii
(vestronidase alfa-vjbk)
Naglazyme
(galsulfase)
Nexviazyme
(avalglucosidase alfa-ngpt)
Nplate
(romiplostim)
Nucala
(mepolizumab)
Nulibry
(fosdenopterin)
Ocrevus
(ocrelizumab)
Onivyde
(irinotecan liposome injection)
Opdivo
(nivolumab)
Opdualag
(nivolumab/relatlimab-rmbw)
Orencia IV
(abatacept)
Pegfilgrastim:
Neulasta
Nyvepria
Ziextenzo
Fulphila
Udenyca
Pemetrexed:
Alimta
Pemfexy
Perjeta
(pertuzumab)
Phesgo
(pertuzumab, trastuzumab and hyaluronidase-zzxf)
Poteligeo
(mogamulizumab-kpkc)
Revcovi
(elapegademase-lvlr)
Rituxan Hycela
(rituximab and hyaluonidase human)
Rituximab:
Rituxan
Truxima
Ruxience
Riabni
Ruconest
(C1 Esterase Inhibitor [recombinant])
Rybrevant
(amivantamab‐vmjw)
Rylaze
(asparaginase Erwinia chrysanthemi (recombinant)-rywn)
Sandostatin LAR
(octreotide suspension)
Saphnelo
(anifrolumab-fnia)
Sarclisa
(isatuximab-irfc)
SCIG (immune globulin SQ):
Cutaquig
Cuvitru
Hizentra
Hyqvia
Xembify
Simponi ARIA
(golimumab)
Soliris
(eculizumab)
Spinraza
(nusinersen)
Stelara
(ustekinumab)
Strensiq
(asfotase alfa)
Sustol
(graniestron extended-release)
Tecentriq
(atezolizumab)
Tepezza
(teprotumumab-trbw)
Tivdak
(tisotumab vedotin-tftv)
Trastuzumab:
Herceptin
Ogivri
Kanjinti
Trazimera
Herzuma
Ontruzant
Trodelvy
(sacituzumab govitecan-hziy)
Tysabri
(natalizumab)
Ultomiris
(ravulizumab-cwvz)
Uplizna
(inebilizumab-cdon)
Vectibix
(panitumumab)
Viltepso
(viltolarsen)
Vimizim
(elosulfase alfa)
Vpriv
(velaglucerase alfa)
(eptinezumab-jjmr)
Vyondys-53
(golodirsen)
(efgartigimod alfa-fcab)
Xolair
(omalizumab)
Yervoy
(ipilimumab)
Yondelis
(trabectedin)
Zaltrap
(ziv-aflibercept)
Zolgensma
(onasemnogene abeparvovac-xioi)
Zynlonta
(loncastuximab tesirine‐lpyl)