Medication Center

Medical Prior Auth and Claims Edits

Abecma (Idecabtagene vicleucel)

Abraxane 
(paclitaxel protein-bound particles)

Actemra
(tocilizumab)

Adakveo

(crizanlizumab-tmca)

Adcetris
(brentuximab)

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

Bendamustine (bendamustine RTD):
Belrapzo

Benlysta IV 
(belimumab)

Beovu
(brolucizumab-dbll)

Berinert
(C1 Esterase Inhibitor Human)

Besponsa
(inotuzumab ozogamicin)

Bevacizumab
Avastin
Mvasi
Zirabev
Alymsys

Blenrep
(belantamab mafodotin-blmf)

Blincyto
(blinatumomab)

Bortezomib
(Intravenous Only)

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)

Corticotropin-ACTH 

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)

Feraheme
ferumoxytol

Filgrastims:
Neupogen (Filgrastim)
Nivestym (Filgrastim-aafi)
Releuko (Tbo‐Filgrastim)

Firazyr
(icatibant)

Fusilev
(levoleucovorin)

Fyarro
(sirolimus albumin-bound nanoparticles)

Gamifant
(emapalumab-lzsg)

Gazyva
(obinutuzumab)

Givlaari
(givosiran)

HA Derivatives

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) 

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)

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)

Monoferric
ferric derisomaltose

Mozobil
(plerixafor)

Mylotarg
(gemtuzumab ozogamicin)

Myobloc
(rimabotulinum toxin B)

Naglazyme 
(galsulfase) 

Neupogen 
(filgrastim)

Nexviazyme (avalglucosidase alfa-ngpt)

Nplate

(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)

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)

Proleukin

(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)

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)