Medica Fax Form

Medica Clinical Guidelines

PLEASE NOTE: These policies do not apply to the SUBCUTANEOUS formulations of Actemra, Cimzia, and Orencia, which are handled by the pharmacy benefit.

Medica Prime Solution® is the only Medicare exclusion from Prior Authorization and Post Service Claim Edits.

Abraxane (paclitaxel protein bound)

Actemra (tocilizumab) Intravenous (IV) only

Adcetris (brentuximab) 

Akynzeo (fosnetupitant/palonosetron)

Aldurazyme (laronidase)

Alimta (pemetrexed)

Aliqopa (copanlisib)

Aloxi (palonosetron)

Aranesp (darbepoetin alfa)

Avastin (bevacizumab) - For Oncology Indications

Bavencio (avelumab)

Beleodaq (belinostat)

Bendeka (bendamustine hcl)

Benlysta (belimumab)

Berinert (C1 esterase inhibitor human)

Besponsa (inotuzumab ozogamicin)

Blincyto (blinatumomab)

Brineura (cerliponase alfa)

Cerezyme (imiglucerase)

Cimzia (certolizumab pegol) - Lyophilized powder only

Cinryze (C1 esterase inhibitor human)

Cinqair (reslizumab)

Crysvita (burosumab-twza)

Cyramza (ramucirumab)

Darzalex (daratumumab)

Elaprase (idursulfase)

Elelyso (taliglucerase alfa)

Empliciti (elotuzumab)

Entyvio (vedolizumab)

Erbitux (cetuximab)

Eylea (aflibercept)

Fabrazyme (agalsidase beta)

Fasenra (benralizumab)

Firazyr (icatibant)

Granix (tbo-filgrastim)

Herceptin (trastuzumab)

Ilumya (tildrakizumab-asmn)

Imfinzi (durvalumab)

Imlygic (talimogene laherparepvec)

Inflectra (infliximab-dyyb)

Intravenous Immune Globulin (IVIG)

Jevtana (cabazitaxel)

Kadcyla (ado-trastuzumab emtansine)

Kalbitor (ecallantide)

Kanuma (sebelipase alfa)

Keytruda (pembrolizumab)

Kymriah (tisagenlecleucel)

Lartruvo (olaratumab)

Lemtrada (alemtuzumab)

Lucentis (Ranibizumab)

Lumizyme (alglucosidase alfa)

Lutathera (lutetium Lu 177 dotatate)

Luxturna (voretigene neparvovec-rzyl)

Macugen (pegaptanib)

Mepsevii (vestronidase alfa-vjbk)

Mylotarg (gemtuzumab ozogamicin)

Naglazyme (galsulfase)

NPlate (romiplostim)

Neulasta (pegfilgrastim)

Neupogen (filgrastim)

Nucala (mepolizumab)

Ocrevus (ocrelizumab)

Onivyde (irinotecan liposome injection)

Opdivo (nivolumab)

Orencia (abatacept) Intravenous IV only

 

Perjeta (pertuzumab)

Portrazza (necitumumab)

Procrit/Epogen (erythropoiesis stimulating agents (ESAs)

Provenge (sipuleucel-T)

Radicava (edaravone)

Remicade (infliximab)

Renflexis (infliximab-abda)

Rituxan (rituximab)

Rituxan Hycela (rituximab and hyaluronidase human)

Ruconest (C1 Esterase Inhibitor [recombinant])

Subcutaneous Immune Globulin (SCIG)

Simponi ARIA (golimumab)

Soliris (eculizumab)

Spinraza (nusinersen)

Stelara (ustekinumab)

Sustol (granisetron extended‐release)

Sylvant (siltuximab)

Synagis (palivizumab)

Tecentriq (atezolizumab)

Treanda (bendamustine)

Trogarzo (ibalizumab-uiyk)

Tysabri (natalizumab)

Vectibix (panitumumab)

Velcade (bortezomib)

Vimizim (elosulfase alfa)

VPRIV (velaglucerase alfa)

Vyxeos (daunorubicin and cytarabine)

Xolair (omalizumab)

Yervoy (ipilimumab)

Yescarta (axicabtagene ciloleucel)

Yondelis (trabectedin)

 

Hemophilia Program

Anti-Inhibitor Coagulant Complex (Feiba NF/Feiba VF) 

Anti-Inhibitor Antibody: Hemlibra (emicizumab-kxwh)

Factor VIIa (Novoseven RT)

Factor VIII
(Advate,
Adynovate,
Afstyla,
Eloctate,
Hemofil M,
Hexilate FS,
Koate DVI,
Kogenate FS,
Kovaltry,
Monoclate-P,
Novoeight,
Nuwiq,
Obizur,
Recombinate,
Xyntha)

Factor IX 
(Alphanine SD,
Alprolix,
Bebulin,
BeneFIX,
Idelvion,
Ixinity,
Mononine,
Profilnine,
Rebinyn,
Rixubis)

Factor X (Coagadex)

Factor XIII (Corifact)

Coagulation Factor XIII A-subunit (Tretten)

von Willebrand Factor (Vonvendi)

Factor VIII/VWF Complex 
(Alphanate,
Humate-P,
Wilate)

Hemophilia Products Prior Authorization Form

Hemophilia Case Review Form

 

Mandatory Site of Service Program

Site of Service Policy