Medication Center

Health New England Clinical Guidelines

Medical Prior Auth

Abraxane
(paclitaxel protein-bound particles)

Actemra
(tocilizumab)

Acthar HP
(corticotropin, ACTH)

Adakveo
(crizanlizumab-tmca)

Adcetris
(brentuximab)

Akynzeo IV 
(fosnetupitant/palonosetron)

Aldurazyme 
(laronidase)

Aliqopa 
(copanlisib)

Aloxi 
(palonosetron)

Alpha-1-Proteinase Inhibitors
Aralast NP
Glassia
Prolastin-C
Zemaira

Amondys-45
(casimersen)

Amvuttra
(vutrisiran)

Aranesp
(darbepoetin alfa)

Arzerra
(ofatumumab)

Asparlas
(calaspargase pegol-mknl)

Bavencio
(avelumab)

Beleodaq
(belinostat)

Bendamustine (bendamustine hcl)
Belrapzo
Bendeka
Treanda
Vivimusta

Benlysta IV 
(belimumab)

Beovu
(brolucizumab-dbll)

Berinert
(C1 Esterase Inhibitor Human)

Besponsa
(inotuzumab ozogamicin)

Bevacizumab
Avastin
Mvasi
Zirabev

Blenrep
(belantamab mafodotin‐blmf)

Blincyto
(blinatumomab)

Bortezomib
(bortezomib Injection)

Botox
(onabotulinumtoxinA)

Brineura
(cerliponase alfa)

Briumvi
(ublituximab-xiiy)

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)

Dysport
(abobotulinumtoxinA)

Elaprase
(idursulfase)

Elelyso
(taliglucerase alfa)

Elzonris
(tagraxofusp-erzs)

Empliciti
(elotuzumab)

Enhertu
(fam-trastuzumab deruxtecan-nxki)

Enjaymo
(sutimlimab-jome)

Entyvio
(vedolizumab)

Erbitux
(cetuximab)

Evenity
(romosozumab-aqqg)

Evkeeza
(evinacumab-dgnb)

Evomela 
(melphalan)

Exondys 51
(eteplirsen)

Eylea
(aflibercept)

Fabrazyme
(agalsidase beta)

Fasenra
(benralizumab)

Faslodex
(fulvestrant)

Fensolvi
(leuprolide suspension)

Filgrastims
Neupogen (Filgrastim)
Granix (Tbo-Filgrastim)
Zarxio (Filgrastim-sndz)

Firazyr
(icatibant)

Folotyn
(pralatrexate)

Fusilev
(levoleucovorin)

Fyarro
(sirolimus albumin-bound)

Gamifant
(emapalumab-lzsg)

Gazyva
(obinutuzumab)

Gemzar
(gemcitabine)

Givlaari
(givosiran)

Haegarda
(C1 esterase inhibitor)

Halaven
(eribulin)

Herceptin Hylecta
(trastuzumab and hyaluronidase-oysk)

Hyaluronic Acid Derivatives
Durolane
GelSyn-3
GenVisc 850
Hyalgan
Hymovis
Monovisc
Orthovisc
Supartz
Supartz FX
Synojoynt
Synvisc
Synvisc-One
Triluron
TriVisc
Visco-3

Ilumya
tildrakizumab-asmn

Imfinzi
(durvalumab)

Imlygic 
(talimogene laherparepvec)

Infliximabs
Remicade
Inflectra
Renflexis
Avsola

Infugem
(gemcitabine)

IVIG (immune globulin):
(Bivigam,
Carimune NF,
Flebogamma/Flebogamma DIF,
Gammaplex,
Gamunex-C,
Gammaked,
Gammagard S/D,
Gammagard Liquid,
Octagam,
Privigen)

Ixempra
(ixabepilone)

Jelmyto
(mitomycin)

Jemperli
(dostarlimab‐gxly)

Jevtana
(cabazitaxel)

Kadcyla
(ado-trastuzumab emtansine)

Kalbitor
(ecallantide)

Kanuma
(sebelipase alfa)

Keytruda
(pembrolizumab)

Khapzory
(levoleucovorin)

Kimmtrak
(tebentafusp-tebn)

Krystexxa
(pegloticase)

Kyprolis
(carfilzomib)

Lanreotide
Somatuline Depot
Lareotide

Lartruvo
(olaratumab)

Lemtrada
(alemtuzumab) 

Leqvio
(inclisiran) 

Leuprolide Depot
Lupron Depot
Lupron Depot-Ped
Eligard
Fensolvi
Camcevi

Libtayo
(cemiplimab-rwlc)

Lumizyme
(alglucosidase alfa)

Lumoxiti
(moxetumomab pasudotox-tdfk)

Luxturna
(voretigene neparvovec-rzyl)

Macugen
(pegaptanib)

Margenza
(margetuximab-cmkb)

Marqibo
(vincristine sulfate liposomal)

Mepsevii
(velaglucerase alfa)

Mircera
(epoetin beta)

Monjuvi
(tafasitamab-cxix)

Mozobil
(plerixafor)

Mylotarg
(gemtuzumab ozogamicin)

Myobloc
(rimabotulinumtoxin B)

Naglazyme 
(galsulfase)

Nexviazyme
(avalglucosidase alfa-ngpt)

Nplate 
(romiplostim)

Nucala
(mepolizumab)

Ocrevus
(ocrelizumab)

Onivyde
(irinotecan liposome injection)

Onpattro
(patisiran lipid complex)

Opdivo
(nivolumab)

Opdualag
nivolumab/relatlimab-rmbw)

Orencia
(abatacept)

Oxlumo
(lumasiran)

Padcev
(enfortumab vedotin-ejfv)

Pedmark
(sodium thiosulfate)

Pegfilgrastim (Colony Stimulating Factors):
Neulasta
Fulphila
Udenyca
Ziextenzo
Nyvepria

Pemetrexed
Alimta
Pemfexy

Pepaxto
(melphalan flufenamide)

Perjeta
(pertuzumab)

Phesgo
(pertuzumab, trastuzumab, and hyaluronidase-zzxf)

Polivy
(polatuzumab vedotin-piiq)

Portrazza
(necitumumab)

Poteligeo
(mogamulizumab-kpkc)

Procrit/Epogen
(epoetin alfa)

Prolia/Xgeva
(denosumab)

Provenge
(sipuleucel-T)

Pulmonary Arterial Hypertension:
Revatio (sildenafil)
Remodulin (treprostinil)
Flolan/Veletri (epoprostenol)
Uptravi (selexipag)

Radicava
(edaravone)

Ranibizumab
Byooviz
Lucentis

Reblozyl
(luspatercept-aamt)

Rituximab
Rituxan
Truxima
Ruxience
Riabni

Rituxan Hycela
(rituximab)

Rolvedon
(eflapegrastim-xnst)

Romidepsin
(istodax)

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):
Cutaquig
Cuvitru
Gammagard Liquid
Gamunex-C
Gammaked
Hizentra
Hyqvia

Signifor LAR
(pasireotide)

Simponi ARIA
(golimumab)

Skyrizi
(risankizumab-rzaa)

Soliris
(eculizumab)

Somatuline Depot
(lanreotide)

Spevigo
(spesolimab)

Spinraza
(nusinersen)

Spravato
(esketamine)

Stelara /Stelara IV
(ustekinumab)

Susvimo
(ranibizumab)

Sylvant
(siltuximab)

Synribo
(omacetaxine)

Takhzyro
(lanadelumab-flyo)

Tecentriq
(atezolizumab)

Tepezza
(teprotumumab-trbw)

Tezspire
(tezepelumab-ekko)

Tivdak
(tisotumab vedotin-tftv)

Trastuzumab:
Herceptin (trastuzumab)
Ogivri (trastuzumab-dkst)
Kanjinti (trastuzumab-anns)
Trazimera (trastuzumab-qyyp)
Herzuma (trastuzumab-pkrb)
Ontruzant (trastuzumab-dttb)

Trelstar
(triptorelin)

Triptodur
(triptorelin)

Trodelvy
(sacituzumab govitecan-hzly)

Trogarzo
(ibalizumab-uiyk)

Tysabri
(natalizumab)

Ultomiris
(ravulizumab-cwvz)

Uplizna
(inebilizumab-cdon)

Vabysmo
(faricimab-svoa)

Vectibix
(panitumumab)

Velcade
(bortezomib)

Viltepso
(viltolarsen)

Vimizim
(elosulfase alfa)

VPRIV
(velaglucerase alfa)

Vyepti
(eptinezumab-jjmr)

Vyondys-53
(golodirsen)

Vyvgart
(efgartigimod alfa-fcab)

Vyxeos
(daunorubicin and cytarabine)

Xeomin
(incobotulinumtoxinA)

Xenpozyme
(olipudase alfa)

Xiaflex
(collagenase)

Xipere
(triamcinolone acetonide injectable suspension)

Xofigo
(radium Ra 223 dichloride)

Xolair
(omalizumab)

Yervoy
(ipilimumab)

Yondelis
(trabectedin)

Zaltrap
(ziv-aflibercept)

Zepzelca
(lurbinectedin)

Zolgensma
(onasemnogene abeparvovec-xioi)

Zynlonta
(oncastuximab tesirine-lpyl)

 

 

Hemophilia Program

Please Note: Authorizations for Hemophilia medications must be phoned in to Magellan Rx Management at 800-424-7892

Anti-Inhibitor Coagulant Complex (Feiba NF/Feiba VF)

Anti-Inhibitor Antibody: Hemlibra (emicizumab-kxwh)

Factor VIIa (Novoseven RT)

Factor VIII
(Advate,
Adynovate,
Afstyla,
Eloctate,
Hemofil M,
Hexilate FS,
Koate DVI,
Kogenate FS,
Kovaltry,
Monoclate-P,
Novoeight,
Nuwiq,
Obizur,
Recombinate,
Xyntha)

Factor VIII/VWF Complex
(Alphanate,
Humate-P,
Wilate)

Health New England - Post Service Claim Edit Policies

Boniva (ibandronate)

Eloxatin (oxaliplatin)

Faslodex (fulvestrant)

Filgrastims
Nivestym (Filgrastim-aafi)
Granix (Tbo-Filgrastim)

Gemzar (gemcitabine)

Hyaluronic Acid Derivatives
Euflexxa
Gel-One

Hycamtin IV (topotecan)

Kytril (granisetron)

Leukine (sargramostim)

Leuprolide Suspension:
Eligard
Lupron Depot
Lupron Depot-Ped

Mircera (methoxy polyethylene glycol‐epoetin beta) *Medicaid Only

Pegfilgrastim: (Medicaid Only)
Fulphila
Neulasta
Nyvepria
Udenyca
Ziextenzo

Taxol (paclitaxel)

Trelstar Depot (triptorelin)

Vantas (histrelin acetate)

Zofran (ondansetron)