Common Ground Healthcare Cooperative Prior Authorization Guidelines
Medical Prior Auth
Abecma
(Idecabtagene vicleucel)
Abraxane
(paclitaxel protein-bound particles)
Actemra
(tocilizumab)
(crizanlizumab-tmca)
Adbry
(tralokinumab-ldrm)
Adcetris
(brentuximab)
Akynzeo IV
(netupiant and palonosetron)
Aldurazyme
(laronidase)
Amondys-45
(casimersen)
Amvuttra
(vutrisiran)
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)
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)
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)
Ocrevus
ocrelizumab
Oncaspar
(pegaspargase)
Onivyde
(irinotecan liposome injection)
Onpattro
(patisiran)
Opdivo
(nivolumab)
Opdualag
(nivolumab/relatlimab-rmbw)
Orencia
(abatacept)
Oxlumo
(lumasiran)
Padcev
(enfortumab vedotin-ejfv)
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
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)
Yervoy
(ipilimumab)
Yescarta
(axicabtagene ciloleucel)
Yondelis
(trabectedin)
Zaltrap
(ziv-aflibercept)
Zepzelca
(lurbinectedin)
Zolgensma
(onasemnogene abeparvovec-xioi)
Zynlonta
(loncastuximab tesirine‐lpyl)