Independent Health Clinical Guidelines

 

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)

Elelyso
(taliglucerase alfa)

Elzonris
(tagraxofusp-erzs)

Empliciti
(tagraxofusp-erzs)

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)

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)

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)

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)

Pegfilgrastim 
(Neulasta,Fulphila, Udenyca)

Perjeta
(pertuzumab)

Polivy
(polatuzumab vedotin-piiq)

Portrazza
(necitumumab)

Poteligeo
(mogamulizumab-kpkc)

Procrit/Epogen
(epoetin alfa)

Prolia/Xgeva
(denosumab)

Provenge
(sipuleucel-T)

Remicade
(infliximab)

Renflexis  
(infliximab-abda)

Revcovi
(elapegademase-lvlr)

Rituxan
(rituximab)

Rituxan Hycela 
(rituxumab hyaluronidase)

Ruconest 
(C1 Esterase Inhibitor [recombinant])

Ruxience
(rituximab-pvvr)

Sandostatin LAR
(octreotide)

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)

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)

Zirabev Oncology
(bevacizumab-bvzr)

Zoledronic Acid
Zometa
Reclast

Pharmacy Prior Auth

Abiraterone  
Zytiga
Yonsa

Actemra SQ
(tocilizumab)

Alecensa
(alectinib)

Alunbrig
(brigatinib)

Balversa
(erafitinib)

Benlysta SQ
(belimumab)

Braftovi
(encorafenib)

Bosulif
(bosutinib)

Cabozantinib
Cabometyx
Cometriq

Calquence
(acalabrutinib)

Caprelsa
(vandetanib)

Cimzia
(certolizumab pegol)

Copiktra
(duvelisib)

Cosentyx **
(secukinumab)

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)

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
Esperoct
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.