Medica Clinical Guidelines
These policies apply Medica's Commercial, Individual & Family, Minnesota Health Care Programs and Medica Health Plan Solutions plans. Medica's Medicare Advantage, Dual Solutions and AccessAbility Solutions Enhanced plans are excluded from Hemophilia Prior Authorization. For Mayo Medical Plan, please reference plan specific 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.
For Medicare Part B Step Therapy Requirements click here
Abecma (idecabtagene vicleucel)
Abraxane (paclitaxel protein bound)
Actemra (tocilizumab) Intravenous (IV) only
Adakveo (crizanlizumab-tmca)
Adcetris (brentuximab)
Adstiladrin (nadofaragene firadenovec-vncg)
Aduhelm (aducanumab-avwa) - Medicaid and Medicare members only
Akynzeo (fosnetupitant/palonosetron)
Aldurazyme (laronidase)
Aliqopa (copanlisib)
Aloxi (palonosetron)
Amondys-45 (casimersen)
Amvuttra (vutrisiran)
Aranesp (darbepoetin alfa)
Azedra (iobenguane)
Bavencio (avelumab)
Beleodaq (belinostat)
Bendamustine (bendamustine hcl)
Belrapzo
Bendeka
Treanda
Vivimusta
Benlysta IV (belimumab)
Beovu (brolucizumab-dbll)
Berinert (C1 esterase inhibitor human)
Besponsa (inotuzumab ozogamicin)
Alymsys
Avastin
Mvasi
Zirabev
Vegzelma
Blenrep (belantamab mafodotin-blmf)
Blincyto (blinatumomab)
Bortezomib Intravenous (IV) only
Breyanzi (lisocabtagene maraleucel)
Brineura (cerliponase alfa)
Briumvi (ublituximab-xiiy)
Carvykti (ciltacabtagene autoleucel)
Cerezyme (imiglucerase)
Cimzia (certolizumab pegol) - Lyophilized powder only
Cinqair (reslizumab)
Cinryze (C1 esterase inhibitor human)
Cosela (trilaciclib)
Crysvita (burosumab-twza)
Cyramza (ramucirumab)
Danyelza (naxitamab-gqgk)
Darzalex (daratumumab)
Darzalex Faspro (daratumumab and hyaluronidase- fihi)
Denosumab - Commercial, IFB, and Medicaid member's only
Prolia
Xgeva
Elahere (mirvetuximab soravtansine-gynx)
Elaprase (idursulfase)
Elelyso (taliglucerase alfa)
Elzonris (tagraxofusp-erzs)
Empliciti (elotuzumab)
Enhertu (fam-trastuzumab deruxtecan-nxki)
Enjaymo (sutimlimab-jome)
Enspryng (satralizumab-mwge)
Entyvio (vedolizumab)
Epoetin (erythropoiesis stimulating agents (ESAs)
Procrit
Epogen
Retacrit
Erbitux (cetuximab)
Evenity (romosozumab-aqqg)
Evkeeza (evinacumab-dgnb)
Exondys-51 (eteplirsen)
Eylea (aflibercept)
Fabrazyme (agalsidase beta)
Fasenra (benralizumab)
Feraheme (ferumoxytol)
Granix
Neupogen
Nivestym
Releuko
Firazyr (icatibant)
Fyarro (sirolimus albumin-bound)
Gamifant (emapalumab-lzsg)
Gazyva (obinutuzumab)
Givlaari (givosiran)
Hemgenix (etranacogene dezaparvovec-drlb)
Herceptin Hylecta (trastuzumab and hyaluronidase-oysk)
Ilumya (tildrakizumab-asmn)
Imfinzi (durvalumab)
Imjudo (tremelimumab-actl)
Imlygic (talimogene laherparepvec)
Avsola
Inflectra
Renflexis
Remicade
Infugem (gemcitabine)
Injectafer (ferric carboxymaltose)
Intravenous Immune Globulin (IVIG)
Asceniv
Bivigam
Flebogamma 10% DIF
Flebogamma 5% DIF
Gamunex-C
Gammagard Liquid
Gammagard S/D
Gammaked
Gammaplex
Octagam 10%
Octagam 5%
Privigen
Panzyga
Jelmyto (mitomycin)
Jemperli (dostarlimab-gxly)
Jevtana (cabazitaxel)
Kadcyla (ado-trastuzumab emtansine)
Kalbitor (ecallantide)
Kanuma (sebelipase alfa)
Keytruda (pembrolizumab)
Krystexxa (pegloticase)
Kymriah (tisagenlecleucel)
Kyprolis (carfilzomib)
Lamzede (velmanase alfa-tycv)
Lemtrada (alemtuzumab)
Leqvio (inclisiran)
Fusilev
Khapzory
Libtayo (cemiplimab-rwlc)
Lumizyme (alglucosidase alfa)
Lumoxiti (moxetumomab pasudotox-tdfk)
Lunsumio (mosunetuzumab-axgb)
Lutathera (lutetium Lu 177 dotatate)
Luxturna (voretigene neparvovec-rzyl)
Macugen (pegaptanib)
Margenza (margetuximab-cmkb)
Mepsevii (vestronidase alfa-vjbk)
Monjuvi (tafasitamab-cxix)
Monoferric (ferric derisomaltose)
Mylotarg (gemtuzumab ozogamicin)
Naglazyme (galsulfase)
Nexviazyme (avalglucosidase alfa-ngpt)
NPlate (romiplostim)
Nucala (mepolizumab)
Nulibry (fosdenopterin)
Ocrevus (ocrelizumab)
Onivyde (irinotecan liposome injection)
Onpattro (patisiran lipid complex)
Opdivo (nivolumab)
Opdualag (nivolumab/relatlimab-rmbw)
Orencia (abatacept) Intravenous IV only
Oxlumo (lumasiran)
Padcev (enfortumab vedotin-ejfv)
Pedmark (sodium thiosulfate)
Fulphila
Fylnetra
Neulasta
Nyvepria
Udenyca
Ziextenzo
Stimufend
Pemetrexed
Alimta
Pemfexy
Pepaxto (melphalan flufenamide)
Perjeta (pertuzumab)
Phesgo (pertuzmab, trastuzumab and hyaluronidase-zzxf)
Pluvicto (lutetium Lu 177 vipivotide tetraxetan)
Polivy (polatuzumab vedotin-piiq)
Portrazza (necitumumab)
Poteligeo (mogamulizumab-kpkc)
Proleukin (aldesleukin, IL-2)
Provenge (sipuleucel-T)
Radicava (edaravone)
Byooviz
Lucentis
Cimerli
Reblozyl (luspatercept-aamt)
Revcovi (elapegademase-lvlr)
Rituxan
Truxima
Ruxience
Riabni
Rituxan Hycela SQ (rituximab and hyaluronidase human)
Rolvedon (eflapegrastim-xnst)
Ruconest (C1 Esterase Inhibitor [recombinant])
Rybrevant (amivantamab-vmjw)
Ryplazim (plasminogen, human-tvmh)
Sandostatin (octreotide suspension) - Commercial & IFB Only
Saphnelo (anifrolumab-fnia)
Sarclisa (isatuximab irfc)
Scenesse (afamelanotide)
Subcutaneous Immune Globulin (SCIG)
Hizentra
Gamunex-C
Gammaked
Gammagard liquid
HyQvia
Cuvitru
Cutaquig
Xembify
Signifor LAR (pasireotide)
Simponi ARIA (golimumab)
Skyrizi IV (risankizumab-rzaa)
Skysona (elivaldogene autotemcel)
Soliris (eculizumab)
Spevigo (spesolimab)
Spravato (esketamine)
Spinraza (nusinersen)
Stelara (ustekinumab)
Sustol (granisetron extended‐release)
Susvimo (ranibizumab)
Syfovre (pegcetacoplan)
Sylvant (siltuximab)
Synagis (palivizumab)
Tecartus (brexucabtagene autoleucel)
Tecentriq (atezolizumab)
Tecvayli (teclistamab-cqyv)
Tepezza (teprotumumab-trbw)
Tezspire (tezepelumab-ekko)
Tivdak (tisotumab vedotin-tftv)
Herceptin
Herzuma
Kanjinti
Ogivri
Ontruzant
Trazimera
Trodelvy (sacituzumab govitecan-hziy)
Trogarzo (ibalizumab-uiyk)
Tysabri (natalizumab)
Tzield (teplizumab-mzwv)
Ultomiris (ravulizumab-cwvz)
Uplizna (inebilizumab-cdon)
Vabysmo (faricimab-svoa)
Vectibix (panitumumab)
Velcade (bortezomib)
Viltepso (viltolarsen)
Vimizim (elosulfase alfa)
VPRIV (velaglucerase alfa)
Vyepti (eptinezumab-jjmr)
Vyondys 53 (golodirsen)
Vyvgart (efgartigimod alfa-fcab)
Vyxeos (daunorubicin and cytarabine)
Xenpozyme (olipudase alfa)
Xipere (triamcinolone acetonide)
Xolair (omalizumab)
Yervoy (ipilimumab)
Yescarta (axicabtagene ciloleucel)
Yondelis (trabectedin)
Zepzelca (lurbinectedin)
Zolgensma (onasemnogene abeparvovec-xioi)
Zynlonta (loncastuximab tesirine-lpyl)
Zynteglo (betibeglogene autotemcel)
Zynyz (retifanlimab-dlwr)