- Abatacept (Orencia) infusion
- Afamelanotide (Scenesse)
- Agalsidase beta (Fabrazyme)
- Alemtuzumab (Lemtrada)
- Alglucosidase Alfa (Lumizyme, Myozyme)
- Alpha-1 proteinase inhibitors (Glassia, Aralast NP, Prolastin C, Zemaira)
- Atezolizumab (Tecentriq)
- Avelumab (Bavencio)
- Belimumab (Benlysta) infusion
- Bevacizumab (Avastin Brand)
- Bezlotoxumab (Zinplava)
- Brexanolone (Zulresso)
- Burosumab (Crysvita)
- C1 esterase inhibitor (Berinert)
- C1 esterase inhibitor (Cinryze)
- C1 esterase inhibitor (Ruconest)
- Calaspargase (Asparlas)
- Canakinumab (Ilaris)
- Caplacizumab (Cablivi)
- Carfilzomib (Kyprolis)
- Cemiplimab (Libtayo)
- Cerliponase Alfa (Brineura)
- Certolizumab (Cimzia)
- Crizanlizumab (Adakveo)
- Crizanlizumab-tmca (Adakveo)
- Daratumumab (Darzalex)
- Daratumumab and hyaluronidase (Darzalex Faspro)
- Deoxycholic acid (Kybella)
- Durvalumab (Imfinzi)
- Ecallantide (Kalbitor)
- Edaravone (Radicava)
- Elapegademase (Revcovi)
- Elotuzumab (Empliciti)
- Emapalumab (Gamifant)
- Emicizumab (Hemlibra)
- Enfortumab vedotin (Padcev)
- Epoetin Alfa (Epogen Brand)
- Epoetin Alfa (Procrit Brand)
- Eptinezumab (Vyepti)
- Esketamine (Spravato)
- Givosiran (Givlaari)
- Golimumab IV (Simponi)
- Golodirsen (Vyvondys 53)
- Guselkumab (Tremfya)
- Human Chorionic Gonadotropin (HCG) (Novarel, Pregnyl)
- Hydroxyprogesterone caproate (Makena)
- Infliximab (Remicade brand)
- Inotersen (Tegsedi)
- Interferon alfa N3 (Alferon N)
- Interferon alfa-2b (Intron A)
- Interferon beta-1a (Avonex, Rebif)
- Iobenguane iodine (Azedra)
- Ipilimumab (Yervoy)
- Isatuximab (Sarclisa)
- Letermovir (Prevymis)
- Lurbinectedin (Zepzelca)
- Luspatercept (Reblozyl)
- Lutetium Lu 177 dotatate (Lutathera)
- Mepolizumab (Nucala)
- Mogamulizumab (Poteligeo)
- Moxetumomab pasudotox (Lumoxiti)
- Natalizumab (Tysabri)
- Necitumumab (Portrazza)
- Nusinersen (Spinraza)
- Ocrelizumab (Ocrevus)
- onasemnogene abeparvovec (Zolgensma)
- Palifermin (Kepivance)
- Palivizumab (Synagis)
- Patisiran (Onpattro)
- Pegfilgrastim (Neulasta Brand)
- Pegloticase (Krystexxa)
- Pembrolizumab (Keytruda)
- Polatuzumab vedotin (Polivy)
- Ramucirumab (Cyramza)
- Ravulizumab (Ultomiris)
- Reslizumab (Cinqair)
- Rilonacept (Arcalyst)
- Rituximab (Rituxan Brand)
- Romiplostim (Nplate)
- Romosozumab (Evenity)
- Sacituzumab (Trodelvy)
- Sebelipase Alfa (Kanuma)
- Siltuximab (Sylvant)
- Tagraxofusp (Elzonris)
- Teprotumumab (Tepezza)
- Testosterone Pellet 75 MG
- Testosterone Subcutaneous Hormone Pellet Implantation
- Testosterone Undecanoate (Aveed)
- Tildrakizumab (Ilumya)
- Tocilizumab (Actemra)
- Trabectedin (Yondelis)
- Trastuzumab (Herceptin Brand)
- Unclassified drugs or biologics (only if >$2500)
- Ustekinumab (Stelara)
- Vedolizumab (Entyvio)
- Viltolarsen (Viltepso)
- Voretigene neparvovec (Luxturna)
- Xofigo (Radium 223 Dichloride)
Medicare Drug Coverage Policies apply (but do not require prior authorization): (for the most up-to-date Medicare policies and coverage, search the Medicare Coverage Database)
- Abarelix (Plenaxis) for the Treatment of Prostate Cancer (NCD 110.19)
- Aflibercept (Eylea) (L33394)
- Bevacizumab and biosimilars (L33394)
- Bortezomib (Velcade) (L33394)
- Botulinum toxins: AbobotulinumtoxinA (Dysport), IncobotulinumtoxinA (Xeomin), OnabotulinumtoxinA (Botox), RimabotulinumtoxinB (Myobloc) (L33394)
- Brolucizumab (Beovu) (L33394)
- Denosumab (Prolia, Xgeva) (L33394)
- Eculizumab (Soliris) (L33394)
- Erythropoiesis Agents in Cancer and Related Neoplastic Conditions (NCD 110.21)
- External Infusion Pumps (and associated drugs) (L33794)
- Filgrastim biosimilars (L33394)
- Hyaluronans (Intra-articular injections) (L33394)
- Ibandronate (Boniva) (L33394)
- Intravenous Immune Globulin (IVIG) (L33394)
- Intravenous Iron Therapy (NCD 110.10)
- Infliximab biosimilars (L33394)
- Leuteinizing Hormone-Releasing Hormone (LHRH) Analogs (Leuprolide, Goserelin, Triptorelin, Histrelin) (L33394)
- Levocarnitine for use in the Treatment of Carnitine Deficiency in ESRD (NCD 230.19)
- Nesiritide (Natrecor) (NCD 200.1)
- Nivolumab (Opdivo) (L33394)
- Omalizumab (Xolair) (L33394)
- Paclitaxel (Taxol, Abraxane) (L33394)
- Pegfilgrastim biosimilars (L33394)
- PrabotulinumtoxinA (Jeuveau) (L33394)
- Ranibizumab (Lucentis) (L33394)
- Rituximab biosimilars (L33394)
- Rituximab & hyaluronidase human (Rituxan Hycela) (L33394)
- Verteporfin (Visudyne) (NCD 80.3.1)
Medications that are usually self-administered are excluded from coverage under Medicare Part B (Per the Self-Administered Drug Exclusion List (A53022))
Questions
If you have any questions about the prior authorization list or want to know if a service or supply requires prior authorization, please contact Customer Service through the message center within My Quartz Tools for providers or MyChart for members or call (800) 394-5566.
