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. 

 

Acthar HP (corticotropin)

Aduhelm (aducanumab-avwa)

Akynzeo (fosnetupitant/palonosetron)

Amondys-45 (casimersen)

Avastin (bevacizumab)

Bavencio (avelumab) 

Blincyto (blinatumomab)

Botox (onabotulinum toxin a)

Breyanzi (lisocabtagene maraleucel)

Cinqair(certolizumab pegol)

Darzalex Faspro (daratumumab and hyaluronidase-fihj)

Evenity (romosozumab-aqqg)

Exondys-51 (eteplirsen)

Fasenra (benralizumab)

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)

Krystexxa (pegloticase)

Kymriah (tisagenlecleucel)

Marqibo (vincristine sulfate liposomal)

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)

Tysabri (natalizumab)

Ultomiris (ravulizumab-cwvz)

Viltepso (viltolarsen)

Vyepti (eptinezumab-jjmr)

Vyondys-53 (golodirsen)

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