Medication Center

 

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