Security Health Plan Clinical Guidelines

 

Effective August 1, 2021 - Step Therapy requirements for Medicare outpatient (Part B) medications

Medical Prior Auth and Claims Edits

Abraxane 
(paclitaxel protein-bound particles)

Actemra
(tocilizumab)

Acthar Gel
(corticotropin, ACTH) 

Adakveo
(crizanlizumab-tmca)

Adcetris
(brentuximab)

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)

Beouv
(brolucizumab-dbll)

Berinert
(C1 Esterase Inhibitor Human)

Bevacizumab
Avastin
Mvasi
Zirabev

Blenrep
(belantamab mafodotin-blmf)

Blincyto
(blinatumomab)

Botox 
(onabotulinum toxin A) 

Brineura
(cerliponase alfa)

Cerezyme
(imiglucerase)

Cimzia
(certolizumab pegol)

Cinqair
(reslizumab)

Cinryze 
(C1 Esterase Inhibitor Human)

Cosela (trilaciclib)

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) 

Enspryng
(satralizumab-mwge)

Entyvio 
(vedolizumab)

Erbitux
(cetuximab)

Evenity
(romozozumab-aqqg) 

Evkeeza (evinacumab-dgnb)

Exondys-51
(eteplirse)

Eylea
(aflibercept)

Fabrazyme 
(agalsidase beta)

Fasenra 
(benralizumab)

Firazyr
(icatibant)

Fusilev
(levoleucovorin)

Gamifant
(emapalumab-lzsg)

Gazyva
(obinutuzumab)

HA Derivatives

Euflexxa
Durolane
Gel-One
Gel-Syn
GenVisc 850
Hylagan
Hymovis
Monovisc
Orthovisc
Supartz/Supartz FX
Synojoynt, Synvisc
Synvisc-One
Triluron, TriVisc
Visco-3

Haegarda
(C1 Esterase Inhibitor (Human))

Halaven
(eribulin)

Herceptin Hylecta
(trastuzumab and hyaluronidase‐oysk)

Iluvien 
(fluocinonide acetonide implant) 

Imfinzi 
(durvalumab)

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)

Krystexxa 
(pegloticase)

Kyprolis
(carfilzomib)

Lemtrada 
(alemtuzumab)

Libtayo
(cemiplimab-rwlc)

Lucentis
(Ranibizumab)

Lumakras
(sotorasib)

Lumizyme 
(alglucosidase alfa)

Lumoxiti
(moxetumomabpasudotox-tdfk)

Lutathera
(lutetium Lu 177 dotatate)

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)

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)

Procrit/Epogen
(epoetin alfa)

Prolia/Xgeva
(denosumab)

Provenge
(sipuleucel-T)

Radicava
(edaravone)

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)

Sandostatin LAR
(octreotide)

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)

Sylvant
(siltuximab)

Synagis
(Palivizumab)

Synribo
(omacetaxine)

Takhzyro
(Lanadelumab-flyo)

Tecentriq
(atezolizumab) 

Tepezza
(teprotumumab-trbw)

Trastuzumab 
Herceptin
Ogivri
Kanjinti
Trazimera
Herzuma
Ontruzant

Trodelvy
(sacituzumab govitecan-hziy)

Truxima
(rituximab-abbs)

Tysabri
(natalizumab)

Ultomiris
(ravulizumab-cwvz)

Uplizna
(inebilizumab-cdon)

Vectibix
(panitumumab)

Vidaza
(Azacitidine)

Viltepso
(viltolarsen)

VPRIV
(velaglucerase alfa) 

Vyepti
(eptinezumab-jjmr)

Vyondys-53 (golodirsen)

Xolair
(omalizumab)

Yervoy
(ipilimumab)

Yondelis
(trabectedin)

Yutiq
(fluocinolone acetonide implant)

Zaltrap 
(ziv-aflibercept) 

Zilretta
(triamcinolone acetonide ER) 

Zynlonta
(loncastuximab tesirine‐lpyl)

 

View the Security Health Plan post service claim edit policies.