Independent Health Clinical Guidelines

Medical Prior Auth and Claims Edits

Abraxane J9264
(paclitaxel protein-bound particles)

Actemra IV** J3262
(tocilizumab)

Acthar J0800
(corticotropin, ACTH)

Adcetris J9042
(brentuximab)

Aldurazyme J1931
(laronidase)

Alimta J9305
(pemetrexed)

Aliqopa J9999
(copanlisib)

Aloxi J2469
(palonosetron)

Anzemet J1260
(dolasetron)

Aranesp J0881
(darbepoetin alfa)

Arzerra J9302
(ofatumumab)

Avastin J9035
(bevacizumab)

Bavencio J9023
(avelumab)

Beleodaq J9032
(belinostat)

Benlysta J0490
(belimumab)

Bendeka J9034 
(bendamustine hcl)

Besponsa J9999
(inotuzumab ozogamicin)

Berinert J0597
(C1 Esterase Inhibitor Human)

Blincyto J9039
(blinatumomab)

Cerezyme J1786
(imiglucerase)

Cimzia** J0717
(certolizumab pegol)

Cinryze J0598
(C1 Esterase Inhibitor Human)

Cosentyx ** J3590
(secukinumab)

Cyramza J9308
(ramucirumab)

Darzalex J9145
(daratumumab)

Elelyso J3060
(taliglucerase alfa)

Eligard J9217 
(leuprolide)

Empliciti J9176
(elotuzumab)

Entyvio J3380
(vedolizumab)

Erbitux J9055
(cetuximab)

Eylea J0178
(aflibercept)

Fabrazyme J0180
(agalsidase beta)

Faslodex J9395
(fulvestrant)

Firazyr J1744
(icatibant)

Fusilev J0641
(levoleucovorin)

Gazyva J9301
(obinutuzumab)

Hyaluronic Acid:
(Euflexxa J7323,
Gel-One J7326,
Gel-Syn J7328,
GenVisc 850 J7320,
Hylagan J7321,
Hymovis J7322
Monovisc J7327,
Orthovisc J7324,
Supartz J7321,
Synvisc J7325,
Synvisc-One J7325,
Visco-3 J7321)

Halaven J9179
(eribulin)

Herceptin J9355
(trastuzumab)

Ilaris J0638
(canakinumab)

Imfinzi J9999
(durvalumab)

Imlygic J9325
(talimogene laherparepvec)

Inflectra ** Q5102 - ZB
(infliximab-dyyb)

IVIG (immune globulin):
(Bivigam J1556,
Carimune NF J1566,
Flebogamma/Flebogamma DIF J1572,
Gammaplex J1557,
Gamunex-C J1561,
Gammaked J1561,
Gammagard S/D J1566,
Gammagard Liquid J1569,
Octagam J1568,
Privigen J1459)

Ixempra J9207
(ixabepilone)

Jevtana J9043
(cabazitaxel)

Kadcyla J9354
(ado-trastuzumab emtansine)

Kalbitor J1290
(ecallantide)

Kanuma J2840
(sebelipase alfa)

Keytruda J9271
(pembrolizumab)

Kyprolis J9047
(carfilzomib)

Lartruvo J9285
(olaratumab)

Lemtrada J0202
(alemtuzumab)

Leukine J2820
(sargramostim)

Lucentis J2778
(ranibizumab)

Lumizyme J0221
(alglucosidase alfa)

Lupron Depot J1950 for doses of 3.75mg and 11.25mg
J9217 for doses of 7.5mg, 15mg, 22.5mg, and 30mg
(leuprolide)

Lupron Depot-Ped J1950 
(leuprolide)

Macugen J2503
(pegaptanib)

Mircera J0888
(methoxy polyethylene glycol-epoetin beta)

Mozobil J2562
(plerixafor)

Mylotarg J9203
(gemtuzumab ozogamicin)

Naglazyme J1458
(galsulfase)

Neulasta J2505
(pegfilgrastim)

Neupogen J1442 
(filgrastim)

Nplate J2796
(romiplostim)

Ocrevus J2350
(ocrelizumab)
Effective 1/1/2018

Onivyde J9205
(irinotecan liposome injection)

Opdivo J9299
(nivolumab)

Orencia ** J0129
(abatacept)

Perjeta J9306
(pertuzumab)

Portrazza J9295
(necitumumab)

Procrit J0885
(epoetin alfa)

Prolia/Xgeva J0897
(denosumab)

Provenge Q2043
(sipuleucel-T)

Remicade ** J1745
(infliximab)

Renflexis ** Q5102-ZC
(infliximab-abda)

Rituxan J9310
(rituximab)

Rituxan Hycela J9999
(rituxumab hyaluronidase)

Ruconest J0596
(C1 Esterase Inhibitor [recombinant])

Sandostatin LAR J2353
(octreotide)

SCIG (immune globulin SQ):
(Cuvitru J3590,
Hizentra J1559,
Gammagard Liquid J1569,
Gamunex-C J1561,
Gammaked J1561,
Hyqvia J1575)

Simponi ARIA** J1602
(golimumab)

Soliris J1300
(eculizumab)

Spinraza J2326
(nusineren)

Stelara ** J3357
(ustekinumab)

Stelara IV ** J3358
(ustekinumab)

Sustol J1627
(granisetron)

Sylvant J2860
(siltuximab)

Synribo J9262
(omacetaxine)

Tecentriq J9022
(atezolizumab)

Treanda J9033
(bendamustine)

Tysabri J2323
(natalizumab)

Unituxin J9999
(dinutuximab)

Vectibix J9303
(panitumumab)

Velcade J9041
(bortezomib)

Vimizim J1322
(elosulfase alfa)

VPRIV J3385
(velaglucerase alfa)

Vyxeos J9999
(cytarabine and daunorubicin liposomal)

Yervoy J9228
(ipilimumab)

Yondelis J9352
(trabectedin)

Zaltrap J9400
(ziv-aflibercept)

Zoledronic Acid
(Zometa J3489,
Reclast J3489)


**No PA required for Medicare Members

Pharmacy Prior Auth

Actemra SQ* (tocilizumab)

Afinitor (everolimus)

Alecensa (alectinib)

Alunbrig (brigatinib)

Bosulif (bosutinib)

Cabometyx (cabozantinib)

Caprelsa (vandetanib)

Cometriq  (cabozantinib)

Cotellic  (cobimetinib)

Erivedge (vismodegib)

Farydak (panobinostat)

Gilotrif (afatinib)

Haegarda (C1 esterase inhibitor)

Hycamtin Oral*** (topotecan)

Ibrance  (palbociclib)

Iclusig (ponatinib)

Idhifa (enasidenib)

Imbruvica (ibrutinib)

Inlyta (axitinib)

Iressa (gefitinib)

Jakafi (ruxolitinib)

Kisqali (ribociclib)

Lenvima (lenvatinib)

Lonsurf  (trifluridine and tipiracil)

Lynparza (olaparib)

Mekinist (trametinib)

Nerlynx (neratinib)

Nexavar (sorafenib)

Ninlaro (ixazomib)

Odomzo (sonidegib)

Pomalyst (pomalidomide)

Promacta (eltrombopag)

Revlimid (lenalidomide)

Rubraca (rucaparib)

Rydapt (midostaurin)

Sprycel (dasatinib)

Stivarga (regorafenib)

Sutent (sunitinib)

Sylatron (Peginterferon alfa-2b)

Tafinlar (dabrafenib)

Tagrisso (osimertinib)

Tarceva (erlotinib)

Targretin* (bexarotene)

Tasigna* (nilotinib)

Tykerb (lapatinib)

Venclexta (venetoclax)

Votrient (pazopanib)

Xalkori (crizotinib)

Xeloda*** (capecitabine)

Xermelo (telotristat ethyl)

Xtandi (enzalutamide)

Zejula (niraparib)

Zelboraf (vemurafenib)

Zolinza* (vorinostat)

Zydelig (idelalisib)

Zykadia (ceritinib)

Zytiga (abiraterone acetate)

 

*No PA required for Medicare Part D.

***For Medicare, Part B drug.

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.