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®)
