Common Ground Healthcare Cooperative Prior Authorization Guidelines 

Medical Prior Auth 

Abecma
(Idecabtagene vicleucel)

Abraxane
(paclitaxel protein-bound particles)

Actemra
(tocilizumab)

Adakveo

(crizanlizumab-tmca)

Adbry
(tralokinumab-ldrm)

Adcetris
(brentuximab)

Akynzeo IV
(netupiant and palonosetron)

Aldurazyme
(laronidase)

Amondys-45
(casimersen)

Aranesp
(darbepoetin alfa)

Arzerra
(ofatumumab)

Asparlas
(calaspargase pegol-mknl)

Bavencio
(avelumab)

Beleodaq
(belinostat)

Bendamustine:
Belrapzo RTD
Bendeka
Treanda

Benlysta IV
(belimumab)

Berinert
(C1 Esterase Inhibitor Human)

Bevacizumab:
Avastin
Mvasi
Zirabev
Alymsys

Blenrep
(belantamab mafodotin-blmf)

Blincyto
(blinatumomab)

Breyanzi
(lisocabtagene maraleucel)

Brineura
(cerliponase alfa)

Carvykt
(ciltacabtagene autoleucel)

Cerezyme
(imiglucerase)

Cimzia
(certolizumab pegol)

Cinqair
(reslizumab)

Cinryze
(C1 Esterase Inhibitor Human)

Corticotropin‐ACTH

Cosela
(trilaciclib)

Cosentyx
(secukinumab)

Crysvita
(burosumab-twza)

Cyramza
(ramucirumab)

Danyelza
(naxitamab-gqgk)

Darzalex
(daratumumab)

Darzalex Faspro
(daratumumab and hyaluronidase-fihj)

Daurismo
(glasdegib)

Elaprase
(idursulfase)

Elelyso
(taliglucerase alfa)

Elzonris
(tagraxofusp-resz)

Empliciti
(elotuzumab)

Enhertu
(fam-trastuzumab deruxtecan-nxki)

Enjaymo
(sutimlimab-jome)

Entyvio
(vedolizumab)

Epotein Alfa (Non Dialysis)
Epogen
Procrit
Retacrit

Erbitux
(cetuximab)

Evenity
(romozozumab-aqqg)

Evkeeza
(evinacumab-dgnb)

Exondys-51
(eteplirse)

Fabrazyme
(agalsidase beta)

Fasenra
(benralizumab)

Filgrastims:
Granix (Tbo-Filgrastim)
Neupogen (Filgrastim)
Nivestym (Filgrastim-aafi)
Releuko (Tbo‐Filgrastim)

Firazyr
(icatibant)

Fyarro
(sirolimus albumin-bound nanoparticles)

Gamifant
(emapalumab-lzsg)

Gazyva
(obinutuzumab)

Givlaar
(givosiran)

Haegarda
(C1 Esterase Inhibitor (Human))

Halaven
(eribulin)

Ilumya
(tildrakizumab-asmn)

Imfinzi
(durvalumab)

Imlygic
(talimogene laherparepvec)

Infliximab:
Avsola
Inflectra
Remicade
Renflexis

Infugem
(gemcitabine)

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)

Kymriah
(tisagenlecleucel)

Kyprolis
(carfilzomib)

Lemtrada
(alemtuzumab)

Leqvio
(inclisiran)

Leuprolide Suspension:
Lupron
Lupron Depot-Ped
Eligard
Fensolvi
Camcevi

Libtayo
(cemiplimab-rwlc)

Lumakras
(sotorasib)

Lumizyme
(alglucosidase alfa)

Lumoxiti
(moxetumomabpasudotox-tdfk)

Lutathera
(lutetium Lu 177 dotatate)

Luxturna
(voretigene neparvovec-rzyl)

Margenza
(margetuximab-cmkb)

Marqibo
(vincristine sulfate liposomal)

Mepsevii
(vestronidase alfa-vjbk)

Mircera
(methoxy polyethylene glycol-epoetin beta)

Monjuvi
(tafasitamab-cxix)

Mozobil
(plerixafor)

Naglazyme
(galsulfase)

Nexviazyme
(avalglucosidase alfa‐ngpt)

Nplate
(romiplostim)

Nucala
(mepolizumab)

Ocrevus
ocrelizumab

Oncaspar
(pegaspargase)

Onivyde
(irinotecan liposome injection)

Onpattro
(patisiran)

Opdivo
(nivolumab)

Opdualag
(nivolumab/relatlimab-rmbw)

Orencia
(abatacept)

Oxlumo
(lumasiran)

Padcev
(enfortumab vedotin-ejfv)

Pegfilgrastim:
Neulasta
Fulphila
Udenyca

Pemetrexed:
Alimta
Pemfexy

Perjeta
(pertuzumab)

Polivy
(polatuzumab vedotinpiiq)

Portrazza
(necitumumab)

Poteligeo
(mogamulizumab-kpkc)

Prolia/Xgeva
(denosumab)

Provenge
(sipuleucel-T)

Radicava
(edaravone)

Reblozyl
(luspatercept-aamt)

Revcovi
(elapegademase-lvlr)

Rituxan IV
(rituximab)

Rituxan Hycela
(rituximab and hyaluonidase human)

Ruconest
(C1 Esterase Inhibitor [recombinant])

Rybrevant
(amivantamab‐vmjw)

Rylaze
(asparaginase Erwinia chrysanthemi (recombinant)‐rywn)

Ryplazim
(plasminogen, human-tvmh)

Sandostatin LAR
(octreotide)

Saphnelo
(anifrolumab‐fnia)

Sarclisa
(isatuximab-irfc)

Scenesse
(afamelanotide)

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

Signifor LAR
(pasireotide)

Simponi ARIA
(golimumab)

Soliris
(eculizumab)

Somatuline Depot
(lanreotide)

Spinraza
(nusinersen)

Stelara
(ustekinumab)

Susvimo
(ranibizumab)

Sylvant
(siltuximab)

Synagis
(Palivizumab)

Synribo
(omacetaxine)

Takhzyro
(Lanadelumab-flyo)

Tecartus
(brexucabtagene autoleucel)

Tecentriq
(atezolizumab)

Tepezza
(teprotumumab-trbw)

Tezspire
(tezepelumab-ekko)

Tivdak
(tisotumab vedotin-tftv)

Trastuzumab:

Herceptin
Herzuma
Kanjinti
Ogivri
Ontruzant
Trazimera

Trastuzumab and hyaluronidase-oysk
(Herceptin Hylecta)

Trelstar
(triptorelin)

Trodelvy
(sacituzumab govitecan-hziy)

Tysabri
(natalizumab)

Ultomiris
(ravulizumab-cwvz)

Uplizna
(inebilizumab-cdon)

Vabysmo
(faricimab‐svoa)

Vectibix
(panitumumab)

Vidaza
(Azacitidine)

Viltepso
(viltolarsen)

VPRIV
(velaglucerase alfa)

Vyepti
(eptinezumab-jjmr)

Vyondys-53
(golodirsen)

Vyvgart
(efgartigimod alfa-fcab)

Xipere
(triamcinolone acetonide)

Xolair
(omalizumab)

Yervoy
(ipilimumab)

Yescarta
(axicabtagene ciloleucel)

Yondelis
(trabectedin)

Zaltrap
(ziv-aflibercept)

Zepzelca
(lurbinectedin)

Zolgensma
(onasemnogene abeparvovec-xioi)

Zynlonta
(loncastuximab tesirine‐lpyl)