Common Ground Healthcare Cooperative Prior Authorization Guidelines 

Medical Prior Auth 

Abraxane  (paclitaxel protein-bound particles)

Actemra (tocilizumab)

Acthar Gel (corticotropin, ACTH) 

Adakveo (crizanlizumab-tmca)

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

Blenrep (belantamab mafodotin-blmf)

Blincyto (blinatumomab)

Brineura (cerliponase alfa)

Cerezyme (imiglucerase)

Cimzia (certolizumab pegol)

Cinqair (reslizumab)

Cinryze  (C1 Esterase Inhibitor Human)

Cosela (trilaciclib)

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) 

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)

Firazyr (icatibant)

Gamifant (emapalumab-lzsg)

Gazyva (obinutuzumab)

Givlaar  (givosiran)

Haegarda (C1 Esterase Inhibitor (Human))

Halaven (eribulin)

Ilumya (tildrakizumab-asmn)

Imfinzi  (durvalumab)

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)

Krystexxa  (pegloticase)

Kyprolis (carfilzomib)

Lemtrada  (alemtuzumab)

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)

Margenza (margetuximab-cmkb)

Marqibo  (vincristine sulfate liposomal)

Mepsevii (vestronidase alfa-vjbk)

Monjuvi (tafasitamab-cxix)

Mozobil (plerixafor)

Naglazyme (galsulfase)

Nplate (romiplostim)

Nucala (mepolizumab)

Oncaspar  (pegaspargase)

Onivyde  (irinotecan liposome injection)

Onpattro (patisiran)

Opdivo (nivolumab)

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)

Sandostatin LAR (octreotide)

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)

Sylvant (siltuximab)

Synagis (Palivizumab)

Synribo (omacetaxine)

Takhzyro (Lanadelumab-flyo)

Tecentriq (atezolizumab) 

Tepezza (teprotumumab-trbw)

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)

Vectibix (panitumumab)

Vidaza (Azacitidine)

Viltepso  (viltolarsen)

VPRIV (velaglucerase alfa) 

Vyepti (eptinezumab-jjmr)

Vyondys-53 (golodirsen)

Xolair (omalizumab)

Yervoy (ipilimumab)

Yondelis (trabectedin)

Zaltrap  (ziv-aflibercept) 

Zynlonta (loncastuximab tesirine‐lpyl)