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)

Alimta J9305
(pemetrexed)

Aloxi J2469
(palonosetron)

Anzemet J1260
(dolasetron)

Aranesp J0881
(darbepoetin alfa)

Arzerra J9302
(ofatumumab)

Avastin J9035
(bevacizumab)

Beleodaq J9032
(belinostat)

Benlysta J0490
(belimumab)

Bendeka J9034 
(bendamustine hcl)

Berinert J0597
(C1 Esterase Inhibitor Human)

Blincyto J9039
(blinatumomab)

Cimzia J0717
(certolizumab pegol)

Cinryze J0598
(C1 Esterase Inhibitor Human)

Cosentyx J3590
(secukinumab)

Cyramza J9308
(ramucirumab)

Darzalex J9145
(daratumumab)

Eligard J9217
(leuprolide)

Empliciti J9176
(elotuzumab)

Entyvio J3380
(vedolizumab)

Erbitux J9055
(cetuximab)

Eylea J0178
(aflibercept)

Faslodex J9395
(fulvestrant)

Firazyr J1744
(icatibant)

Fusilev J0641
(levoleucovorin)

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)

Halaven J9179
(eribulin)

Herceptin J9355
(trastuzumab)

Ilaris J0638
(canakinumab)

Imlygic J9325
(talimogene laherparepvec)

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)

Keytruda J9271
(pembrolizumab)

Kyprolis J9047
(carfilzomib)

Leukine J2820
(sargramostim)

Lucentis J2778
(ranibizumab)

Lupron Depot J1950
(leuprolide)

Lupron Depot-Ped J1950
(leuprolide)

Macugen J2503
(pegaptanib)

Mozobil J2562
(plerixafor)

Neulasta J2505
(pegfilgrastim)

Nplate J2796
(romiplostim)

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)

Rituxan J9310
(rituximab)

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)

Stelara J3357
(ustekinumab)

Stelara IV J3590
(ustekinumab)

Sylvant J2860
(siltuximab)

Synribo J9262
(omacetaxine)

Treanda J9033
(bendamustine)

Tysabri J2323
(natalizumab)

Unituxin J9999
(dinutuximab)

Vectibix J9303
(panitumumab)

Velcade J9041
(bortezomib)

Yervoy J9228
(ipilimumab)

Yondelis J9352
(trabectedin)

Zoledronic Acid
(Zometa J3489,
Reclast J3489)

Pharmacy Prior Auth

Afinitor (everolimus)

Alecensa
(alectinib)

Bosulif (bosutinib)

Caprelsa (vandetanib)

Cometriq, Cabometyx Tabs  (cabozantinib)

Cotellic
(cobimetinib)

Erivedge (vismodegib)

Farydak
(panobinostat)

Gilotrif (afatinib)

Granix (tbo-filgrastim)

Hycamtin Oral** (topotecan)

Ibrance
(palbociclib)

Iclusig (ponatinib)

Imbruvica (ibrutinib)

Inlyta (axitinib)

Iressa
(gefitinib)

Jakafi (ruxolitinib)

Lenvima
(lenvatinib)

Lonsurf
(trifluridine and tipiracil)

Mekinist (trametinib)

Neupogen (filgrastim)

Nexavar (sorafenib)

Ninlaro
(ixazomib)

Odomzo
(sonidegib)

Pomalyst (pomalidomide)

Promacta (eltrombopag)

Revlimid (lenalidomide)

Sprycel (dasatinib)

Stivarga (regorafenib)

Sutent (sunitinib)

Sylatron (Peginterferon alfa-2b)

Tafinlar (dabrafenib)

Tagrisso
(osimertinib)

Tarceva (erlotinib)

Targretin* (bexarotene)

Tasigna* (nilotinib)

Tykerb (lapatinib)

Votrient (pazopanib)

Xalkori (crizotinib)

Xeloda** (capecitabine)

Xtandi (enzalutamide)

Zarxio
(filgrastim-sndz)

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 2017 Medicare Part D criteria.

View the Independent Health post service claim edit policies.