Dean Health Clinical Guidelines

Coverage of any drug intervention discussed in the plans prior authorization guideline is subject to the limitations and exclusions outlined in the member's benefit certificate or policy and to applicable state and/or federal laws. Prior authorization is not required for Medicare Cost products (Dean Care Gold) and Medicare Supplement (Select) when this drug is provided by participating providers. Prior authorization is required if a member has Medicare primary and the plan secondary coverage. These policies are not applicable to our Medicare Replacement products.

 

Abecma (idecabtagene vicleucel) 

Abraxane (paclitaxel protein-bound particles)

Adcetris (brentuximab vedotin)

Akynzeo (fosnetupitant/palonosetron)

Aliqopa (copanlisib)

Aloxi (palonosetron)

Aranesp (darbepoetin alfa) 

Azedra (iobenguane I-131)

Bavencio (avelumab)

Beleodaq (belinostat) 

Bendamustine 

Treanda

Bendeka

Belrapzo

Besponsa (inotuzumab ozogamicin) 

Bevacizumab 

Avastin

Mvasi

Zirabev

Alymsys

Blenrep (belantamab mafodotin-blmf)

Blincyto (blinatumomab) 

Bortezmib

Breyanzi (lisocabtagene maraleucel)

Carvykti (ciltacabtagene autoleucel) 

Cosela (trilaciclib)

Cyramza (ramucirumab)

Danyelza (naxitamab-gqgk)

Darzalex IV (daratumumab)

Darzalex SQ (daratumumab and hyaluronidase-fihj)

Elzonris (tagraxofusp-erzs)

Empliciti (elotuzumab)

Enhertu (fam-trastuzumab deruxtecan-nxki)

Epoetin alfa

Epogen

Procrit

Reacrit

Erbitux alfa (cetuximab)

Filgrastim

Neupogen

Nivestym

Zarxio

Releuko

Granix

Fyarro (sirolimus albumin-bound)

Gazyva (obinutuzumab) 

Herceptin Hylecta (trastuzumab and hyaluronidase-oysk)

Imfinzi (durvalumab)

Imlygic (talimogene laherparepvec)

Infugem (gemcitabine)

Jelmyto (mitomycin)

Jemperli (dostarlimab-gxly)

Jevtana (cabazitaxel)

Kadcyla (ado-trastuzumab emtansine)

Keytruda (pembrolizumab)

Kymriah (tisagenlecleucel) 

Levoleucovorin

Fusilev

Khapzory

Libtayo (cemiplimab-rwlc) 

Lumoxiti (moxetumomab pasudotox-tdfk) 

Lutathera (lutetium Lu 177 dotatate)

Margenza (margetuximab-cmkb)

Marqibo (vincristine sulfate liposomal)

Monjuvi (tafasitamab-cxix) 

Mylotarg (gemtuzumab ozogamicin) 

Nplate (romiplostim) 

Onivyde (irinotecan liposome injection) 

Opdivo (nivolumab) 

Opdualag (nivolumab/relatlimab-rmbw)

Padcev (enfortumab vedotin-ejfv)

Pegfilgrastim

Neulasta

Fulphila

Udenyca

Ziextenzo

Nyvepria

Pemetrexed

Alimta

Pemfexy

Pepaxto (melphalan flufenamide) 

Perjeta (pertuzumab)

Phesgo (pertuzumab, trastuzumab and hyaluronidase-zzxf)

Pluvicto (lutetium Lu 177 vipivotide tetraxetan)

Polivy (polatuzumab vedotin-piiq)

Portrazza (necitumumab)

Poteligeo (mogamulizumab-kpkc)

Proleukin (aldesleukin, IL-2) 

Provenge (sipuleucel-T)

Rituximab IV

Rituxan

Truxima

Ruxience

Riabni

Rituximab SQ (rituximab and hyaluronidase human)

Rybrevant (amivantamab-vmjw)

Sandostatin LAR (octreotide suspension)

Sarclisa (isatuximab-irfc)

Sustol (granisetron extended-release)

Sylvant (siltuximab) 

Tecartus (brexucabtagene autoleucel) 

Tecentriq (atezolizumab)

Tivdak (tisotumab vedotin-tftv)

Trastuzumab

Herceptin

Ogivri

Kanjinti

Trazimera

Herzuma

Ontruzant

Trodelvy (sacituzumab govitecan-hziy)

Vectibix (panitumumab)

Velcade (bortezomib)

Vyxeos (daunorubicin and cytarabine – liposome)

Yervoy (ipilimumab) 

Yescarta (axicabtagene ciloleucel) 

Yondelis (trabectedin) 

Zepzelca (lurbinectedin) 

Zynlonta (loncastuximab tesirine-lpyl)