Independent Health Clinical Guidelines
Medical Prior Auth and Claims Edits
Abraxane
(paclitaxel protein-bound particles)
(tocilizumab)
Acthar
(corticotropin, ACTH)
(brentuximab)
(fosnetupitant/palonosetron)
(laronidase)
(pemetrexed)
(copanlisib)
Aloxi (palonosetron)
Aralast NP
Glassia
Prolastin-C
Zemaira
(darbepoetin alfa)
(ofatumumab)
(calaspargase pegol-mknl)
(bevacizumab)
(avelumab)
(belinostat)
(bendamustine hcl):
Bendeka,
Treanda
(bendamustine hcl):
(belimumab)
Besponsa
(inotuzumab ozogamicin)
Berinert
(C1 Esterase Inhibitor Human)
(blinatumomab)
Bortezomib
(bortezomib Injection)
(imiglucerase)
Cinryze
(C1 Esterase Inhibitor Human)
Cosentyx **
(secukinumab)
(ramucirumab)
(daratumumab)
(taliglucerase alfa)
(tagraxofusp-erzs)
(elotuzumab)
(vedolizumab)
(cetuximab)
(romosozumab-aqqg)
(aflibercept)
(agalsidase beta)
(fulvestrant)
(icatibant)
(pegfilgrastim-jmdb)
(levoleucovorin)
(emapalumab-lzsg)
(obinutuzumab)
Granix -
(tbo-filgrastim)
Hyaluronic Acid:
the Hyaluronic Acid Policy only pertains to the Medicare LOB
Euflexxa
Durolane
Gel-One
Gel-Syn
GenVisc 850
Hylagan
Hymovis
Monovisc
Orthovisc
Supartz/Supartz FX
Synojoynt, Synvisc
Synvisc-One
Triluron, TriVisc
Visco-3
(eribulin)
(trastuzumab)
Herceptin Hylecta
(trastuzumab and hyaluronidase-oysk)
(trastuzumab-pkrb)
(canakinumab)
Ilumya
(tildrakizumab-asmn)
(durvalumab)
Imlygic
(talimogene laherparepvec)
(infliximab-dyyb)
(immune globulin):
Bivigam
Carimune NF
Flebogamma/Flebogamma DIF
Gammaplex
Gamunex-C
Gammaked
Gammagard S/D
Gammagard Liquid
Octagam
Privigen
(ixabepilone)
(cabazitaxel)
(ado-trastuzumab emtansine)
(ecallantide)
(trastuzumab-anns)
(sebelipase alfa)
(levoleucovorin)
(pembrolizumab)
(carfilzomib)
(olaratumab)
(alemtuzumab)
(sargramostim)
(Intravenous):
Fusilev,
Khapzory
(cemiplimab-rwlc)
(ranibizumab)
(alglucosidase alfa)
(moxetumomab pasudotox-tdfk)
Lupron Depot, Lupron Depot-Ped, Eligard
(leuprolide)
(pegaptanib)
Mepsevii
(vestronidase alfa-vjbk)
Mircera
(methoxy polyethylene glycol-epoetin beta)
(plerixafor)
(bevacizumab-awwb)
(gemtuzumab ozogamicin)
(galsulfase)
(pegfilgrastim)
(filgrastim)
(filgrastim-aafi)
(romiplostim)
(ocrelizumab)
(trastuzumab-dkst)
Onpattro (patisiran lipid complex)
Onivyde
(irinotecan liposome injection)
(trastuzumab-dttb)
(nivolumab)
(abatacept)
(pertuzumab)
(polatuzumab vedotin-piiq)
(necitumumab)
Poteligeo (mogamulizumab-kpkc)
(epoetin alfa)
(denosumab)
(sipuleucel-T)
(epoetin alfa-epbx)
(infliximab)
Renflexis
(infliximab-abda)
(elapegademase-lvlr)
(rituximab)
Rituxan Hycela
(rituxumab hyaluronidase)
Ruconest
(C1 Esterase Inhibitor [recombinant])
(octreotide)
(immune globulin SQ):
(Cuvitru, Cutaquig,
Hizentra,
Gammagard Liquid,
Gamunex-C ,
Gammaked,
Hyqvia, Xembify)
(golimumab)
(eculizumab)
(nusineren)
Stelara **
(ustekinumab)
(ustekinumab)
(granisetron)
(siltuximab)
(omacetaxine)
(lanadelumab-flyo)
(atezolizumab)
(inotersen)
(trastuzumab-qyyp)
(rituximab-abbs)
(natalizumab)
(pegfilgrastim-cbqv)
(ravulizumab-cwvz)
(dinutuximab)
(panitumumab)
(bortezomib)
(elosulfase alfa)
(velaglucerase alfa)
Vyxeos
(cytarabine and daunorubicin liposomal)
(ipilimumab)
(trabectedin)
(ziv-aflibercept)
(bevacizumab-bvzr)
Zoledronic Acid
Zometa,
Reclast
Pharmacy Prior Auth
Abiraterone
Zytiga,
Yonsa
(tocilizumab)
(everolimus)
(alectinib)
(brigatinib)
(erafitinib)
(belimumab)
(encorafenib)
(bosutinib)
(cabozantinib)
(vandetanib)
(certolizumab pegol)
(cabozantinib)
(duvelisib)
(cobimetinib)
(glasdegib)
(avatrombopag)
(vismodegib)
(panobinostat)
(migalastat)
(afatinib)
(C1 esterase inhibitor)
(topotecan)
(palbociclib)
(ponatinib)
(enasidenib)
(ibrutinib)
(axitinib)
(fedratinib)
(gefitinib)
(ruxolitinib)
(ribociclib)
(trifluridine and tipiracil)
(lorlatinib)
(olaparib)
(trametinib)
(binimetinib)
(lusutrombopag)
(neratinib)
(sorafenib)
(ixazomib)
(daroltamide)
(sonidegib)
(abatacept)
(alpelisb)
(pomalidomide)
(eltrombopag)
(lenalidomide)
(entrectinib)
(rucaparib)
(midostaurin)
(dasatinib)
(regorafenib)
(sunitinib)
(Peginterferon alfa-2b)
Tafamidis -
(Vyndamax,
Vyndaqel)
(dabrafenib)
(osimertinib)
(talazoparib)
(erlotinib)
(bexarotene)
(nilotinib)
(fostamatinib disodium hexahydrate)
(ivosidenib)
(pexidartinib)
(lapatinib)
(pegfilgrastim-cbqv)
(venetoclax)
(larotrectinib)
(dacomitinib)
(pazopanib)
(crizotinib)
(telotristat ethyl)
(gilteritinib)
(enzalutamide)
(niraparib)
(vemurafenib)
(vorinostat)
(idelalisib)
(ceritinib)
(abiraterone acetate)
Hemophilia Program
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 IX
(Alphanine SD,
Alprolix,
Bebulin,
BeneFIX,
Idelvion,
Ixinity,
Mononine,
Profilnine,
Rebinyn,
Rixubis)
Factor X (Coagadex)
Factor XIII (Corifact)
Coagulation Factor XIII A-subunit (Tretten)
von Willebrand Factor (Vonvendi)
Factor VIII/VWF Complex
(Alphanate,
Humate-P,
Wilate)
**No PA required for Medicare Members
*No PA required for Medicare Part D.
***For Medicare, Part B drug.
2020 Step Therapy Criteria for Medicare Part B Drugs
The criteria for drugs covered under the Medicare Part D benefit can be found in the Medicare Part D criteria.
View the Independent Health post service claim edit policies.