DMBA Clinical Guidelines for Drugs that Require Preauthorization by Magellan Rx Management

The following provides lists of medications for which preauthorization is required. This list is not all inclusive. Inclusion or exclusion of a medication on the preauthorization list does not guarantee coverage. Benefit coverage for any service is determined by the plan in which the participant is enrolled and applicable medical criteria.

Medical Prior Authorization

Abraxane (paclitaxel protein-bound particles)

Actemra (tocilizumab)

Acthar (corticotropin, ACTH)

Adcetris (brentuximab)

Akynzeo IV (fosnetupitant/palonosetron)

Aldurazyme (laronidase)

Alimta (pemetrexed)

Aliqopa (copanlisib)

Aloxi (palonosetron)

Alpha-1PI (proteinase inhibitor): 
Aralast,
Glassia,
Prolastin,
Zemaira

Aranesp (darbepoetin alfa)

Asparlas (calaspargase pegol-mknl)

Arzerra (ofatumumab)

Avastin (bevacizumab) 
For Oncology Indications Only

Avsola (Infliximab)

Bavencio (avelumab)

Beleodaq (belinostat) 

Bendamustine (bendamustine hcl): 
Bendeka,
Treanda

Bendamustine RTD (bendamustine hcl): 
Belrapzo

Benlysta (belimumab)

Besponsa (inotuzumab ozogamicin)

Blenrep (belantamab mafodotin-blmf)

Blincyto (blinatumomab)

Bortezomib (intravenous only)

Cerezyme (imiglucerase)

Cimzia (certolizumab pegol)

Cinqair (reslizumab)

Cyramza (ramucirumab)

Danyelza (naxitamab-gqgk)

Darzalex (daratumumab)

Elaprase (idursulfase)

Elelyso (taliglucerase alfa)

Elzonris ((tagraxofusp-erzs)

Empliciti (elotuzumab)

Enhertu (fam-trastuzumab deruxtecan-nxki)

Entyvio (vedolizumab)

Erbitux (cetuximab)

Erwinaze (asparainase)

Evenity (romosozumab-aqqg)

Fabrazyme (agalsidase beta)

Folotyn (pralatrexate)

Fulphila (pegefilfrastim-jmdb)

Gazyva (obinutuzumab)

Givlaari (givosiran)

Halaven (eribulin)

Herceptin (trastuzumab)

Herzuma (trastuzumab-pkrb)

Ilaris (canakinumab)

Imfinzi (durvalumab)

Imlygic (tamlimogene laherparepvec)

Inflectra (infliximab-dyyb)

Infugem (gemcitabine)

IVIG (immune globulin):

Asceniv
Bivigam,
Carimune NF,
Flebogamma/Flebogamma DIF,
Gammaplex,
Gamunex-C,
Gammaked,
Gammagard S/D,
Gammagard Liquid,
Octagam,
Panzyga,
Privigen

Istodax (romidepsin)

Jelmyto (mitomycin)

Jevtana (cabazitaxel)

Kadcyla (ado-trastuzumab emtansine)

Kalbitor (ecallantide)

Kanjinti  (trastuzumab-anns)

Kanuma (sebelipase alfa)

Keytruda (pembrolizumab)

Krystexxa (pegloticase)

Kyprolis (carfilzomib)

Lemtrada (alemtuzumab)

Levoleucovorin: 
Fusilev,
Khapzory

Libtayo (cemiplimab-rwlc)

Lumizyme (alglucosidase alfa)

Lumoxiti (moxetumomab pasudotox-tdfk)

Marqibo (vincristine liposomal)

Mepsevii (vestronidase alfa-vjbk)

Mircera  (methoxy polyethylene glycol-epoetin beta (non-esrd))

Monjuvi (tafasitamab-cxix)

Mozobil (plerixafor)

Mvasi (bevacizumab-awwb)

Mylotarg (gemtuzumab ozogamicin)

Naglazyme  (galsulfase)

Neulasta (pegfilgrastim)

Nplate (romiplostim)

Nucala (mepolizumab)

Nyvepria (pegfilgrastim)

Ocrevus (ocrelizumab)

Ogivri (trastuzumab-dkst)

Oncaspar  (pegaspargase)

Onivyde (irinotecan liposome)

Onpattro (patisiran lipid complex)

Ontruzant (Intravenous)

Opdivo (nivolumab)

Orencia (abatacept)

Padcev (enfortumab vedotin-ejfv)

Perjeta (pertuzumab)

Phesgo (pertuzumab, trastuzumab and hyaluronidase-zzxf)

Polivy (polatuzumab vedotin-piiq)

Poteligeo (mogamulizumab-kpkc)

Procrit/Epogen (epoetin alfa)

Prolia / Xgeva (denosumab)

Provenge  (sipuleucel-t)

Radicava (edaravone)

Reblozyl (luspatercept-aamt)

Remicade  (infliximab)

Renflexis (infliximab-abda)

Retacrit (epoetin alfa-epbx)

Revcovi (elapegademase-lvlr)

Riabni (rituximab)

Rituxan IV (rituximab)

Rituxan Hycela  (rituximab and hyaluronidase human)

Romidepsin (Intravenous)

Ruxience (rituximab-pvvr)

Sandostatin LAR (octreotide depot)

Sarclisa (isatuximab-irfc)

Scenesse (afamelanotide)

Simponi (golimumab)

Soliris (eculizumab)

Stelara (ustekinumab)

Sustol (granisetron extended-release)

Sylvant (siltuximab)

Synagis (palivizumab)

Synribo (omacetaxine)

Tecentriq (atezolizumab0)

Tepezza (teprotumumab-trbw)

Torisel (temsirolimus)

Trazimera (trastuzumab-qyyp)

Triptodur (triptorelin)

Trodelvy (sacituzumab govitecan-hziy)

Trogarzo (ibalizumab-uiyk)

Truxima (rituximab-abbs)

Tysabri (natalizumab)

Udenyca (pegfilgrastim‐cbqv)

Ultomiris (ravulizumab-cwvz)

Unituxin (dinutuximab)

Uplizna (inebilizumab-cdon)

Vectibix (panitumumab)

Velcade (bortezomib)

Vimizim (elosulfase alfa)

Vyxeos (daunorubicin and cytarabine, liposome)

Vpriv (velaglucerase alfa)

Xolair (omalizumab)

Yervoy (ipilimumab)

Yondelis (trabectedin)

Zaltrap (ziv-aflibercept)

Zepzelca (lurbinectedin)

Ziextenzo (Pegfilgrastim)

Zirabev (bevacizumab-awwb)

Zolgensma (onasemnogene abeparvovec-xioi)

 

Medical Pharmacy Claims Edit Policies

Beovu (brolucizumab-dbll)

Botox  (onabotulinumtoxina)

Cinvanti (aprepitant)

Doxorubicin Liposomal (Doxil, Lipodox) (doxorubicin))

Dysport (abobotulinumtoxina)

Eloxatin (oxaliplatin)

Emend  (fosaprepitant)

Eylea (aflibercept)

Faslodex (fulvestrant)

Fensolvi (leuprolide)

Granix (tbo-filgrastim)

Hyaluronic Acid Derivatives:
(Euflexxa, Synvisc/Synvisc-One) 

Hycamtin (topotecan)

Iluvien (fluocinolone acetonide intravitreal implant)

Leukine (sargramostim)

Lucentis (ranibizumab)

Lupron Depot  Eligard (leuprolide acetate (for depot suspension))

Macugen (pegaptanib sodium)

Myobloc (rimabotulinumtoxinb)

Neupogen (filgrastim)

Nivestym (filgrastim-aafi)

Retisert (Fluocinolone acetonide intravitreal implant)

Taxotere /Docefrez (docetaxel)

Trelstar (triptorelin pamoate)

Vantas (histrelin acetate)

Xeomin (incobotulinumtoxina)

Yutiq (fluocinolone acetonide implant)

Zarxio (filgrastim-sndz)

Zoladex (goserelin acetate implant)