ABECMA® (idecabtagene vicleucel) |
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Abraxane® (paclitaxel protein-bound particles) |
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Actemra (tocilizumab) |
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Adakveo (crizanlizumab injection) |
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Adasuve® (loxapine) |
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Adcetris (brentuximab vedotin) |
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Adstiladrin® (nadofaragene firadenovec-vncg) intravesical suspension |
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Aduhelm™ (aducanumab-avwa) |
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Aduhelm™ (aducanumab-avwa) —Medicaid Only |
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Akynzeo (fosnetupitant and palonosetron) Injection |
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Aldurazyme (laronidase) |
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Alferon-N (interferon alfa-n3) |
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Alimta® (pemetrexed) |
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Aliqopa™ (copanlisib) |
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Aloxi® (palonosetron) |
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Alpha-1-Proteinase Inhibitors Infusion Therapy |
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Alprostadil —Medicaid Only |
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Amondys 45™ (casimersen intravenous infusion) |
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Amvuttra (vutrisiran) |
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Apokyn (apomorphine) |
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Arcalyst (rilonacept) |
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Arzerra (ofatumumab) |
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Asparlas (calaspargase pegol-mknl) |
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Avastin (bevacizumab) for oncology diagnosis |
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Aveed (testosterone undecanoate) |
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Azacitidine (Vidaza®) |
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Azedra® (Iobenguane I-131) |
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Barhemsys (amisulpride) |
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Bavencio® (avelumab) |
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Baxdela (delafloxacin) |
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Bendamustine (Bendeka, Treanda, Belrapzo) |
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Benlysta (belimumab) |
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Berinert (C1 Esterase Inhibitor Human) |
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Besponsa® (inotuzumab ozogamicin) |
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Blenrep (belantamab mafodotin-blmf) |
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Blincyto™ (blinatumomab) |
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Boniva (ibandronate) |
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Breyanzi (lisocabtagene maraleucel) |
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Brineura (cerliponase alfa) |
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Briumvi (ublituximab-xiii) |
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Cabenuva (cabotegravir rilpivirine) |
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Cablivi (caplacizumab-yhdp) |
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Campath® (Alemtuzumab) |
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CARVYKTI (ciltacabtagene autoleucel) intravenous infusion |
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Cerezyme (imiglucerase) |
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Cimzia® (certolizumab pegol) |
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Cinqair (reslizumab) |
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Cinryze (C1 Esterase Inhibitor Human) |
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Cinvanti (aprepitant) Injectable Emulsion |
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Clolar (clofarabine) |
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Clotting Disorder Therapy |
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Colony Stimulating Factors: Fulphila™ (pegfilgrastim-jmdb) |
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Colony Stimulating Factors: Leukine® (sargramostim) |
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Colony Stimulating Factors: Neulasta® (pegfilgrastim) |
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Colony Stimulating Factors: Neupogen®, Granix® and Zarxio® (filgrastim) |
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Colony Stimulating Factors: Nivestym™ (filgrastim-aafi) |
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Colony Stimulating Factors: Rolvedon™ (eflapegrastim-xnst)
|
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Colony Stimulating Factors: Stimufend (pegfilgrastim-fpgk) subcutaneous injection
|
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Colony Stimulating Factors: Udenyca™ (pegfilgrastim-cbqv) |
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Colony Stimulating Factors: Ziextenzo (pegfilgrastim-bmez) |
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Cosela™ (trilaciclib injection) powder for injection |
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Cresemba® (isavuconazonium sulfate) |
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Crysvita (burosumab-twza) |
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Cyramza® (ramucirumab) |
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Cytogam (cytomegalovirus immune globulin, human) |
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Dacogen (decitabine) |
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DANYELZA® (naxitamab-gqgk) injection |
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Darzalex (daratumumab) |
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Duchenne Muscular Dystrophy (DMD) Drugs (Amondys 45, Exondys 51, Vyondys 53 and Viltepso)—Medicaid Only |
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Elahere (mirvetuximab soravtansine-gynx) |
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Elaprase® (idursulfase) |
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Elelyso (taliglucerase alfa |
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Eloxatin (oxaliplatin) |
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Elzonris (Tagraxofusp-erzs) |
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Empaveli™ (pegcetacoplan) |
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Empliciti (elotuzumab) |
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Enhertu (fam-trastuzumab deruxtecan-nxki) |
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ENJAYMO™ (sutimlimab-jome) Intravenous Infusion |
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Entyvio (vedolizumab) |
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Epkinly (epcoritamab-bysp) subcutaneous injection |
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Erbitux® (cetuximab) |
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Erythropoiesis Stimulating Agents (ESAs): Aranesp® (darbepoetin alfa) |
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Erythropoiesis Stimulating Agents (ESAs): Epogen, Procrit, Retacrit (epoetin alfa) |
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Eteplirsen (Exondys 51™) |
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Evenity (romosozumab-aqqg) |
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EVKEEZA (evinacumab-dgnb) |
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Fabrazyme (agalsidase beta) |
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Fasenra™ (benralizumab) |
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Fensolvi (leuprolide_acetate) |
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Fetroja® (cefiderocol) |
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Firazyr (icatibant) |
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Folotyn (pralatrexate) |
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Fusilev (levoleucovorin) |
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Fyarro™ (sirolimus protein-bound particles intravenous infusion) |
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Fylnetra (pegfilgrastim-pbbk) |
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Gamifant (Emapalumab-lzsg) |
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Gastric Eletric Stimulation |
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Gazyva (obinutuzumab) |
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Givlaari (givosiran) |
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H.P. Acthar® Gel (repository corticotropin injection) |
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Haegarda® (C1 esterase inhibitor human) and Takhzyro® (lanadelumab-flyo) |
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Halaven™ (eribulin) |
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Hemgenix (etranacogene dezaparvovec-drlb) |
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Hepagam B (hepatitis B immune globulin) |
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Hyaluronate Injections for Osteoarthritis of the Knee — COMMERICAL and MEDICARE |
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Hydroxyprogesterone Caproate (Makena®) for the Prevention of Preterm Labor |
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Ilaris (canakinumab) |
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Ilumya (tildrakizumab-asmn) |
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Imfinzi™ (durvalumab) |
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Imjudo (tremelimumab-actl) |
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Imlygic (Talimogene laherparepvec) |
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Infliximab Injectable (Avsola, Inflectra®, Remicade®, Renflexis™) |
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Infugem (gemcitabine) |
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Intravenous Immune Globulins (immune globulin) |
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Intravitreal Injections/Implants |
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Istodax (romidepsin) |
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Ixempra (ixabepilone) |
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Jelmyto (mitomycin solution for pyelocalyceal administration) |
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Jemperli (dostarlimab-gxly) |
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Jevtana (cabazitaxel) |
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Kadcyla® (ado-trastuzumab emtansine) |
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Kalbitor (ecallantide) |
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Kanuma (sebelipase alfa) |
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Keytruda® (pembrolizumab) |
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KIMMTRAK (tebentafusp-tebn) intravenous infusion |
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Khapzory (levoleucovorin) |
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KORSUVA (difelikefalin) intravenous injection |
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Krystexxa (pegloticase) |
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Kymriah™ (tisagenlecleucel) |
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Kyprolis (carfilzomib) |
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Lamzede (velmanase alfa-tycv), injection powder for solution |
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Lartruvo (olaratumab) |
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Lemtrada® (alemtuzumab) |
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Leqembi (lecanemab-irmb) |
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Leqvio® (inclisiran), subcutaneous injection |
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LHRH Agonists/Antagonists (Camcevi, Firmagon, Lupron Depot, Lupron Depot-Ped, Trelstar, Zoladex) |
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Libtayo (cemiplimab-rwlc) |
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Liposomal Doxorubicin (Doxil & Lipodox) |
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Lumizyme (alglucosidase alfa) |
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Lumoxiti (moxetumomab pasudotox-tdfk) |
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Lunsumio (mosunetuzumab-axgb) |
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Lutathera® (lutetium Lu 177 dotatate) |
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Luxturna™ (Voretigene neparvovec) |
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Marqibo® (vincristine sulfate liposomal) |
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Margenza (margetuimab) |
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Mepsevii (vestronidase alfa-vjbk) |
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Monjuvi (tafasitamab-cxix) |
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Mozobil (plerixafor) |
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Mvasi (bevacizumab-awwb), Zirabev® (bevacizumab-bvcr) |
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Mylotarg (gemtuzumab ozogamicin) |
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Naglazyme (galsulfase) |
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Nexviazyme® (avalglucosidase alfa-ngpt) intravenous infusion |
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Neurotoxins (Botox®, Dysport®, Myobloc® and Xeomin®) |
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Nplate (romiplostim) |
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Nulibry™ (fosdenopterin) |
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Nucala® (mepolizumab) |
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Nulojix (belatacept) |
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NYVEPRIA™ (pegfilgrastim-apgf) |
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Ocrevus™ (ocrelizumab) |
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Omisirge (omidubicel-onlv) intravenous suspension |
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Onivyde (irinotecan liposome) |
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Onpattro (patisiran) |
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Opdivo® (nivolumab) |
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OPDUALAG (nivolumab and relatlimab-rmbw) intravenous infusion |
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Orencia (abatacept) |
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Oxlumo™ (lumasiran) |
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Padcev (enfortumab vedotin-ejfv) |
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Parsabiv (Etelcalcetide) |
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Pasireotide (Signifor® LAR) |
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Pedmark (sodium thiosulfate) |
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Pemfexy (pemetrexed injection), for intravenous use |
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Perjeta (pertuzumab) |
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Phentolamine and Papaverine—Medicaid Only |
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Phesgo (pertuzumab, trastuzumab and hyaluronidase-zzxf) |
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Pluvicto (lutetium Lu 177 vipivotide tetraxetan) |
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Polivy (polatuzumab vedotin) |
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Portrazza (necitumumab) |
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Poteligeo (mogamulizumab-kpkc) |
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Probuphine (buprenorphine) |
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Proleukin (aldesleukin) |
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Prolia®/Xgeva® (denosumab) |
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PROVENGE® (sipuleucel-T) |
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Pulmonary Arterial Hypertension (Remodulin, Tyvaso, Veletri, Ventavis) |
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Qalsody (tofersen) intrathecal injection |
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Qutenza (capsaicin) |
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Radicava (Edaravone) |
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Reblozyl (luspatercept-aamt) |
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Rebyota (fecal microbiota, live-jslm) |
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Relistor (methylnatrexone) |
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Relizorb (immobilized lipase) Cartridge |
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Revcovi (Elapegademase-lvlr) |
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RiaSTAP (fibrinogen) |
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Rituxan Hycela (rituximab and hyaluronidase Human) |
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Rituximab Injectable (Rituxan®, Ruxience®, Truxima®) |
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Ruconest (C1 esterase inhibitor [recombinant]) |
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RYBREVANT (amivantamab-vmjw) |
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Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn) |
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Ryplazim™ (human plasminogen), injection |
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Sandostatin LAR (octreotide suspension) |
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Saphnelo™ (anifrolumab-fnia) intravenous infusion |
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Sarclisa® (isatuximab) |
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Simponi ARIA (golimumab) |
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SITE OF SERVICE MEDICAL POLICY – Infusions and Injectables |
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Skysona (elivaldogene autotemcel) |
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Skyrizi (risankizumab-rzaa) |
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Soliris® (eculizumab) |
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Somatuline Depot (lanreotide) |
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Spinraza™ (Nusinersen) |
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Spevigo (spesolimab-sbzo) |
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Spravato (esketamine hydrochloride) |
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Stelara® (ustekinumab) |
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Subcutaneous immune globulins (SCIG): Hizentra®, Gammagard Liquid®, Gamunex®-C, Gammaked®, Hyqvia, Cuvitru |
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Sunlenca (lenacapavir) |
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Supprelin LA (histrelin acetate) |
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Syfovre |
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Sylvant (siltuximab) |
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Synagis |
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Synribo (omacetaxine) |
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Tecartus (brexucabtagene autoleucel) |
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Tecentriq (atezolizumab) |
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Tecvayli (teclistamab-cqyv) subcutaneous injection |
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Tegsedi |
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Temodar (temozolomide) |
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Tepadina (thiotepa) |
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Tepezza® (teprotumumab-trbw) |
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Tezspire (tezepelumab-ekko) subcutaneous injection |
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Thyrogen (thyrotropine alfa) |
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TIVDAK™ (tisotumab vedotin) injection, powder, for solution |
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Torisel (temsirolimus) |
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Trastuzumab Injection (Herceptin, Herceptin Hylecta, Herzuma, Kanjinti, Ontruzant, Ogivri, Trazimera) |
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Tremfya (guselkumab) |
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Trodelvy™ (sacituzumab govitecan-hziy) |
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Trogarzo (Ibalizumab-uiyk) |
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Tysabri (natalizumab) |
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Tzield (teplizumab-mzwv) |
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Ultomiris (Ravulizumab-cwvz) |
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Unituxin™ (dinutuximab) |
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Uplizna (inebilizumab-cdon) |
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Vantas® (histrelin acetate) |
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Vectibix® (panitumumab) |
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Velcade (bortezomib) |
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Viltepso (viltolarsen) |
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Vimizim (elosulfase) |
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Vpriv (velaglucerase alfa) |
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Vyepti™ (eptinezumab-jjmr) |
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VYONDYS 53® (golodirsen) |
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Vyvgart (efgartigimod alfa-fcab intravenous infusion) |
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Vyxeos™ (daunorubicin and cytarabine) |
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Xaracoll (bupivacaine hydrochloride) Implant |
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Xenpozyme (olipudase alfa-rpcp) |
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Xiaflex (collagenase clostridium histolyticum) |
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Xofigo for Castration-Resistant Prostate Cancer |
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Xolair® (omalizumab) |
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Yervoy™ (ipilimumab) |
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Yescarta (axicabtagene ciloleucel) |
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Yondelis (trabectedin) |
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Zaltrap (ziv-aflibercept) |
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Zepzelca (lurbinectedin) |
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Zevalin (ibritumomab tiuxetan) |
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Zilretta (triamcinolone acetonide extended release injection) |
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Zinplava (bezlotoxumab) |
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Zoledronic acid (Zometa®, Reclast®) |
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Zolgensma (onasemnogene abeparvovec-xioi) |
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Zulresso (brexanolone) |
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Zynlonta (loncastuximab-tesirine) |
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Zynteglo |
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Zynyz |
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