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)

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

Benlysta IV (belimumab)

Beovu (brolucizumab-dbll)

Berinert (C1 esterase inhibitor human)

Besponsa (inotuzumab ozogamicin)

Bevacizumab

Alymsys

Avastin

Mvasi

Zirabev

Blenrep (belantamab mafodotin-blmf)

Blincyto (blinatumomab)

Bortezomib Intravenous (IV) only

Breyanzi (lisocabtagene maraleucel)

Brineura (cerliponase alfa)

Carvykti (ciltacabtagene autoleucel)

Cerezyme (imiglucerase)

Cimzia (certolizumab pegol) - Lyophilized powder only

Cinqair (reslizumab)

Cinryze (C1 esterase inhibitor human)

Cosela ( trlaciclib)

Crysvita (burosumab-twza)

Cyramza (ramucirumab)

Danyelza (naxitamab-gqgk)

Darzalex (daratumumab)

Darzalex Faspro (daratumumab and hyaluronidase- fihi)

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)

Filgrastim

Granix

Neupogen

Nivestym

Releuko

Firazyr (icatibant)

Fyarro (sirolimus albumin-bound)

Gamifant (emapalumab-lzsg)

Gazyva (obinutuzumab)

Givlaari (givosiran)

Herceptin Hylecta (trastuzumab and hyaluronidase-oysk)

Ilumya (tildrakizumab-asmn)

Imfinzi (durvalumab)

Imlygic (talimogene laherparepvec)

Infliximab

Avsola

Inflectra

Renflexis

Remicade

Infugem (gemcitabine)

Injectafer (ferric carboxymaltose)

Intravenous Immune Globulin (IVIG)

Asceniv

Bivigam

Carimune NF

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)

Lemtrada (alemtuzumab)

Leqvio (inclisiran)

Levoleucovorin

Fusilev 

Khapzory

Libtayo (cemiplimab-rwlc)

Lumizyme (alglucosidase alfa)

Lumoxiti (moxetumomab pasudotox-tdfk)

Lutathera (lutetium Lu 177 dotatate)

Luxturna (voretigene neparvovec-rzyl)

Macugen (pegaptanib)

Margenza (margetuximab-cmkb)

Marqibo (vincristine sulfate liposomal)

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)

Pegfilgrastim

Fulphila

Fylnetra

Neulasta

Nyvepria

Udenyca

Ziextenzo

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)

Ranibizumab

Byooviz

Lucentis

Reblozyl (luspatercept-aamt)

Revcovi (elapegademase-lvlr)

Rituximab

Rituxan

Truxima

Ruxience

Riabni

Rituxan Hycela SQ (rituximab and hyaluronidase human)

Ruconest (C1 Esterase Inhibitor [recombinant])

Rybrevant (amivantamab-vmjw)

Ryplazim (plasminogen, human-tvmh)

Sandostatin (octreotide suspension) - Commercial & IFB Only

Saphnelo (anifrolumab-fnia)

Sarclisa (isatuximab irfc)

Subcutaneous Immune Globulin (SCIG)

Hizentra

Gamunex-C

Gammaked

Gammagard liquid

HyQvia

Cuvitru

Cutaquig

Xembify

Simponi ARIA (golimumab)

Skyrizi IV (risankizumab-rzaa)

Soliris (eculizumab)

Spinraza (nusinersen)

Stelara (ustekinumab)

Sustol (granisetron extended‐release)

Susvimo (ranibizumab)

Sylvant (siltuximab)

Synagis (palivizumab)

Tecartus (brexucabtagene autoleucel)

Tecentriq (atezolizumab)

Tepezza (teprotumumab-trbw)

Tezspire (tezepelumab-ekko)

Tivdak (tisotumab vedotin-tftv)

Trastuzumab

Herceptin

Herzuma

Kanjinti

Ogivri

Ontruzant

Trazimera

Trodelvy (sacituzumab govitecan-hziy)

Trogarzo (ibalizumab-uiyk)

Tysabri (natalizumab)

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)

Xipere (triamcinolone acetonide)

Xolair (omalizumab)

Yervoy (ipilimumab)

Yescarta (axicabtagene ciloleucel)

Yondelis (trabectedin)

Zepzelca (lurbinectedin)

Zolgensma (onasemnogene abeparvovec-xioi)

Zynlonta (loncastuximab tesirine-lpyl)