Medication Center

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)

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)

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)

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

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)