Independent Health Clinical Guidelines

Medical Prior Auth and Claims Edits

Abraxane J9264
(paclitaxel protein-bound particles)

Actemra** J3262
(tocilizumab)

Acthar J0800
(corticotropin, ACTH)

Adcetris J9042
(brentuximab)

Aldurazyme J1931
(laronidase)
Effective 1/1/2018

Alimta J9305
(pemetrexed)

Aliqopa J9999
(copanlisib)
Effective 1/1/2018

Aloxi J2469
(palonosetron)

Anzemet J1260
(dolasetron)

Aranesp J0881
(darbepoetin alfa)

Arzerra J9302
(ofatumumab)

Avastin J9035
(bevacizumab)

Bavencio J9023
(avelumab)
Effective 1/1/2018

Beleodaq J9032
(belinostat)

Benlysta J0490
(belimumab)

Bendeka J9034 
(bendamustine hcl)

Besponsa J9999
(inotuzumab ozogamicin)
Effective 1/1/2018

Berinert J0597
(C1 Esterase Inhibitor Human)

Blincyto J9039
(blinatumomab)

Cerezyme J1786
(imiglucerase)
Effective 1/1/2018

Cimzia** J0717
(certolizumab pegol)

Cinryze J0598
(C1 Esterase Inhibitor Human)

Cosentyx ** J3590
(secukinumab)

Cyramza J9308
(ramucirumab)

Darzalex J9145
(daratumumab)

Elelyso J3060
(taliglucerase alfa)
Effective 1/1/2018

Eligard J9217
(leuprolide)

Empliciti J9176
(elotuzumab)

Entyvio J3380
(vedolizumab)

Erbitux J9055
(cetuximab)

Eylea J0178
(aflibercept)

Fabrazyme J0180
(agalsidase beta)
Effective 1/1/2018

Faslodex J9395
(fulvestrant)

Firazyr J1744
(icatibant)

Fusilev J0641
(levoleucovorin)

Gazyva J9301
(obinutuzumab)
Effective 1/1/2018

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)
Effective 1/1/2018

Imlygic J9325
(talimogene laherparepvec)

Inflectra ** Q5102 - ZB
(infliximab-dyyb)
Effective 1/1/2018

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)
Effective 1/1/2018

Keytruda J9271
(pembrolizumab)

Kyprolis J9047
(carfilzomib)

Lartruvo J9285
(olaratumab)
Effective 1/1/2018

Lemtrada J0202
(alemtuzumab)
Effective 1/1/2018

Leukine J2820
(sargramostim)

Lucentis J2778
(ranibizumab)

Lumizyme J0221
(alglucosidase alfa)
Effective 1/1/2018

Lupron Depot J1950
(leuprolide)

Lupron Depot-Ped J1950
(leuprolide)

Macugen J2503
(pegaptanib)

Mircera J0888
(methoxy polyethylene glycol-epoetin beta)
Effective 1/1/2018

Mozobil J2562
(plerixafor)

Mylotarg J9203
(gemtuzumab ozogamicin)
Effective 1/1/2018

Naglazyme J1458
(galsulfase)
Effective 1/1/2018

Neulasta J2505
(pegfilgrastim)

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)
Effective 1/1/2018

Rituxan J9310
(rituximab)

Rituxan Hycela J9999
(rituxumab hyaluronidase)
Effective 1/1/2018

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)
Effective 1/1/2018

Stelara ** J3357
(ustekinumab)

Stelara IV ** J3358
(ustekinumab)

Sustol J1627
(granisetron)
Effective 1/1/2018

Sylvant J2860
(siltuximab)

Synribo J9262
(omacetaxine)

Tecentriq J9022
(atezolizumab)
Effective 1/1/2018

Treanda J9033
(bendamustine)

Tysabri J2323
(natalizumab)

Unituxin J9999
(dinutuximab)

Vectibix J9303
(panitumumab)

Velcade J9041
(bortezomib)

Vimizim J1322
(elosulfase alfa)
Effective 1/1/2018

VPRIV J3385
(velaglucerase alfa)
Effective 1/1/2018

Vyxeos J9999
(cytarabine and daunorubicin liposomal)
Effective 1/1/2018

Yervoy J9228
(ipilimumab)

Yondelis J9352
(trabectedin)

Zaltrap J9400
(ziv-aflibercept)
Effective 1/1/2018

Zoledronic Acid
(Zometa J3489,
Reclast J3489)


**No PA required for Medicare Members

Pharmacy Prior Auth

Afinitor (everolimus)

Alecensa (alectinib)

Alunbrig (brigatinib)
Effective 1/1/2018

Bosulif (bosutinib)

Cabometyx (cabozantinib)
Effective 1/1/2018

Caprelsa (vandetanib)

Cometriq  (cabozantinib)

Cotellic  (cobimetinib)

Erivedge (vismodegib)

Farydak (panobinostat)

Gilotrif (afatinib)

Haegarda (C1 esterase inhibitor)
Effective 1/1/2018

Hycamtin Oral** (topotecan)

Ibrance  (palbociclib)

Iclusig (ponatinib)

Idhifa (enasidenib)
Effective 1/1/2018

Imbruvica (ibrutinib)

Inlyta (axitinib)

Iressa (gefitinib)

Jakafi (ruxolitinib)

Kisqali (ribociclib)
Effective 1/1/2018

Lenvima (lenvatinib)

Lonsurf  (trifluridine and tipiracil)

Lynparza (olaparib)
Effective 1/1/2018

Mekinist (trametinib)

Nerlynx (neratinib)
Effective 1/1/2018

Nexavar (sorafenib)

Ninlaro (ixazomib)

Odomzo (sonidegib)

Pomalyst (pomalidomide)

Promacta (eltrombopag)

Revlimid (lenalidomide)

Rubraca (rucaparib)
Effective 1/1/2018

Rydapt (midostaurin)
Effective 1/1/2018

Sprycel (dasatinib)

Stivarga (regorafenib)

Sutent (sunitinib)

Sylatron (Peginterferon alfa-2b)

Tafinlar (dabrafenib)

Tagrisso (osimertinib)

Tarceva (erlotinib)

Targretin* (bexarotene)

Tasigna* (nilotinib)

Tykerb (lapatinib)

Venclexta (venetoclax)
Effective 1/1/2018

Votrient (pazopanib)

Xalkori (crizotinib)

Xeloda** (capecitabine)

Xermelo (telotristat ethyl)
Effective 1/1/2018

Xtandi (enzalutamide)

Zejula (niraparib)
Effective 1/1/2018

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.