Security Health Plan Clinical Guidelines
Effective July 1, 2023 - 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)
Adakveo
(crizanlizumab-tmca)
Adcetris
(brentuximab)
Adstiladrin
(nadofaragene firadenovec-vncg)
Adbry
(tralokinumab-ldrm)
Akynzeo IV
(netupiant and palonosetron)
Aldurazyme
(laronidase)
Aliqopa
(copanlisib)
Aloxi
(palonosetron)
Alpha-1-Proteinase Inhibitors:
Aralast NP
Glassia
Prolastin-C
Zemaira
Amondys-45 (casimersen)
Amvuttra
vutrisiran
Aranesp
(darbepoetin alfa)
Arzerra
(ofatumumab)
Asparlas
(calaspargase pegol-mknl)
Bavencio
(avelumab)
Beleodaq
(belinostat)
Bendamustine (bendamustine hcl):
Bendeka
Treanda
Vivimusta
Bendamustine (bendamustine RTD):
Belrapzo
Benlysta IV
(belimumab)
Beovu
(brolucizumab-dbll)
Berinert
(C1 Esterase Inhibitor Human)
Besponsa
(inotuzumab ozogamicin)
Bevacizumab
Avastin
Mvasi
Zirabev
Alymsys
Vegzelma
Blenrep
(belantamab mafodotin-blmf)
Blincyto
(blinatumomab)
Bortezomib
(Intravenous Only)
Botox
(onabotulinum toxin A)
Breyanzi (lisocabtagene maraleucel)
Brineura
(cerliponase alfa)
Briumvi
(ublituximab-xiiy)
Carvykti
(ciltacabtagene autoleucel)
Cerezyme
(imiglucerase)
Cimzia
(certolizumab pegol)
Cinqair
(reslizumab)
Cinryze
(C1 Esterase Inhibitor Human)
Corticotropin-ACTH
Acthar Gel (repository corticotropin injection)
Cortrophin Gel (repository corticotropin injection)
Cosela
(trilaciclib)
Cosentyx
(secukinumab)
Crysvita
(burosumab-twza)
Cyramza
(ramucirumab)
Danyelza
(naxitamab-gqgk)
Darzalex
(daratumumab)
Darzalex Faspro
(daratumumab and hyaluronidase-fihj)
Dysport
(abobotulinum toxin A)
Elahere
(mirvetuximab soravtansine‐gynx)
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)
Feraheme
ferumoxytol
Filgrastims:
Neupogen (Filgrastim)
Nivestym (Filgrastim-aafi)
Releuko (Tbo‐Filgrastim)
Firazyr
(icatibant)
Fulvestrant
Faslodex
Fulvestrant Ψ
Fyarro
(sirolimus albumin-bound nanoparticles)
Gamifant
(emapalumab-lzsg)
Gazyva
(obinutuzumab)
Givlaari
(givosiran)
HA Derivatives
Durolane
Euflexxa
GelSyn-3
GenVisc 850
Hymovis
Monovisc
Orthovisc
Supartz
Synojoynt
Synvisc
Synvisc-One
TriVisc
Visco-3
Haegarda
(C1 Esterase Inhibitor (Human))
Halaven
(eribulin)
Hemgenix
(etranacogene dezaparvovec‐drlb)
Herceptin Hylecta
(trastuzumab and hyaluronidase‐oysk)
Ilumya (tildrakizumab-asmn)
Iluvien
(fluocinonide acetonide implant)
Imfinzi
(durvalumab)
Imjudo
(tremelimumab‐actl)
Imlygic
(talimogene laherparepvec)
Infliximabs
(Remicade,
Inflectra,
Renflexis,
Avsola)
Infugem
(gemcitabine)
Injectafer
ferric carboxymaltose injection
IVIG (immune globulin):
(Asceniv,Bivigam,
Carimune NF,
Flebogamma/Flebogamma DIF,
Gammaplex,
Gamunex-C,
Gammaked,
Gammagard S/D,
Gammagard Liquid,
Octagam,Panzyga
Privigen)
Ixempra
(ixabepilone)
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)
Lamzede
(velmanase alfa-tycv)
Lanreotide:
Somatuline Depot; Lanreotide
Lemtrada
(alemtuzumab)
Leqvio
(inclisiran)
Levoleucovorin
Fusilev
Khapzory
Libtayo
(cemiplimab-rwlc)
Lumakras
(sotorasib)
Lumizyme
(alglucosidase alfa)
Lumoxiti
(moxetumomabpasudotox-tdfk)
Lunsumio
(mosunetuzumab-axgb)
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
Mozobil
(plerixafor)
Mylotarg
(gemtuzumab ozogamicin)
Myobloc
(rimabotulinum toxin B)
Naglazyme
(galsulfase)
Neupogen
(filgrastim)
Nexviazyme (avalglucosidase alfa-ngpt)
(romiplostim)
Nucala
(mepolizumab)
Nulibry
(fosdenopterin)
Ocrevus
(ocrelizumab)
Oncaspar
(pegaspargase)
Onivyde
(irinotecan liposome injection)
Onpattro
(patisiran)
Opdivo
(nivolumab)
Opdualag
(nivolumab/relatlimab-rmbw)
Orencia
(abatacept)
Oxlumo
(lumasiran)
Ozurdex
(dexamethasone implant)
Padcev
(enfortumab vedotin-ejfv)
Pedmark
(sodium thiosulfate)
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
Rolvedon
(eflapegrastim‐xnst)
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)
Skyrizi
(risankizumab-rzaa)
Skysona
(elivaldogene autotemcel)
Soliris
(eculizumab)
Somatuline Depot
(lanreotide)
Spinraza
(nusinersen)
Stelara
(ustekinumab)
Sustol
(graniestron extended-release)
Susvimo
(ranibizumab)
Syfovre
(pegcetacoplan)
Sylvant
(siltuximab)
Synagis
(Palivizumab)
Synribo
(omacetaxine)
Takhzyro
(Lanadelumab-flyo)
Tecartus
(brexucabtagene autoleucel)
Tecentriq
(atezolizumab)
Tecvayli
(teclistamab‐cqyv)
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)
Tzield
(teplizumab‐mzwv)
Ultomiris
(ravulizumab-cwvz)
Uplizna
(inebilizumab-cdon)
Vabysmo
(faricimab-svoa)
Vectibix
(panitumumab)
Velcade
(bortezomib)
Vidaza
(Azacitidine)
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)
Yutiq
(fluocinolone acetonide implant)
Zaltrap
(ziv-aflibercept)
Zepzelca
(lurbinectedin)
Zilretta
(triamcinolone acetonide ER)
Zolgensma
(onasemnogene abeparvovac-xioi)
Zynlonta
(loncastuximab tesirine‐lpyl)
Zynyz
(retifanlimab-dlwr)
View the Security Health Plan post service claim edit policies.