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)

Onpattro

(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

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.