Security Health Plan Clinical Guidelines
Effective Oct 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)
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)
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)
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)
(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)
(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)
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