Independent Health Clinical Guidelines
Medical Prior Auth and Claims Edits
Abraxane
(paclitaxel protein-bound particles)
Actemra
(tocilizumab)
Acthar
(corticotropin, ACTH)
Adcetris
(brentuximab)
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)
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)
Bevacizumab
Avastin
MVASI
Zirabev
Blincyto
(blinatumomab)
Bortezomib
(bortezomib Injection)
Cerezyme
(imiglucerase)
Cimzia
(certolizumab pegol)
Cinryze
(C1 Esterase Inhibitor Human)
Crysvita
(burosumab-twza)
Cyramza
(ramucirumab)
Darzalex
(daratumumab)
Darzalex Faspro
(daratumumab and hyaluronidase-fihj)
Elelyso
(taliglucerase alfa)
Elzonris
(tagraxofusp-erzs)
Empliciti
(elotuzumab)
Enhertu
(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)
Haegarda
(C1 Esterase Inhibitor Subcutaneous [Human])
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 Hylecta
(trastuzumab and hyaluronidase-oysk)
Ilaris
(canakinumab)
Ilumya
(tildrakizumab-asmn)
Imfinzi
(durvalumab)
Imlygic
(talimogene laherparepvec)
Infliximab
Avsola (infliximab-axxq)
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
(mitomycin)
Jevtana
(cabazitaxel)
Kadcyla
(ado-trastuzumab emtansine)
Kalbitor
(ecallantide)
(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
(leuprolide)
Macugen
(pegaptanib)
Mepsevii
(vestronidase alfa-vjbk)
Mircera
(methoxy polyethylene glycol-epoetin beta)
Mozobil
(plerixafor)
Mylotarg
(gemtuzumab ozogamicin)
Naglazyme
(galsulfase)
Neupogen
(filgrastim)
Nivestym
(filgrastim-aafi)
Nplate
(romiplostim)
Ocrevus
(ocrelizumab)
(patisiran lipid complex)
Onivyde
(irinotecan liposome injection)
Opdivo
(nivolumab)
Orencia
(abatacept)
Padcev
(enfortumab vedotin-ejfv)
Pegfilgrastim
Fulphila
Neulasta
Nyvepria
Udenyca
Ziextenxo
Perjeta
(pertuzumab)
Polivy
(polatuzumab vedotin-piiq)
Portrazza
(necitumumab)
Poteligeo
(mogamulizumab-kpkc)
Procrit/Epogen
(epoetin alfa)
Prolia/Xgeva
(denosumab)
Provenge
(sipuleucel-T)
Reblozyl
(luspatercept-aamt)
Revcovi
(elapegademase-lvlr)
Rituximab
Rituxan
Ruxience
Truxima
Rituxan Hycela
(rituxumab hyaluronidase)
Ruconest
(C1 Esterase Inhibitor [recombinant])
Sandostatin LAR
(octreotide)
Sarclisa
(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)
Trastuzumab
Herceptin
Herzuma
Kanjinti
Ogivri
Ontruzant
Trazimera
Trodelvy
(sacituzumab govitecan-hziy)
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
(lurbinectedin)
Zoledronic Acid
Zometa
Reclast
Pharmacy Prior Auth
Abiraterone
Yonsa
Actemra SQ
(tocilizumab)
Alecensa
(alectinib)
Alunbrig
(brigatinib)
Ayvakit
(avapritinib)
Balversa
(erdafitinib)
Benlysta SQ
(belimumab)
Braftovi
(encorafenib)
Brukinsa
(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
(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
(pemigatinib)
Piqray
(alpelisb)
Pomalyst
(pomalidomide)
Promacta
(eltrombopag)
Qinlock
(ripretinib)
Retevmo
(selpercatinib)
Revlimid
(lenalidomide)
Rozlytrek
(entrectinib)
Rubraca
(rucaparib)
Rydapt
(midostaurin)
Sprycel
(dasatinib)
Stivarga
(regorafenib)
Sutent
(sunitinib)
Tabrecta
(capmatinib)
Tafamidis -
(Vyndamax,
Vyndaqel)
Tafinlar
(dabrafenib)
Tagrisso
(osimertinib
Takhzyro
(lanadelumab-flyo)
Talzenna
(talazoparib)
(nilotinib)
Tavalisse
(fostamatinib disodium hexahydrate)
Tegsedi
(inotersen)
Tibsovo
(ivosidenib)
Tukysa
(tucatinib)
Turalio
(pexidartinib)
Tykerb
(lapatinib)
Udenyca
(pegfilgrastim-cbqv)
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)
Hemophilia Program
Anti-Inhibitor Coagulant Complex (Feiba NF/Feiba VF)
Anti-Inhibitor Antibody: Hemlibra (emicizumab-kxwh)
Factor VIIa
Novoseven RT
Sevenfact
Factor VIII
(Advate
Adynovate
Afstyla
Eloctate
Esperoct
Hexilate FS
Jivi
Koate DVI
Kogenate FS
Kovaltry
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.
2021 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.