Security Health Plan Clinical Guidelines
Effective July 1, 2022 - Step Therapy requirements for Medicare outpatient (Part B) medications
Medical Prior Auth and Claims Edits
Abecma (Idecabtagene vicleucel)
Abraxane
(paclitaxel protein-bound particles)
Actemra
(tocilizumab)
(crizanlizumab-tmca)
Adcetris
(brentuximab)
Adbry
(tralokinumab-ldrm)
Akynzeo IV
(netupiant and palonosetron)
Aldurazyme
(laronidase)
Aloxi
(palonosetron)
Alpha-1-Proteinase Inhibitors:
Aralast NP
Glassia
Prolastin-C
Zemaira
Amondys-45 (casimersen)
Aranesp
(darbepoetin alfa)
Arzerra
(ofatumumab)
Asparlas
(calaspargase pegol-mknl)
Bavencio
(avelumab)
Beleodaq
(belinostat)
Bendamustine (bendamustine hcl):
Bendeka
Treanda
Bendamustine (bendamustine RTD):
Belrapzo
Benlysta IV
(belimumab)
Beovu
(brolucizumab-dbll)
Berinert
(C1 Esterase Inhibitor Human)
Bevacizumab
Avastin
Mvasi
Zirabev
Blenrep
(belantamab mafodotin-blmf)
Blincyto
(blinatumomab)
Botox
(onabotulinum toxin A)
Breyanzi (lisocabtagene maraleucel)
Brineura
(cerliponase alfa)
Carvykti
(ciltacabtagene autoleucel)
Cerezyme
(imiglucerase)
Cimzia
(certolizumab pegol)
Cinqair
(reslizumab)
Cinryze
(C1 Esterase Inhibitor Human)
Cosela (trilaciclib)
Cosentyx
(secukinumab)
Crysvita
(burosumab-twza)
Cyramza
(ramucirumab)
Danyelza
(naxitamab-gqgk)
Darzalex
(daratumumab)
Darzalex Faspro
(daratumumab and hyaluronidase-fihj)
Dysport
(abobotulinum toxin A)
Elaprase
(idursulfase)
Elelyso
(taliglucerase alfa)
Elzonris
(tagraxofusp-resz)
Empliciti
(elotuzumab)
Enhertu
(fam-trastuzumab deruxtecan-nxki)
Enjaymo
(sutimlimab‐jome)
Enspryng
(satralizumab-mwge)
Entyvio
Effective 7/1/22
(vedolizumab)
Epoetin alfa:
Epogen
Procrit
Retacrit
Erbitux
(cetuximab)
Evenity
(romozozumab-aqqg)
Evkeeza
(evinacumab-dgnb)
Exondys-51
(eteplirse)
Eylea
(aflibercept)
Fabrazyme
(agalsidase beta)
Fasenra
(benralizumab)
filgrastims:
Neupogen
Nivestym
Firazyr
(icatibant)
Fusilev
(levoleucovorin)
Fyarro
(sirolimus albumin-bound nanoparticles)
Gamifant
(emapalumab-lzsg)
Gazyva
(obinutuzumab)
Givlaari
(givosiran)
Haegarda
(C1 Esterase Inhibitor (Human))
Halaven
(eribulin)
Herceptin Hylecta
(trastuzumab and hyaluronidase‐oysk)
Ilumya (tildrakizumab-asmn)
Iluvien
(fluocinonide acetonide implant)
Imfinzi
(durvalumab)
Imlygic (talimogene laherparepvec)
Infliximabs
(Remicade,
Inflectra,
Renflexis,
Avsola)
Infugem
(gemcitabine)
IVIG (immune globulin):
(Asceniv,Bivigam,
Carimune NF,
Flebogamma/Flebogamma DIF,
Gammaplex,
Gamunex-C,
Gammaked,
Gammagard S/D,
Gammagard Liquid,
Octagam,Panzyga
Privigen)
Jemperli
(dostarlimab‐gxly)
Jevtana
(cabazitaxel)
Kadcyla
(ado-trastuzumab emtansine)
Kalbitor
(ecallantide)
Kanuma
(sebelipase alfa)
Keytruda
(pembrolizumab)
Kimmtrak
(tebentafusp‐tebn)
Krystexxa
(pegloticase)
Kymriah
(tisagenlecleucel)
Kyprolis
(carfilzomib)
Lemtrada
(alemtuzumab)
Leqvio
(inclisiran)
Libtayo
(cemiplimab-rwlc)
Lumakras
(sotorasib)
Lumizyme
(alglucosidase alfa)
Lumoxiti
(moxetumomabpasudotox-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)
Mozobil
(plerixafor)
Myobloc
(rimabotulinum toxin B)
Naglazyme
(galsulfase)
Neupogen
(filgrastim)
Nexviazyme (avalglucosidase alfa-ngpt)
Nivestym
(filgrastim-aafi)
Nplate
(romiplostim)
Nucala
(mepolizumab)
Nulibry
(fosdenopterin)
Ocrevus
(ocrelizumab)
Oncaspar
(pegaspargase)
Onivyde
(irinotecan liposome injection)
Onpattro
(patisiran)
Opdivo
(nivolumab)
Orencia
(abatacept)
Oxlumo
(lumasiran)
Ozurdex
(dexamethasone implant)
Padcev
(enfortumab vedotin-ejfv)
Pegfilgrastim:
Neulasta
Fulphila
Udenyca
Ziextenzo
Nyvepria
Pemetrexed:
Alimta
Pemfexy
Pepaxto (melphalan flufenamide)
Perjeta
(pertuzumab)
Phesgo
(pertuzumab, trastuzumab and hyaluronidase-zzxf)
Polivy
(polatuzumab vedotinpiiq)
Portrazza
(necitumumab)
Poteligeo
(mogamulizumab-kpkc)
(aldesleukin)
Prolia/Xgeva
(denosumab)
Provenge
(sipuleucel-T)
Radicava
(edaravone)
Ranibizumab:
Byooviz
Lucentis
Reblozyl
(luspatercept-aamt)
Retacrit
(Anemia)
Retisert
(fluocinolone acetonide implant)
Revcovi
(elapegademase-lvlr)
Rituxan Hycela
(rituximab and hyaluonidase human)
Rituximab:
Rituxan
Truxima
Ruxience
Riabni
Ruconest
(C1 Esterase Inhibitor [recombinant])
Ruxience
(rituximab-pvvr)
Rybrevant
(amivantamab‐vmjw)
Rylaze
(asparaginase Erwinia chrysanthemi (recombinant)-rywn)
Ryplazim (plasminogen, human-tvmh)
Sandostatin LAR
(octreotide)
Saphnelo
(anifrolumab-fnia)
Sarclisa
(isatuximab-irfc)
Scenesse (afamelanotide)
SCIG (immune globulin SQ):
(Cuvitru,
Hizentra,
Gammagard Liquid,
Gamunex-C,
Gammaked,
Hyqvia)
Signifor LAR
(pasireotide)
Simponi ARIA
(golimumab)
Soliris
(eculizumab)
Somatuline Depot
(lanreotide)
Spinraza
(nusinersen)
Stelara
(ustekinumab)
Sustol
(graniestron extended-release)
Susvimo
(ranibizumab)
Sylvant
(siltuximab)
Synagis
(Palivizumab)
Synribo
(omacetaxine)
Takhzyro
(Lanadelumab-flyo)
Tecartus
(brexucabtagene autoleucel)
Tecentriq
(atezolizumab)
Tepezza
(teprotumumab-trbw)
Tezspire
(tezepelumab-ekko)
Tivdak
(tisotumab vedotin-tftv)
Trastuzumab
Herceptin
Ogivri
Kanjinti
Trazimera
Herzuma
Ontruzant
Trodelvy
(sacituzumab govitecan-hziy)
Truxima
(rituximab-abbs)
Tysabri
(natalizumab)
Ultomiris
(ravulizumab-cwvz)
Uplizna
(inebilizumab-cdon)
Vabysmo
(faricimab-svoa)
Vectibix
(panitumumab)
Vidaza
(Azacitidine)
Viltepso
(viltolarsen)
Vimizim
(elosulfase alfa)
VPRIV
(velaglucerase alfa)
Vyepti
(eptinezumab-jjmr)
Vyondys-53 (golodirsen)
Vyvgart
(efgartigimod alfa-fcab)
Xipere
(triamcinolone acetonide)
Xolair
(omalizumab)
Yervoy
(ipilimumab)
Yescarta
(axicabtagene ciloleucel)
Yondelis
(trabectedin)
Yutiq
(fluocinolone acetonide implant)
Zaltrap
(ziv-aflibercept)
Zepzelca
(lurbinectedin)
Zilretta
(triamcinolone acetonide ER)
Zolgensma
(onasemnogene abeparvovac-xioi)
Zynlonta
(loncastuximab tesirine‐lpyl)
View the Security Health Plan post service claim edit policies.