Independent Health Clinical Guidelines

 

Medical Prior Auth and Claims Edits

Abraxane
(paclitaxel protein-bound particles)

Actemra IV

(tocilizumab)

Acthar 
(corticotropin, ACTH)

Adcetris

(brentuximab)

Akynzeo_IV

(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 Oncology

(bevacizumab)

Bavencio 

(avelumab)

Beleodaq

(belinostat)

Bendamustine 

(bendamustine hcl):
Bendeka,
Treanda

Bendamustine RTD  

(bendamustine hcl):

Benlysta IV 

(belimumab)

Besponsa
(inotuzumab ozogamicin)

Berinert
(C1 Esterase Inhibitor Human)

Blincyto

(blinatumomab)

Bortezomib
(bortezomib Injection)

Cerezyme 

(imiglucerase)

Cinryze 
(C1 Esterase Inhibitor Human)

Cosentyx **
(secukinumab)

Crysvita 

(burosumab-twza)

Cyramza 

(ramucirumab)

Darzalex

(daratumumab)

Elelyso 

(taliglucerase alfa)

Elzonris

(tagraxofusp-erzs)

Empliciti

(elotuzumab)

Entyvio

(vedolizumab)

Erbitux

(cetuximab)

Evenity

(romosozumab-aqqg)

Eylea

(aflibercept)

Fabrazyme 

(agalsidase beta)

Fasenra 

(benralizumab)

Faslodex 

(fulvestrant)

Firazyr 

(icatibant)

Fulphila

(pegfilgrastim-jmdb)

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 IV

(trastuzumab)

Herceptin Hylecta
(trastuzumab and hyaluronidase-oysk)

Herzuma

(trastuzumab-pkrb)

Ilaris

(canakinumab)

Ilumya 
(tildrakizumab-asmn)

Imfinzi  

(durvalumab)

Imlygic 
(talimogene laherparepvec)

Inflectra 

(infliximab-dyyb)

IVIG

(immune globulin): 
Bivigam
Carimune NF
Flebogamma/Flebogamma DIF
Gammaplex 
Gamunex-C 
Gammaked 
Gammagard S/D 
Gammagard Liquid
Octagam 
Privigen

Ixempra

(ixabepilone)

Jevtana

(cabazitaxel)

Kadcyla

(ado-trastuzumab emtansine)

Kalbitor 

(ecallantide)

Kanjinti

(trastuzumab-anns)

Kanuma 

(sebelipase alfa)

Khapzory

(levoleucovorin)

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
(leuprolide) 

Macugen

(pegaptanib)

Mepsevii 
(vestronidase alfa-vjbk)

Mircera 
(methoxy polyethylene glycol-epoetin beta)

Mozobil 

(plerixafor)

Mvasi

(bevacizumab-awwb)

Mylotarg 

(gemtuzumab ozogamicin)

Naglazyme 

(galsulfase)

Neulasta 

(pegfilgrastim)

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)

Perjeta

(pertuzumab)

Polivy 

(polatuzumab vedotin-piiq)

Portrazza

(necitumumab)

Poteligeo (mogamulizumab-kpkc)

Procrit/Epogen

(epoetin alfa)

Prolia/Xgeva

(denosumab)

Provenge 

(sipuleucel-T)

Retacrit

(epoetin alfa-epbx)

Remicade 

(infliximab)

Renflexis  
(infliximab-abda)

Revcovi

(elapegademase-lvlr)

Rituxan IV 

(rituximab)

Rituxan Hycela 
(rituxumab hyaluronidase)

Ruconest 
(C1 Esterase Inhibitor [recombinant])

Sandostatin LAR

(octreotide)

SCIG

(immune globulin SQ): 
(Cuvitru, Cutaquig,
Hizentra,
Gammagard Liquid,
Gamunex-C ,
Gammaked,
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)

Truxima

(rituximab-abbs)

Tysabri

(natalizumab)

Udenyca

(pegfilgrastim-cbqv)

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)

Zirabev Oncology

(bevacizumab-bvzr)

Zoledronic Acid
Zometa,
Reclast

Pharmacy Prior Auth

Abiraterone  
Zytiga,
Yonsa

Actemra SQ  

(tocilizumab)

Afinitor 

(everolimus)

Alecensa 

(alectinib)

Alunbrig 

(brigatinib)

Balversa 

(erafitinib)

Benlysta SQ 

(belimumab)

Braftovi

(encorafenib)

Bosulif

(bosutinib)

Cabometyx 

(cabozantinib)

Calquence

(acalabrutinib)

Caprelsa

(vandetanib)

Cimzia

(certolizumab pegol)

Cometriq 

(cabozantinib)

Copiktra 

(duvelisib) 

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)

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)

Piqray 

(alpelisb)

Pomalyst

(pomalidomide)

Promacta

(eltrombopag)

Revlimid

(lenalidomide)

Rozlytrek 

(entrectinib)

Rubraca 

(rucaparib)

Rydapt 

(midostaurin)

Sprycel

(dasatinib)

Stivarga

(regorafenib)

Sutent

(sunitinib)

Sylatron 

(Peginterferon alfa-2b)

Tafamidis -
(Vyndamax,
Vyndaqel)

Tafinlar

(dabrafenib)

Tagrisso 

(osimertinib)

Takhzyro (lanadelumab-flyo)

Talzenna 

(talazoparib)

Tarceva

(erlotinib)

Targretin*

(bexarotene)

Tasigna*

(nilotinib)

Tavalisse

(fostamatinib disodium hexahydrate)

Tegsedi (inotersen)

Tibsovo

(ivosidenib)

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)

Zytiga

(abiraterone acetate)

 

 

Hemophilia Program

Anti-Inhibitor Coagulant Complex (Feiba NF/Feiba VF) 

Anti-Inhibitor Antibody: Hemlibra (emicizumab-kxwh)

Factor VIIa (Novoseven RT)

Factor VIII
(Advate, 
Adynovate, 
Afstyla, 
Eloctate, 
Hemofil M, 
Hexilate FS, 
Jivi,
Koate DVI, 
Kogenate FS, 
Kovaltry, 
Monoclate-P, 
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.

2020 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.