Medication Center

 

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)