Medicare Part B Drugs



Gundersen Health System

Clinic-Administered Medications Requiring Prior Authorization


Monthly updates may be added to the Prior Authorization list. Providers are reminded to review the Prior Authorization list on a regular basis for any updates or changes which may be added.

Please contact Customer Service with specific code information to determine if an item or service requires prior authorization.

Prior authorization is required for clinic-administered medications listed below. Practitioners must submit a prior authorization request via My Quartz Tools or fax a Medication Prior Request Form to Quartz at (888) 450-4711.

View the applicable Quartz Medicare Advantage 2021 Part B Prior Autorization Criteria.

  • Abatacept (Orencia) infusion
  • 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)
  • 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)
  • Pegfilgrastim (Neulasta)
  • 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)
  • 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.

This webpage was updated on October 1, 2020.