Medical Policy Update For March 15, 2022

The following policies have been permanently moved from the Medical Policy pages to the Prior Review and Limitations page. To locate a policy, search by drug name in the "Drugs that Need Prior Authorization" section.

• Abatacept (Orencia®)
• Aducanumab-avwa (Aduhelm™)
• Alemtuzumab (Lemtrada®)
• Allogeneic Processed Thymus Tissue-agdc (Rethymic®)
• Alpha 1-Antitrypsin Inhibitor Therapy (example: Aralast NP™)
• Anifrolumab-fnia (Saphnelo™)
• Antiemetic Injection Therapy (example: Aloxi®)
• Antisense Oligonucleotide Therapy for Duchenne Muscular Dystrophy (example: Amondys 45®)
• Belimumab (Benlysta®)
• Bezlotoxumab (Zinplava™)
• Bimatoprost Intracameral Implant (Durysta™)
• Botulinum Toxin Injection (example: Dysport®)
• Brexanolone (Zulresso™)
• Buprenorphine Extended-Release (Sublocade®)
• Burosumab-twza (Crysvita®)
• Canakinumab (Ilaris®)
• CAR-T Therapy (example: Yescarta®)
• Certolizumab pegol (Cimzia®)
• Crizanlizumab (Adakveo®)
• Denosumab (Prolia®, Xgeva®)
• Eculizumab (Soliris®)
• Edaravone (Radicava®)
• Efgartigimod Alfa-fcab (Vyvgart™)
• Emapalumab-lzsg (Gamifant™)
• Enzyme Replacement Therapy (ERT) for Lysosomal Storage Disorders (example: Cerezyme®)
• Eptinezumab-jjmr (Vyepti™)
• Erythropoietin Stimulating Agents (example: Epogen®)
• Esketamine (Spravato®) Nasal Spray
• Evinacumab-dgnb (Evkeeza™)
• Fosdenopterin (Nulibry™)
• Givosiran (Givlaari®)
• Golimumab (Simponi Aria®)
• Guselkumab (Tremfya®)
• Ibalizumab-uiyk (Trogarzo®)
• Immunoglobulin Therapy (example: Asceniv™)
• Inclisiran (Leqvio®)
• Inebilizumab-cdon (Uplizna™)
• Infliximab (Remicade®) and Infliximab Biosimilars
• Injectable and Healthcare Administered Oncology Drugs (example: Abraxane®)
• Injectable Clostridial Collagenase for Fibroproliferative Disorders (example: Xiaflex®)
• Interleukin-5 Antagonists (example: Fasenra®)
• Intra Articular Hyaluronan Injections for Treatment of Osteoarthritis of the Knee (example: Durolane®)
• Intravenous Iron Replacement Therapy (example: Injectafer®)
• Letermovir (Prevymis™)
• Lumasiran (Oxlumo™)
• Luspatercept-aamt (Reblozyl®)
• Natalizumab (Tysabri®)
• New to Market Specialty Drug PPA Requirements
• Nusinersen (Spinraza®)
• Ocrelizumab (Ocrevus®)
• Ocular Angiogenesis Inhibitor Agents (example: Beovu®)
• Omalizumab (Xolair®)
• Onasemnogene abeparvovec (Zolgensma®)
• Patisiran (Onpattro®)
• Pegcetacoplan (Empaveli™)
• Pegloticase (Krystexxa®)
• Place of Service for Medical Infusions
• Plasminogen, human-tvmh (Ryplazim®)
• Pulmonary Hypertension, Drug Management (example: (Flolan®)
• Ravulizumab-cwvz (Ultomiris®)
• Repository Corticotropin (Acthar® Gel)
• Respiratory Syncytial Virus Prophylaxis (example: Synagis®)
• Rituximab for the Treatment of Rheumatoid Arthritis (example: Truxima®)
• Romiplostim (NPlate®)
• Romosozumab-aqqg (Evenity™)
• Somatostatin Analogs (example: Somatuline® Depot)
• Sutimlimab (Enjaymo™)
• Teprotumumab-trbw (Tepezza™)
• Testosterone Pellet Implantation for Androgen Deficiency (example: Testopel®)
• Tezepelumab-ekko (Tezspire™)
• Tildrakizumab-asmn (Ilumya®)
• Tocilizumab (Actemra®)
• Treatment of Hereditary Angioedema (example: Berinert®)
• Trilaciclib (Cosela™)
• Ustekinumab (Stelara®)
• Vedolizumab (Entyvio®)
• Voretigene neparvovec (Luxturna®)
• White Blood Cell Growth Factors (example: Fulphila®)