2022/02/02 |
ABECMA® (idecabtagene vicleucel) |
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2021/09/16 |
Abraxane® (paclitaxel protein-bound particles) |
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2021/09/15 |
Actemra (tocilizumab) |
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2021/04/13 |
Adakveo (crizanlizumab injection) |
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2021/01/01 |
Adasuve® (loxapine) |
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2021/02/12 |
Adcetris (brentuximab vedotin) |
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2021/03/12 |
Aduhelm™ (aducanumab-avwa) |
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2021/02/10 |
Ajovy (fremanezumab-vfrm) |
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2021/03/28 |
Akynzeo (fosnetupitant and palonosetron) Injection |
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2020/01/22 |
Aldurazyme (laronidase) |
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2021/03/28 |
Alimta® (pemetrexed) |
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2021/02/09 |
Aliqopa™ (copanlisib) |
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2020/12/02 |
Aloxi® (palonosetron) |
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2021/06/10 |
Alpha-1-Proteinase Inhibitors Infusion Therapy |
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2021/09/02 |
Amondys 45™ (casimersen intravenous infusion) |
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2020/01/22 |
Apokyn (apomorphine) |
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2021/01/20 |
Arcalyst (rilonacept) |
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2021/02/09 |
Arzerra (ofatumumab) |
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2020/12/02 |
Asparlas (calaspargase pegol-mknl) |
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2020/12/02 |
Avastin (bevacizumab) for oncology diagnosis |
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2021/06/10 |
Aveed (testosterone undecanoate) |
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2021/09/02 |
Azacitidine (Vidaza®) |
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2021/09/02 |
Azedra® (Iobenguane I-131) |
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2021/10/22 |
Barhemsys (amisulpride) |
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2021/01/20 |
Bavencio® (avelumab) |
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2021/10/09 |
Baxdela (delafloxacin) |
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2021/10/02 |
Bendamustine (Bendeka, Treanda, Belrapzo) |
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2021/10/02 |
Benlysta (belimumab) |
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2021/10/10 |
Berinert (C1 Esterase Inhibitor Human) |
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2021/09/02 |
Besponsa® (inotuzumab ozogamicin) |
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2021/09/02 |
Blenrep (belantamab mafodotin-blmf) |
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2021/09/02 |
Blincyto™ (blinatumomab) |
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2021/09/02 |
Boniva (ibandronate) |
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2021/09/02 |
Breyanzi (lisocabtagene maraleucel) |
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2021/09/02 |
Brineura (cerliponase alfa) |
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2021/09/02 |
Cabenuva (cabotegravir rilpivirine) |
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2021/09/02 |
Cablivi (caplacizumab-yhdp) |
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2021/09/02 |
Campath® (Alemtuzumab) |
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2022/05/19 |
CARVYKTI (ciltacabtagene autoleucel) intravenous infusion |
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2021/09/02 |
Cerezyme (imiglucerase) |
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2021/09/02 |
Cimzia® (certolizumab pegol) |
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2021/09/02 |
Cinqair (reslizumab) |
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2021/09/02 |
Cinryze (C1 Esterase Inhibitor Human) |
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2021/09/02 |
Cinvanti (aprepitant) Injectable Emulsion |
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2021/09/02 |
Clolar (clofarabine) |
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2022/03/08 |
Clotting Disorder Therapy |
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2021/09/02 |
Colony Stimulating Factors: Fulphila™ (pegfilgrastim-jmdb) |
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2021/09/02 |
Colony Stimulating Factors: Leukine® (sargramostim) |
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2021/09/02 |
Colony Stimulating Factors: Neulasta® (pegfilgrastim) |
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2022/05/19 |
Colony Stimulating Factors: Neupogen®, Granix® and Zarxio® (filgrastim) |
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2021/09/02 |
Colony Stimulating Factors: Nivestym™ (filgrastim-aafi) |
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2021/09/02 |
Colony Stimulating Factors: Udenyca™ (pegfilgrastim-cbqv) |
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2021/09/02 |
Colony Stimulating Factors: Ziextenzo (pegfilgrastim-bmez) |
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2021/09/02 |
Cosela™ (trilaciclib injection) powder for injection |
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2021/09/02 |
Cresemba® (isavuconazonium sulfate) |
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2021/09/02 |
Crysvita (burosumab-twza) |
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2021/09/02 |
Cyramza® (ramucirumab) |
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2021/09/02 |
Cytogam (cytomegalovirus immune globulin, human) |
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2021/09/02 |
Dacogen (decitabine) |
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2021/09/02 |
DANYELZA® (naxitamab-gqgk) injection |
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2021/09/02 |
Darzalex (daratumumab) |
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2022/03/31 |
Duchenne Muscular Dystrophy (DMD) Drugs (Amondys 45, Exondys 51, Vyondys 53 and Viltepso)—MEDICAID ONLY |
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2021/09/02 |
Elaprase® (idursulfase) |
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2021/09/02 |
Elelyso (taliglucerase alfa |
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2021/09/02 |
Eloxatin (oxaliplatin) |
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2021/09/02 |
Elzonris (Tagraxofusp-erzs) |
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2022/02/02 |
Empaveli™ (pegcetacoplan) |
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2021/09/02 |
Empliciti (elotuzumab) |
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2021/09/02 |
Enhertu (fam-trastuzumab deruxtecan-nxki) |
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2022/05/19 |
ENJAYMO™ (sutimlimab-jome) Intravenous Infusion |
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2021/09/02 |
Entyvio (vedolizumab) |
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2021/09/02 |
Erbitux® (cetuximab) |
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2021/09/02 |
Erythropoiesis Stimulating Agents (ESAs): Aranesp® (darbepoetin alfa) |
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2021/09/02 |
Erythropoiesis Stimulating Agents (ESAs): Epogen, Procrit, Retacrit (epoetin alfa) |
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2021/09/02 |
Eteplirsen (Exondys 51™) |
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2021/09/02 |
Evenity (romosozumab-aqqg) |
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2022/05/19 |
EVKEEZA (evinacumab-dgnb) |
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2021/09/02 |
Fabrazyme (agalsidase beta) |
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2021/09/02 |
Fasenra™ (benralizumab) |
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2021/09/02 |
Fensolvi (leuprolide_acetate) |
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2021/09/02 |
Fetroja® (cefiderocol) |
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2021/09/02 |
Firazyr (icatibant) |
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2021/09/02 |
Folotyn (pralatrexate) |
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2021/09/02 |
Fusilev (levoleucovorin) |
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2022/03/09 |
Fyarro™ (sirolimus protein-bound particles intravenous infusion) |
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2021/09/02 |
Gamifant (Emapalumab-lzsg) |
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2021/09/02 |
Gazyva (obinutuzumab) |
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2021/09/02 |
Givlaari (givosiran) |
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2021/09/02 |
H.P. Acthar® Gel (repository corticotropin injection) |
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2021/09/02 |
Haegarda® (C1 esterase inhibitor human) and Takhzyro® (lanadelumab-flyo) |
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2021/09/02 |
Halaven™ (eribulin) |
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2021/09/02 |
Hepagam B (hepatitis B immune globulin) |
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2021/09/02 |
Hyaluronate Injections for Osteoarthritis of the Knee — COMMERICAL and MEDICARE |
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2021/09/03 |
Hydroxyprogesterone Caproate (Makena®) for the Prevention of Preterm Labor |
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2021/09/02 |
Ilaris (canakinumab) |
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2021/09/02 |
Ilumya (tildrakizumab-asmn) |
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2021/09/02 |
Imfinzi™ (durvalumab) |
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2021/09/02 |
Imlygic (Talimogene laherparepvec) |
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2021/09/02 |
Infliximab Injectable (Avsola, Inflectra®, Remicade®, Renflexis™) |
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2021/09/02 |
Infugem (gemcitabine) |
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2021/09/02 |
Intravenous Immune Globulins (immune globulin) |
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2022/05/19 |
Intravitreal Injections/Implants |
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2021/09/02 |
Istodax (romidepsin) |
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2021/09/02 |
Ixempra (ixabepilone) |
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2021/09/02 |
Jelmyto (mitomycin solution for pyelocalyceal administration) |
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2021/09/02 |
Jemperli (dostarlimab-gxly) |
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2021/09/02 |
Jevtana (cabazitaxel) |
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2021/09/02 |
Kadcyla® (ado-trastuzumab emtansine) |
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2021/09/02 |
Kalbitor (ecallantide) |
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2021/09/02 |
Kanuma (sebelipase alfa) |
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2021/09/02 |
Keytruda® (pembrolizumab) |
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2022/05/19 |
KIMMTRAK (tebentafusp-tebn) intravenous infusion |
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2021/09/02 |
Khapzory (levoleucovorin) |
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2022/05/19 |
KORSUVA (difelikefalin) intravenous injection |
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2021/09/02 |
Krystexxa (pegloticase) |
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2021/09/02 |
Kymriah™ (tisagenlecleucel) |
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2021/09/02 |
Kyprolis (carfilzomib) |
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2021/09/02 |
Lartruvo (olaratumab) |
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2021/09/02 |
Lemtrada® (alemtuzumab) |
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2022/03/09 |
Leqvio® (inclisiran), subcutaneous injection |
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2021/09/02 |
Libtayo (cemiplimab-rwlc) |
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2021/09/02 |
Liposomal Doxorubicin (Doxil & Lipodox) |
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2021/09/02 |
Lumizyme (alglucosidase alfa) |
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2021/09/02 |
Lumoxiti (moxetumomab pasudotox-tdfk) |
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2021/09/02 |
Lutathera® (lutetium Lu 177 dotatate) |
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2021/09/02 |
Luxturna™ (Voretigene neparvovec) |
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2021/09/02 |
Marqibo® (vincristine sulfate liposomal) |
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2021/09/02 |
Margenza (margetuimab) |
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2021/09/02 |
Mepsevii (vestronidase alfa-vjbk) |
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2021/09/02 |
Monjuvi (tafasitamab-cxix) |
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2021/09/02 |
Mozobil (plerixafor) |
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2021/09/02 |
Mvasi (bevacizumab-awwb), Zirabev® (bevacizumab-bvcr) |
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2021/09/02 |
Mylotarg (gemtuzumab ozogamicin) |
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2021/09/02 |
Naglazyme (galsulfase) |
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2022/01/07 |
Nexviazyme® (avalglucosidase alfa-ngpt) intravenous infusion |
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2021/09/02 |
Neurotoxins (Botox®, Dysport®, Myobloc® and Xeomin®) |
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2021/09/02 |
Nplate (romiplostim) |
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2022/02/02 |
Nulibry™ (fosdenopterin) |
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2021/09/02 |
Nucala® (mepolizumab) |
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2021/09/02 |
Nulojix (belatacept) |
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2021/09/02 |
NYVEPRIA™ (pegfilgrastim-apgf) |
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2021/09/02 |
Ocrevus™ (ocrelizumab) |
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2021/09/02 |
Onivyde (irinotecan liposome) |
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2021/09/02 |
Onpattro (patisiran) |
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2021/09/02 |
Opdivo® (nivolumab) |
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2022/05/19 |
OPDUALAG (nivolumab and relatlimab-rmbw) intravenous infusion |
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2021/09/02 |
Orencia (abatacept) |
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2021/09/02 |
Oxlumo™ (lumasiran) |
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2021/09/02 |
Padcev (enfortumab vedotin-ejfv) |
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2021/09/02 |
Parsabiv (Etelcalcetide) |
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2021/09/02 |
Pasireotide (Signifor® LAR) |
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2021/09/02 |
Pemfexy (pemetrexed injection), for intravenous use |
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2021/09/02 |
Perjeta (pertuzumab) |
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2021/09/02 |
Phesgo (pertuzumab, trastuzumab and hyaluronidase-zzxf |
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2021/09/02 |
Polivy (polatuzumab vedotin) |
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2021/09/02 |
Portrazza (necitumumab) |
|
2021/09/02 |
Poteligeo (mogamulizumab-kpkc) |
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2021/09/02 |
Probuphine (buprenorphine) |
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2021/09/02 |
Proleukin (aldesleukin) |
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2021/09/02 |
Prolia®/Xgeva® (denosumab) |
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2021/09/02 |
PROVENGE® (sipuleucel-T) |
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2021/09/02 |
Pulmonary Arterial Hypertension (Remodulin, Tyvaso, Veletri, Ventavis) |
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2021/09/02 |
Qutenza (capsaicin) |
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2021/09/02 |
Radicava (Edaravone) |
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2021/09/02 |
Reblozyl (luspatercept-aamt) |
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2021/09/02 |
Relistor (methylnatrexone) |
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2021/09/02 |
Relizorb (immobilized lipase) Cartridge |
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2021/09/02 |
Revcovi (Elapegademase-lvlr) |
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2021/09/02 |
RiaSTAP (fibrinogen) |
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2021/09/02 |
Rituxan Hycela (rituximab and hyaluronidase Human) |
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2021/09/02 |
Rituximab Injectable (Rituxan®, Ruxience®, Truxima®) |
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2021/09/02 |
Ruconest (C1 esterase inhibitor [recombinant]) |
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2022/02/02 |
RYBREVANT (amivantamab-vmjw) |
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2022/02/02 |
Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn) |
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2022/03/09 |
Ryplazim™ (human plasminogen), injection |
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2022/01/07 |
Saphnelo™ (anifrolumab-fnia) intravenous infusion |
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2021/09/02 |
Sarclisa® (isatuximab) |
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2021/09/02 |
Simponi Aria (golimumab) |
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2021/09/02 |
Soliris® (eculizumab) |
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2021/09/02 |
Somatuline Depot (lanreotide) |
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2021/09/02 |
Spinraza™ (Nusinersen) |
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2021/09/02 |
Spravato (esketamine hydrochloride) |
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2022/05/10 |
SITE OF SERVICE MEDICAL POLICY – Infusions and Injectables |
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2021/09/02 |
Stelara® (ustekinumab) |
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2021/09/02 |
Subcutaneous immune globulins (SCIG): Hizentra®, Gammagard Liquid®, Gamunex®-C, Gammaked®, Hyqvia, Cuvitru |
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2021/09/02 |
Supprelin LA (histrelin acetate) |
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2021/09/02 |
Sylvant (siltuximab) |
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2021/09/02 |
Synagis |
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2021/09/02 |
Synribo (omacetaxine) |
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2021/09/02 |
Tecartus (brexucabtagene autoleucel) |
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2021/09/02 |
Tecentriq (atezolizumab) |
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2021/09/02 |
Temodar (temozolomide) |
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2021/09/02 |
Tepadina (thiotepa) |
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2021/09/02 |
Tepezza® (teprotumumab-trbw) |
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2022/05/25 |
Tezspire (tezepelumab-ekko) subcutaneous injection |
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2021/09/02 |
Thyrogen (thyrotropine alfa) |
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2022/01/07 |
TIVDAK™ (tisotumab vedotin) injection, powder, for solution |
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2021/09/02 |
Torisel (temsirolimus) |
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2021/09/02 |
Trastuzumab Injection (Herceptin, Herceptin Hylecta, Herzuma, Kanjinti, Ontruzant, Ogivri, Trazimera) |
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2021/09/02 |
Tremfya (guselkumab) |
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2021/09/02 |
Trodelvy™ (sacituzumab govitecan-hziy) |
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2021/09/02 |
Trogarzo (Ibalizumab-uiyk) |
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2021/09/02 |
Tysabri (natalizumab) |
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2021/09/02 |
Ultomiris (Ravulizumab-cwvz) |
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2021/09/02 |
Unituxin™ (dinutuximab) |
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2021/09/02 |
Uplizna (inebilizumab-cdon) |
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2021/09/02 |
Vantas® (histrelin acetate) |
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2021/09/02 |
Vectibix® (panitumumab) |
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2021/09/02 |
Velcade (bortezomib) |
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2021/09/02 |
Viltepso (viltolarsen) |
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2021/09/02 |
Vimizim (elosulfase) |
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2021/09/02 |
Vpriv (velaglucerase alfa) |
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2021/09/02 |
Vyepti™ (eptinezumab-jjmr) |
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2021/09/02 |
VYONDYS 53® (golodirsen) |
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2022/03/09 |
Vyvgart (efgartigimod alfa-fcab intravenous infusion) |
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2021/09/02 |
Vyxeos™ (daunorubicin and cytarabine) |
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2022/02/03 |
Xaracoll (bupivacaine hydrochloride) Implant |
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2021/09/03 |
Xiaflex (collagenase clostridium histolyticum) |
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2021/09/02 |
Xofigo for Castration-Resistant Prostate Cancer |
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2021/09/02 |
Xolair® (omalizumab) |
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2021/09/02 |
Yervoy™ (ipilimumab) |
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2021/09/02 |
Yescarta (axicabtagene ciloleucel) |
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2021/09/02 |
Yondelis (trabectedin) |
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2021/09/02 |
Zaltrap (ziv-aflibercept) |
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2021/09/02 |
Zepzelca (lurbinectedin) |
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2021/09/02 |
Zevalin (ibritumomab tiuxetan) |
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2021/09/02 |
Zilretta (triamcinolone acetonide extended release injection) |
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2021/09/02 |
Zinplava (bezlotoxumab) |
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2021/09/02 |
Zoledronic acid (Zometa®, Reclast®) |
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2021/09/02 |
Zolgensma (onasemnogene abeparvovec-xioi) |
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2021/09/02 |
Zulresso (brexanolone) |
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2021/09/02 |
Zynlonta (loncastuximab-tesirine) |
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