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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.

Medicare is excluded from Prior Authorization and Post Service Claim Edits 

Abraxane (paclitaxel protein bound)

Actemra (tocilizumab) Intravenous (IV) only

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)

Cimzia (certolizumab pegol) - Lyophilized powder only

Cinryze (C1 esterase inhibitor human)

Cinqair (reslizumab)

Cyramza (ramucirumab)

Darzalex (daratumumab)

Elaprase (idursulfase)

Elelyso (taliglucerase alfa)

Empliciti (elotuzumab)

Entyvio (vedolizumab)

Erbitux (cetuximab)

Fabrazyme (agalsidase beta)

Firazyr (icatibant)

Gazyva (obinutuzumab)

Herceptin (trastuzumab)

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)

Lumizyme (alglucosidase alfa)

Mircera (epoetin beta)

Mylotarg (gemtuzumab ozogamicin)

Naglazyme (galsulfase)

NPlate (romiplostim)

Neulasta (pegfilgrastim)

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)

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)

Tysabri (natalizumab)

Vectibix (panitumumab)

Velcade (bortezomib)

VPRIV (velaglucerase alfa)

Vyxeos (daunorubicin and cytarabine)

Xolair (omalizumab)

Yervoy (ipilimumab)

Yondelis (trabectedin)

View Medica Medical Pharmacy Claims Edit policies.