Independent Health Clinical Guidelines

 

Medical Prior Auth and Claims Edits

Abraxane
(paclitaxel protein-bound particles)

Actemra 
(tocilizumab)

Acthar 
(corticotropin, ACTH)

Adcetris
(brebtuximab)

Akynzeo
(fosnetupitant/palonosetron)

Aldurazyme
(laronidase)

Alimta
(pemetrexed)

Aliqopa
(copanlisib)

Aloxi
(palonosetron)

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

Aranesp
(darbepoetin alfa)

Arzerra
(ofatumumab)

Asparlas
(calaspargase pegol-mknl)

Avastin
(bevacizumab)

Bavencio
(avelumab)

Beleodaq
(belinostat)

Bendamustine
(bendamustine hcl):
Bendeka
Treanda

Bendamustine RTD
(bendamustine hcl)

Benlysta
(belimumab)

Beovu
(brolucizumab-dbll)

Besponsa
(inotuzumab ozogamicin)

Berinert
(C1 Esterase Inhibitor Human)

Blincyto
(blinatumomab)

Bortezomib
(bortezomib Injection)

Cerezyme
(imiglucerase)

Cinryze 
(C1 Esterase Inhibitor Human)

Crysvita
(burosumab-twza)

Cyramza
(ramucirumab)

Darzalex
(daratumumab)

Darzalex Faspro (10/1/20 )
(daratumumab and hyaluronidase-fihj)

Elelyso
(taliglucerase alfa)

Elzonris
(tagraxofusp-erzs)

Empliciti
(tagraxofusp-erzs)

Enhertu (10/1/20)
(fam-trastuzumab deruxtecan-nxki)

Epogen; Procrit; Retacrit-ESRD
(Epoetin alfa)

Epogen; Procrit; Retacrit-Non Dialysis
(Epoetin alfa)

Entyvio
(vedolizumab)

Erbitux
(cetuximab)

Evenity
(romosozumab-aqqg)

Eylea
(aflibercept)

Fabrazyme
(agalsidase beta)

Fasenra
(benralizumab)

Faslodex
(fulvestrant)

Fusilev
(levoleucovorin)

Gamifant
(emapalumab-lzsg)

Gazyva
(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

Halaven
(eribulin)

Herceptin
(trastuzumab)

Herceptin Hylecta
(trastuzumab and hyaluronidase-oysk)

Herzuma
(trastuzumab-pkrb)

Ilaris
(canakinumab)

Ilumya 
(tildrakizumab-asmn)

Imfinzi 
(durvalumab)

Imlygic 
(talimogene laherparepvec)


Infliximab
Avsola (infliximab-axxq) (10/1/20)
Inflectra (infliximab-dyyb)
Remicade (infliximab)
Renflexis (infliximab-abda)

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

Ixempra
(ixabepilone)

Jelmyto (10/1/20)
(mitomycin)

Jevtana
(cabazitaxel)

Kadcyla
(ado-trastuzumab emtansine)

Kalbitor
(ecallantide)

Kanjinti
(trastuzumab-anns)

Kanuma
(sebelipase alfa)

Keytruda
(pembrolizumab)

Kyprolis
(carfilzomib)

Lartruvo
(olaratumab)

Lemtrada
(alemtuzumab)

Leukine
(sargramostim)

Levoleucovorin
(Intravenous):
Fusilev
Khapzory

Libtayo
(cemiplimab-rwlc)

Lucentis
(ranibizumab)

Lumizyme
(alglucosidase alfa)

Lumoxiti
(moxetumomab pasudotox-tdfk)

Lupron Depot, Lupron Depot-Ped, Eligard ,Fensolvi (10/1/20)
(leuprolide) 

Macugen
(pegaptanib)

Mepsevii 
(vestronidase alfa-vjbk)

Mircera 
(methoxy polyethylene glycol-epoetin beta)

Mozobil
(plerixafor)

Mvasi
(bevacizumab-awwb)

Mylotarg
(gemtuzumab ozogamicin)

Naglazyme
(galsulfase)

Neupogen
(filgrastim) 

Nivestym
(filgrastim-aafi) 

Nplate
(romiplostim)

Ocrevus
(ocrelizumab)

Ogivri
(trastuzumab-dkst)

Onpattro
(patisiran lipid complex) 

Onivyde 
(irinotecan liposome injection)

Ontruzant
(trastuzumab-dttb)

Opdivo
(nivolumab)

Orencia
(abatacept)

Padcev
(enfortumab vedotin-ejfv) (10/1/20)

Pegfilgrastim 
(Fulphila,Neulasta,Nyvepria (10/1/20), Udenyca, Ziextenxo (10/1/20))

Perjeta
(pertuzumab)

Polivy
(polatuzumab vedotin-piiq)

Portrazza
(necitumumab)

Poteligeo
(mogamulizumab-kpkc)

Procrit/Epogen
(epoetin alfa)

Prolia/Xgeva
(denosumab)

Provenge
(sipuleucel-T)

Reblozyl (10/1/20)
(luspatercept-aamt)

Revcovi
(elapegademase-lvlr)

Rituxan
(rituximab)

Rituxan Hycela 
(rituxumab hyaluronidase)

Ruconest 
(C1 Esterase Inhibitor [recombinant])

Ruxience
(rituximab-pvvr)

Sandostatin LAR
(octreotide)

Sarclisa (10/1/20)
(isatuximab-irfc)

SCIG
(immune globulin SQ):
Cutaquig
Cuvitru
Gammagard Liquid
Gammaked
Gamunex-C
Hizentra
Hyqvia
Xembify

Simponi ARIA
(golimumab)

Soliris
(eculizumab)

Spinraza
(nusineren)

Stelara **
(ustekinumab)

Stelara IV
(ustekinumab)

Sustol
(granisetron)

Sylvant
(siltuximab)

Synribo
(omacetaxine)

Takhzyro
(lanadelumab-flyo)

Tecentriq
(atezolizumab)

Tegsedi
(inotersen)

Trazimera
(trastuzumab-qyyp)

Trodelv (10/1/20)
(sacituzumab govitecan-hziy)

Truxima
(rituximab-abbs)

Tysabri
(natalizumab)

Ultomiris
(ravulizumab-cwvz)

Unituxin
(dinutuximab)

Vectibix
(panitumumab)

Velcade
(bortezomib)

Vimizim
(elosulfase alfa)

VPRIV
(velaglucerase alfa)

Vyxeos 
(cytarabine and daunorubicin liposomal)

Yervoy
(ipilimumab)

Yondelis
(trabectedin)

Zaltrap
(ziv-aflibercept)

Zepzelca (10/1/20)
(lurbinectedin)

Zirabev Oncology
(bevacizumab-bvzr)

Zoledronic Acid
Zometa
Reclast

Pharmacy Prior Auth

Abiraterone  
Zytiga
Yonsa

Actemra SQ
(tocilizumab)

Alecensa
(alectinib)

Alunbrig
(brigatinib)

Ayvakit (10/1/20)
(avapritinib)

Balversa
(erafitinib)

Benlysta SQ
(belimumab)

Braftovi
(encorafenib)

Brukinsa (10/1/20)
(zanubrutinib)

Bosulif
(bosutinib)

Cabozantinib
Cabometyx
Cometriq

Calquence
(acalabrutinib)

Caprelsa
(vandetanib)

Cimzia
(certolizumab pegol)

Copiktra
(duvelisib)

Cosentyx **
(secukinumab)

Cotellic 
(cobimetinib)

Daurismo
(glasdegib)

Doptelet
(avatrombopag)

Erleada
(apalutamide)

Erivedge
(vismodegib)

Farydak
(panobinostat)

Galafold
(migalastat)

Gilotrif
(afatinib)

Haegarda
(C1 esterase inhibitor)

Hycamtin Oral***
(topotecan)

Ibrance 
(palbociclib)

Iclusig
(ponatinib)


Idhifa
(enasidenib)

Imbruvica
(ibrutinib)

Inlyta
(axitinib)

Inrebic
(fedratinib)

Iressa
(gefitinib)

Jakafi
(ruxolitinib)

Kisqali
(ribociclib)

Koselugo (10/1/20)
(selumetinib)

Lenvima
(lenvatinib)

Lonsurf 
(trifluridine and tipiracil)

Lorbrena
(lorlatinib)

Lynparza
(olaparib)

Mekinist
(trametinib)

Mektovi
(binimetinib)

Mulpleta
(lusutrombopag)

Nerlynx
(neratinib)

Nexavar
(sorafenib)

Ninlaro
(ixazomib)

Nubeqa
(daroltamide)

Odomzo
(sonidegib)

Orencia
(abatacept)

Pemazyre (10/1/20)
(pemigatinib)

Piqray
(alpelisb)

Pomalyst
(pomalidomide)

Promacta
(eltrombopag)

Qinlock (10/1/20)
(ripretinib)


Retevmo (10/1/20)
(selpercatinib)

Revlimid
(lenalidomide)

Rozlytrek
(entrectinib)


Rubraca
(rucaparib)

Rydapt
(midostaurin)

Sprycel
(dasatinib)

Stivarga
(regorafenib)

Sutent
(sunitinib)

Sylatron
(Peginterferon alfa-2b)

Tabrecta (10/1/20)
(capmatinib)

Tafamidis -
(Vyndamax,
Vyndaqel)

Tafinlar

(dabrafenib)

Tagrisso 

(osimertinib)

Takhzyro
(lanadelumab-flyo)

Talzenna 

(talazoparib)

Tarceva

(erlotinib)

Targretin*

(bexarotene)

Tasigna*

(nilotinib)

Tavalisse

(fostamatinib disodium hexahydrate)

Tegsedi (inotersen)

Tibsovo

(ivosidenib)

Tukysa (10/1/20)
(tucatinib)

Turalio 

(pexidartinib)

Tykerb

(lapatinib)

Venclexta 

(venetoclax)

Verzenio

(abemaciclib)

Vitrakvi  

(larotrectinib)

Vizimpro 

(dacomitinib)

Votrient

(pazopanib)

Xalkori

(crizotinib)

Xermelo 

(telotristat ethyl)

Xospata 

(gilteritinib)

Xtandi

(enzalutamide)

Zejula 

(niraparib)

Zelboraf

(vemurafenib)

Zolinza*

(vorinostat)

Zydelig

(idelalisib)

Zykadia

(ceritinib)

Zytiga

(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
Esperoct
Hexilate FS
Jivi
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

https://www.independenthealth.com/IndividualsFamilies/Medicare/PrescriptionCoverage/FormulariesPharmacies

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.