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ServicesBasics Medicines
The medicines that need prior authorization
Immunoglobulins (Prior authorization needed for
the drug and site of care):
Asceniv (immune globulin)
Bivigam (immune globulin)
Carimune NF (immune globulin)
Cutaquig (immune globulin)
Cuvitru (immune globulin SC [human])
Flebogamma (immune globulin)
GamaSTAN (immune globulin)
Gammagard, Gammagard S/D (immune globulin)
Gammaked (immune globulin)
Gammaplex (immune globulin)
Gamunex-C (immune globulin)
Hizentra (immune globulin)
HyQvia (immune globulin)
Octagam (immune globulin)
Panzyga (immune globulin)
Privigen (immune globulin)
Xembify (immune globulin)
Immunologic agents:
Actemra (tocilizumab) — prior authorization
n
eeded for the drug and site of care
Actemra SC (tocilizumab) — prior authorization
needed for Medicare Advantage members only
Cimzia (certolizumab pegol)
Cosentyx (secukinumab) — prior authorization
needed for Medicare Advantage members only
Enspryng (satralizumab) — prior authorization
needed for Medicare Advantage members only
Entyvio (vedolizumab) — prior authorization
needed for the drug and site of care
Ilumya (tildrakizumab)
Orencia SQ (abatacept) — prior authorization
needed for Medicare Advantage members only
Orencia IV (abatacept) — prior authorization
needed for the drug and site of care
Riabni (rituximab-arrx)
Rituxan (rituximab)
Immunologic agents (continued):
Rituxan Hycela (rituximab/hyaluronidase human)
Ruxience (rituximab-pvvr)
Simponi Aria (golimumab) — prior authorization
n
eeded for the drug and site of care
Skyrizi (risankizumab-rzaa) — prior authorization
needed for Medicare Advantage members only
Skyrizi IV (risankizumab-rzaa) — prior
authorization needed eective September 12,
2022
Stelara (ustekinumab) — prior authorization
needed for Medicare Advantage members only
Stelara IV (ustekinumab)
Tremfya (guselkumab) — prior authorization
needed for Medicare Advantage members only
Truxima (rituximab-abbs)
Vyvgart (efgartigimod alfa-fcab) — prior
authorization needed eective March 15, 2022
Injectable infertility drugs:
Chorionic gonadotropin
B
ravelle (urofollitropin)
Cetrotide (cetrorelix acetate)
Follistim AQ (follitropin beta)
Ganirelix AC (ganirelix acetate)
Gonal-f (follitropin alfa)
Gonal-f RFF (follitropin alfa)
Menopur (menotropins)
Novarel (chorionic gonadotropin)
Ovidrel (choriogonadotropin alfa)
Pregnyl (chorionic gonadotropin)
Injectafer (ferric carboxymaltose injection)
Jelmyto (mitomycin)
Khapzory (levoleucovorin)
Kimmtrak (tebentafusp-tebn) — prior authorization
n
eeded eective April 15, 2022