Prevea 360 Clinical Guidelines
Coverage of any drug intervention discussed in the plans prior authorization guideline is subject to the limitations and exclusions outlined in the member's benefit certificate or policy and to applicable state and/or federal laws. Prior authorization is not required for Medicare Cost products (Dean Care Gold) and Medicare Supplement (Select) when this drug is provided by participating providers. Prior authorization is required if a member has Medicare primary and the plan secondary coverage. These policies are not applicable to our Medicare Replacement products.
Oncology Policies
Abecma (idecabtagene vicleucel)
Abraxane (paclitaxel protein-bound particles)
Adcetris (brentuximab vedotin)
Adstiladrin (nadofaragene firadenovec-vncg)
Akynzeo (fosnetupitant/palonosetron)
Aliqopa (copanlisib)
Aranesp (darbepoetin alfa)
Azedra (iobenguane I-131)
Bavencio (avelumab)
Beleodaq (belinostat)
Treanda
Bendeka
Belrapzo
Vivimusta
Besponsa (inotuzumab ozogamicin)
Avastin
Mvasi
Zirabev
Alymsys
Vegzelma
Blincyto (blinatumomab)
Velcade
Bortezomib
Breyanzi (lisocabtagene maraleucel)
Jevtana
Cabazitaxel
Carvykti (ciltacabtagene autoleucel)
Cosela (trilaciclib)
Cyramza (ramucirumab)
Danyelza (naxitamab-gqgk)
Darzalex IV (daratumumab)
Darzalex SQ (daratumumab and hyaluronidase-fihj)
Elzonris (tagraxofusp-erzs)
Empliciti (elotuzumab)
Enhertu (fam-trastuzumab deruxtecan-nxki)
Epogen
Procrit
Retacrit
Erbitux alfa (cetuximab)
Neupogen
Nivestym
Zarxio
Releuko
Granix
Fyarro (sirolimus albumin-bound)
Gazyva (obinutuzumab)
Herceptin Hylecta (trastuzumab and hyaluronidase-oysk)
Imfinzi (durvalumab)
Imjudo (tremelimumab-actl)
Imlygic (talimogene laherparepvec)
Infugem (gemcitabine)
Jelmyto (mitomycin)
Jemperli (dostarlimab-gxly)
Kadcyla (ado-trastuzumab emtansine)
Keytruda (pembrolizumab)
Kymriah (tisagenlecleucel)
Kyprolis (carfilzomib)
Lanreotide Somatuline Depot; Lanreotide
Fusilev
Khapzory
Libtayo (cemiplimab-rwlc)
Lumoxiti (moxetumomab pasudotox-tdfk)
Lunsumio (mosunetuzumab-axgb)
Lutathera (lutetium Lu 177 dotatate)
Margenza (margetuximab-cmkb)
Monjuvi (tafasitamab-cxix)
Mylotarg (gemtuzumab ozogamicin)
Nplate (romiplostim)
Onivyde (irinotecan liposome injection)
Opdivo (nivolumab)
Opdualag (nivolumab/relatlimab-rmbw)
Omisirge (omidubicel-onlv)
Padcev (enfortumab vedotin-ejfv)
Pedmark (sodium thiosulfate)
Neulasta
Fulphila
Udenyca
Ziextenzo
Nyvepria
Stimufend
Alimta
Pemfexy
Pepaxto (melphalan flufenamide)
Perjeta (pertuzumab)
Phesgo (pertuzumab, 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)
Rituxan
Truxima
Ruxience
Riabni
Rituximab SQ (rituximab and hyaluronidase human)
Rolvedon (eflapegrastim-xnst)
Rybrevant (amivantamab-vmjw)
Ryplazim (plasminogen, human-tvmh)
Sandostatin LAR (octreotide suspension)
Sarclisa (isatuximab-irfc)
Sustol (granisetron extended-release)
Sylvant (siltuximab)
Tecartus (brexucabtagene autoleucel)
Tecentriq (atezolizumab)
Tecvayli (teclistamab-cqyv)
Tivdak (tisotumab vedotin-tftv)
Herceptin
Ogivri
Kanjinti
Trazimera
Herzuma
Ontruzant
Trodelvy (sacituzumab govitecan-hziy)
Vectibix (panitumumab)
Vyxeos (daunorubicin and cytarabine – liposome)
Yervoy (ipilimumab)
Yescarta (axicabtagene ciloleucel)
Yondelis (trabectedin)
Zepzelca (lurbinectedin)
Zynlonta (loncastuximab tesirine-lpyl)
Zynyz (retifanlimab-dlwr)