Independent Health Clinical Guidelines
Medical Prior Auth and Claims Edits
Abraxane
(paclitaxel protein-bound particles)
Actemra
(tocilizumab)
Acthar
(corticotropin, ACTH)
Adakveo
(crizanlizumab-tmca)
Adcetris
(brentuximab)
Akynzeo
(fosnetupitant/palonosetron)
Aldurazyme
(laronidase)
Alimta
(pemetrexed)
Aliqopa
(copanlisib)
Alpha-1-Proteinase Inhibitors
Aralast NP
Glassia
Prolastin-C
Zemaira
Aranesp
(darbepoetin alfa)
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
Alymsys
Avastin
Mvasi
Zirabev
Blenrep
(belantamab mafodotin-blmf)
Blincyto
(blinatumomab)
Bortezomib
(bortezomib Injection)
Byooviz
(ranibizumab)
Cerezyme
(imiglucerase)
Cimzia
(certolizumab pegol)
Cinryze
(C1 Esterase Inhibitor Human)
Cosela
(trilaciclib)
Crysvita
(burosumab-twza)
Cyramza
(ramucirumab)
Danyelza
(naxitamab-gqgk)
Darzalex
(daratumumab)
Darzalex Faspro
(daratumumab and hyaluronidase-fihj)
Elelyso
(taliglucerase alfa)
Elzonris
(tagraxofusp-erzs)
Empaveli
(pegcetacoplan)
Empliciti
(elotuzumab)
Enhertu
(fam-trastuzumab deruxtecan-nxki)
Entyvio
(vedolizumab)
Epogen; Procrit; Retacrit-Non Dialysis
(Epoetin alfa)
Erbitux
(cetuximab)
Evenity
(romosozumab-aqqg)
Eylea
(aflibercept)
Fabrazyme
(agalsidase beta)
Fasenra
(benralizumab)
Faslodex
(fulvestrant)
Fyarro
(sirolimus albumin‐bound)
Gamifant
(emapalumab-lzsg)
Gazyva
(obinutuzumab)
Givlaari
(givosiran)
Granix
(tbo-filgrastim)
Haegarda
(C1 Esterase Inhibitor Subcutaneous [Human])
Halaven
(eribulin)
Herceptin Hylecta
(trastuzumab and hyaluronidase-oysk)
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
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)
Jemperli
(dostarlimab-gxly)
Jevtana
(cabazitaxel)
Kadcyla
(ado-trastuzumab emtansine)
Kalbitor
(ecallantide)
Kanuma
(sebelipase alfa)
Keytruda
(pembrolizumab)
Kyprolis
(carfilzomib)
Lartruvo
(olaratumab)
Lemtrada
(alemtuzumab)
Leukine
(sargramostim)
Leuprolide
Lupron Depot
Lupron Depot-Ped
Eligard
Fensolvi
Camcevi
Levoleucovorin
(Intravenous):
Fusilev
Khapzory
Libtayo
(cemiplimab-rwlc)
Lucentis
(ranibizumab)
Lumizyme
(alglucosidase alfa)
Lumoxiti
(moxetumomab pasudotox-tdfk)
Macugen
(pegaptanib)
Margenza
(margetuximab-cmkb)
Mepsevii
(vestronidase alfa-vjbk)
Mircera
(methoxy polyethylene glycol-epoetin beta)
Monjuvi
(tafasitamab-cxix)
Mozobil
(plerixafor)
Mylotarg
(gemtuzumab ozogamicin)
Naglazyme
(galsulfase)
Neupogen
(filgrastim)
Nexviazyme
(avalglucosidase alfa‐ngpt)
Nivestym
(filgrastim-aafi)
Nplate
(romiplostim)
Nulibry
(fosdenopterin)
Ocrevus
(ocrelizumab)
(patisiran lipid complex)
Onivyde
(irinotecan liposome injection)
Opdivo
(nivolumab)
Orencia
(abatacept)
Oxlumo
(lumasiran)
Padcev
(enfortumab vedotin-ejfv)
Pegfilgrastim
Fulphila
Neulasta
Nyvepria
Udenyca
Ziextenxo
Perjeta
(pertuzumab)
Phesgo
(pertuzumab, trastuzumab and hyaluronidase-zzxf)
Polivy
(polatuzumab vedotin-piiq)
Portrazza
(necitumumab)
Poteligeo
(mogamulizumab-kpkc)
Procrit/Epogen/Retacrit
(epoetin alfa)
Prolia/Xgeva
(denosumab)
Provenge
(sipuleucel-T)
Purified Cortrophin Gel
(corticotropin, ACTH)
Reblozyl
(luspatercept-aamt)
Releuko
(filgrastim-ayow)
Revcovi
(elapegademase-lvlr)
Rituximab
Riabni
Rituxan
Ruxience
Truxima
Rituxan Hycela
(rituxumab hyaluronidase)
Ruconest
(C1 Esterase Inhibitor [recombinant])
Rybrevant
(amivantamab‐vmjw)
Ryplazim
(plasminogen, human‐tvmh)
Sandostatin LAR
(octreotide)
Saphnelo
(anifrolumab‐fnia)
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)
Sustol
(granisetron)
Sylvant
(siltuximab)
Synribo
(omacetaxine)
Takhzyro
(lanadelumab-flyo)
Tecentriq
(atezolizumab)
Tegsedi
(inotersen)
Tepezza
(teprotumumab-trbw)
Tivdak
(tisotumab vedotin-tftv)
Trastuzumab
Herceptin
Herzuma
Kanjinti
Ogivri
Ontruzant
Trazimera
Trodelvy
(sacituzumab govitecan-hziy)
Tysabri
(natalizumab)
Ultomiris
(ravulizumab-cwvz)
Unituxin
(dinutuximab)
Uplizna
(inebilizumab-cdon)
Vabysmo
(faricimab-svoa)
Vectibix
(panitumumab)
Velcade
(bortezomib)
Vimizim
(elosulfase alfa)
VPRIV
(velaglucerase alfa)
Vyvgart
(efgartigimod alfa-fcab)
Vyxeos
(cytarabine and daunorubicin liposomal)
Xipere
(triamcinolone acetonide)
Yervoy
(ipilimumab)
Yondelis
(trabectedin)
Zaltrap
(ziv-aflibercept)
Zepzelca
(lurbinectedin)
Zoledronic Acid
Zometa
Reclast
Zynlonta
(loncastuximab tesirine-lpyl)
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)
Empaveli
(pegcetacoplan)
Enspryng
(satralizumab-mwge)
Erleada
(apalutamide)
Erivedge
(vismodegib)
Evrysdi
(risdiplam)
Exkivity
(mobocertinib)
Fasenra
(benralizumab)
Fotivda
(tivozanib)
Galafold
(migalastat)
Gavreto
(pralsetinib)
Gilotrif
(afatinib)
Haegarda
(C1 esterase inhibitor)
Hycamtin Oral***
(topotecan)
Ibrance
(palbociclib)
Iclusig
(ponatinib)
Idhifa
(enasidenib)
Imbruvica
(ibrutinib)
Inlyta
(axitinib)
Inqovi
(decitabine and cedazuridine)
Inrebic
(fedratinib)
Iressa
(gefitinib)
Jakafi
(ruxolitinib)
Kisqali
(ribociclib)
Koselugo
(selumetinib)
Lenvima
(lenvatinib)
Lonsurf
(trifluridine and tipiracil)
Lorbrena
(lorlatinib)
Lumakras
(sotorasib)
Lynparza
(olaparib)
Mekinist
(trametinib)
Mektovi
(binimetinib)
Mulpleta
(lusutrombopag)
Nerlynx
(neratinib)
Ninlaro
(ixazomib)
Nubeqa
(daroltamide)
Odomzo
(sonidegib)
Onureg
(azacitidine)
Orencia
(abatacept)
Orgovyx
(relugolix)
Orladeyo
(berotralstat)
Oxbryta
(voxelotor)
Pemazyre
(pemigatinib)
Piqray
(alpelisb)
Pomalyst
(pomalidomide)
Promacta
(eltrombopag)
Qinlock
(ripretinib)
Retevmo
(selpercatinib)
Revlimid
(lenalidomide)
Rezurock
(belumosudil)
Rozlytrek
(entrectinib)
Rubraca
(rucaparib)
Rydapt
(midostaurin)
Scemblix
(asciminib)
Sprycel
(dasatinib)
Stivarga
(regorafenib)
Sutent
(sunitinib)
Tabrecta
(capmatinib)
Tafamidis -
(Vyndamax,
Vyndaqel)
Tafinlar
(dabrafenib)
Tagrisso
(osimertinib
Takhzyro
(lanadelumab-flyo)
Talzenna
(talazoparib)
Tasigna
(nilotinib)
Tavalisse
(fostamatinib disodium hexahydrate)
Tazverik
(tazemetostat)
Tegsedi
(inotersen)
Tepmetko
(tepotinib)
Tibsovo
(ivosidenib)
Truseltiq
(infigratinib)
Tukysa
(tucatinib)
Turalio
(pexidartinib)
Tykerb
(lapatinib)
Udenyca
(pegfilgrastim-cbqv)
Ukoniq
(umbralisib)
Venclexta
(venetoclax)
Verzenio
(abemaciclib)
Vitrakvi
(larotrectinib)
Vizimpro
(dacomitinib)
Votrient
(pazopanib)
Welireg
(belzutifan)
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)
Anti-Inhibitor Antibody: Hemlibra (emicizumab-kxwh)
Factor VIIa
Novoseven RT
Sevenfact
Factor VIII
(Advate
Adynovate
Afstyla
Eloctate
Esperoct
Hemofil M
Jivi
Koate DVI
Kogenate FS
Kovaltry
Novoeight
Nuwiq
Obizur
Recombinate
Xyntha)
Factor IX
(Alphanine SD,
Alprolix,
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.
2022 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.