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)
Adstiladrin (nadofaragene firadenovec-vncg)
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)
Elahere (mirvetuximab soravtansine‐gynx)
Evenity (romosozumab-aqqg)
Evkeeza (evinacumab-dgnb)
Exondys-51 (eteplirsen)
Gamifant (emapalumab-lzsg)
Hemgenix (etranacogene dezaparvovec-drlb)
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)
Lamzede (velmanase alfa-tycv)
Leqembi (lecanemab-irmb)
Leqvio (inclisiran)
Lumizyme (alglucosidase alfa)
Lunsumio (mosunetuzumab-axgb)
Luxturna (voretigene neparvovec-rzyl)
Nexviazyme (avalglucosidase alfa‐ngpt)
Nucala (mepolizumab)
Opdivo (nivolumab)
Opdualag (nivolumab/relatlimab-rmbw)
Oxlumo (lumarsiran)
Pedmark (sodium thiosulfate)
Pegfilgrastim (Neulasta Prefilled Syringe)
Prolia/Xgeva (denosumab)
Rituxan Hyclea (rituximab)
Skyrizi IV (risankizumab-rzaa)
Skysona (elivaldogene autotemcel)
Spevigo (spesolimab)
Spinraza (nusinersen)
Sustol (granisetron extended‐release)
Synagis (palivizumab)
Tecartus (brexucabtagene autoleucel)
Tecentriq (atezolizumab)
Tecvayli (teclistamab-cqyv)
Tezspire (tezepelumab-ekko)
Tysabri (natalizumab)
Ultomiris (ravulizumab-cwvz)
Viltepso (viltolarsen)
Vyepti (eptinezumab-jjmr)
Vyondys-53 (golodirsen)
Vyvgart (efgartigimod alfa-fcab)
Xenpozyme (olipudase alfa)
Xolair (omalizumab)
Yervoy (ipilimumab)
Yescarta (axicabtagene ciloleucel)
Zaltrap (ziv-aflibercept)
Zilretta (triamcinolone acetonide ER)
Zolgensma (onasemnogene abeparvovec-xioi)
Zynteglo (betibeglogene autotemcel)
View Mayo Medical Plan List of Drugs Excluded from Coverage (PDF)