Mayo Medical Plan Clinical Guidelines and Exclusions

(effective 1/1/2019)

PLEASE NOTE: This list of policies only applies to Mayo Medical Plan for Mayo Clinic employees. 

 

ACTH (repository corticotropin)
Acthar Gel
Cortrophin Gel

Abecma (idecabtagene vicleucel)

Aduhelm (aducanumab-avwa)

Akynzeo (fosnetupitant/palonosetron)

Amondys-45 (casimersen)

Avastin (bevacizumab)

Bavencio (avelumab) 

Blincyto (blinatumomab)

Botox (onabotulinum toxin a)

Breyanzi (lisocabtagene maraleucel)

Carvykti (ciltacabtagene autoleucel)

Darzalex Faspro (daratumumab and hyaluronidase-fihj)

Evenity (romosozumab-aqqg)

Evkeeza (evinacumab-dgnb)

Exondys-51 (eteplirsen)

Gamifant (emapalumab-lzsg)

HA Derivatives

Herceptin (Trastuzumab)

Herceptin Hylecta (trastuzumab and hyaluronidase-oysk)

Ilaris (canakinumab)

Imfinzi (durvalumab)

Imlygic (talimogene laherparepvec)

Jelmyto (mitomycin)

Kadcyla (ado-trastuzumab emtansine)

Keytruda (pembrolizumab)

Kimmtrak (tebentafusp-tebn)

Krystexxa (pegloticase)

Kymriah (tisagenlecleucel)

Leqvio (inclisiran)

Lumizyme (alglucosidase alfa)

Marqibo (vincristine sulfate liposomal)

Nexviazyme (avalglucosidase alfa‐ngpt)

Nucala (mepolizumab)

Opdivo (nivolumab)

Oxlumo (lumarsiran)

Prolia/Xgeva (denosumab)

Rituxan Hyclea (rituximab)

Soliris (eculizumab)

Spinraza (nusinersen)

Sustol (granisetron extended‐release)

Synagis (palivizumab)

Tecartus (brexucabtagene autoleucel)

Tecentriq (atezolizumab)

Tezspire (tezepelumab-ekko)

Tysabri (natalizumab)

Ultomiris (ravulizumab-cwvz)

Viltepso (viltolarsen)

Vyepti (eptinezumab-jjmr)

Vyondys-53 (golodirsen)

Vyvgart (efgartigimod alfa-fcab)

Xolair (omalizumab)

Yervoy (ipilimumab)

Yescarta (axicabtagene ciloleucel)

Zaltrap (ziv-aflibercept)

Zilretta (triamcinolone acetonide ER)

Zolgensma (onasemnogene abeparvovec-xioi)

 

View Mayo Medical Plan List of Drugs Excluded from Coverage (PDF)

Medica Guidelines Home Page

For Medica's Drug Coverage Policies refer to Medica.com