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.

 

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

Azedra (iobenguane)

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)

Fulphila (pegfilgrastim-jmdb)

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)

Nivestym (filgrastim-aafi)

Nucala (mepolizumab)

Ocrevus (ocrelizumab)

Onivyde (irinotecan liposome injection)

Onpattro (patisiran lipid complex)

Opdivo (nivolumab)

Orencia (abatacept) Intravenous IV only

Perjeta (pertuzumab)

Portrazza (necitumumab)

Poteligeo (mogamulizumab-kpkc)

Procrit/Epogen (erythropoiesis stimulating agents (ESAs)

Provenge (sipuleucel-T)

Radicava (edaravone)

Remicade (infliximab)

Renflexis (infliximab-abda)

Retacrit (epoetin alfa-epbx)

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)