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Medical Drug Policies
Medical Drug Policies
Viva Health will utilize consistent resources/criteria for Part B organizational determinations. CMS NCDs and LCDs supersede all other criteria; health plans are allowed to utilize other criteria/policies only in the absence of CMS coverage policies. For requests in which there are no fully established CMS NCDs or LCDs which apply, the following sources will be referenced and utilized as appropriate:
- National Comprehensive Cancer Network (for oncology drug requests)
- CMS Approved Compendia
- Internal medical drug policies
- FDA approved prescribing information
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Abecma® (idecabtagene vicleucel)
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Abraxane® (paclitaxel albumin-bound)
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Actemra® (tocilizumab)
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Acthar_HP® (corticotropin)
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Adakveo® (crizanlizumab-tmca)
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Adcetris® (brentuximab vedotin)
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Adstiladrin® (nadofaragene firadenovec-vncg)
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Adzynma® (ADAMTS13, recombinant-krhn)
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Ahzantive® (aflibercept-mrbb)
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Akynzeo IV® (fosnetupitant/palonosetron)
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Aldurazyme® (laronidase)
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Alimta® (pemetrexed)
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Alyglo® (intravenous immune globulin)
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Alymsys® (bevacizumab-maly)
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Amondys 45™ (casimersen )
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Amtagvi® (lifileucel)
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Amvuttra® (vutrisiran)
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Anktiva® (nogapendekin alfa inbakicept-pmln)
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Aphexda® (motixafortide)
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Aralast® (alpha1-proteinase inhibitor) COMMERCIAL POLICY ONLY
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Aranesp® (darbepoetin)
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Armlupeg® (pegfilgrastim-unne)
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Asceniv® (intravenous immune globulin)
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Asparlas® (calaspargase pegol-mknl)
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Aucatzyl® (obecabtagene autolecel)
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Avastin® (bevacizumab)
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Avlayah™ (tividenofusp alfa-eknm)
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Avsola™ (infliximab-axxq)
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Avtozma® (tocilizumab-anoh)
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Avzivi (bevacizumab-tnjn)
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Axtle™ (Intravenous/Intrathecal)
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Bavencio® (avelumab)
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Belrapzo® (bendamustine)
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bendamustine hydrochloride (apotex)
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bendamustine hydrochloride (baxter)
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Bendeka® (bendamustine)
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Benlysta® (belimumab )
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Beovu® (brolucizumab intravitreal injection )
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Beqvez® (fidanacogene elaparvovec-dzkt)
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Berinert® (C1 esterase inhibitor )
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Besponsa® (inotuzumab ozogamicin)
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Bivigam® (intravenous immune globulin)
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Bizengri® (zenocutuzumab-zbco intravenous infusion)
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Bkemv™ (eculizumab-aeeb)
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Blenrep® (belantamab mefadontin-blmf)
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Blincyto® (blinatumomab)
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Botox® (onabotulinumtoxin a)
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Breyanzi® (lisocabtagene maraleucel)
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Brineura® (cerliponase alfa )
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Briumv® (ublituximab-xiiy )
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Byooviz™ (ranibizumab-nuna intravitreal)
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Camcevi™ (leuprolide)
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Camcevi™ ETM (leuprolide subcutaneous)
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Carvykti® (ciltacabtagene autoleucel)
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Casgevy® (exagamglogene autotemcel)
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Cerezyme® (imiglucerase)
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Cimerli® (ranibizumab-eqrn)
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Cimzia® (certolizumab pegol )
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Cinqair® (reslizumab )
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Cinryze® (C1 esterase inhibitor )
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Coagadex® (coagulation Factor X [human]
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Columvi™ (glofitamab-gxbm)
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Cortrophin® Gel (repository corticotropin injection)
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Corifact® (Factor XIII Concentrate [human]
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Cosela® (trilaciclib)
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Cosentyx® IV (secukinumab)
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Cosentyx® SQ (secukinumab)
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Crysvita® (burosumab-twxa)
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Cutaquig® (subcutaneous immune globulin)
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Cuvitru® (subcutaneous immune globulin)
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Cyramza® (ramucirumab)
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Danyelza® (naxitamab-gqgk)
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Darzalex™ (daratumumab)
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Darzalex Faspro® (daratumumab+hyaluronidase-fihj)
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Datroway® (datopotamab deruxtecan-dlnk intravenous infusion)
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Dawnzera™ (donidalorsen)
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Daxxify® (daxibotulinumtoxin a-lanm)
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Decnupaz® (pivekimab sunirine-pvzy)
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Dysport® (abobotulinumtoxin a)
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Elahere® (mirvetuximab soravtansine-gynx)
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Elaprase® (idursulfase)
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Elelyso® (taliglucerase)
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Elevidys® (delandistrogene moxeparvovec-rokl)
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Elfabrio® (pegunigalsidase alfa)
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Elitek® (rasburicase)
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Elrexfio® (elranatamab-bcmm)
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Elzonris® (tagraxofusp-erzs)
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Empliciti® (elotuzumab)
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Emrelis® (telisotuzumab vedotin-tllv)
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Encelto™ (revakinagene)
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Enhertu® (fam-trastuzumab deruxtecan-nxki)
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Enjaymo® (sutimlimab-jome)
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Entyvio® (vedolizumab )
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Enzeevu® (aflibercept-abzv)
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Epkinly™ (epcoritamab-bysp)
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Epysqli® (eculizumab-aagh)
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Erbitux® (cetuximab)
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Evenity® (romosozumab-aqqg subcutaneous)
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Evkeeza® (evinacumab-dgnb)
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Exdensur® (depemokimab-ulaa)
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Exondys 51™ (eteplirsen )
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Eydenzelt® (aflibercept-boav)
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Eylea® (aflibercept intravitreal injection )
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Eylea HD® (aflibercept)
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Fabrazyme® (agalsidase)
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Fasenra® (benralizumab )
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Faslodex® (injection, fulvestrant)
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Fensolvi® (leuprolide acetate for depot suspension)
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Feraheme® (ferumoxytol)
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Filkri®
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Firazyr® (icatibant )
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Firmagon® (degarelix)
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Flebogamma® (intravenous immune globulin)
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Fulphila® (pegfilgrastim-cbqv)
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fulvestrant (Fresenius) (fulvestrant (fresenius kabi))
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fulvestrant (Teva) (fulvestrant (teva))
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Fusilev® (levoleucovorin calcium)
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Fyarro® (sirolimus-albumin-bound)
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Fylnetra® (pegfilgrastim-pbbk)
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Gamifant® (emapalumab-lzsg)
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Gammagard Liquid® (intravenous immune globulin)
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Gammagard S/D® (immune globulin)
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Gammaked® (intravenous immune globulin)
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Gammaplex® (intravenous immune globulin)
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Gamunex-C® (intravenous immune globulin)
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Gazyva® (obinutuzumab)
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Givlaari™ (givosiran)
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Glassia® (Injection, alpha 1 proteinase inhibitor (human)) COMMERCIAL POLICY ONLY
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Grafapex™ (treosulfan)
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Granix (tbo-filgrastim)
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Haegarda® (C1 esterase inhibitor )
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Halaven® (eribulin)
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Hemgenix® (etranacogene dezaparvovec-drlb)
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Herceptin® (trastuzumab)
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Herceptin Hylecta™ (trastuzumab-hyaluronidase-oysk)
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Hercessi™ (trastuzumab-strf)
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Hernexeos® (zongertinib)
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Herzuma® (trastuzumab-pkrb)
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Hizentra® (subcutaneous immune globulin)
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Hyqvia® (subcutaneous immune globulin)
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Ilaris® (canakinumab )
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Ilumya® (tildrakizumab-asmn )
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Imaavy™ (nipocalimab-aahu)
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Imdelltra™ (tarlatamab-dlle)
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Imfinzi® (durvalumab)
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Imjudo® (tremelimumab-actl)
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Imlygic® (talimogene laherparepvec)
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Immgolis INTRI®
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Imuldosa® (ustekinumab-srlf)
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Inflectra® (infliximab-dyyb)
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Injectafer® (ferric carboxymaltose )
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Inlexzo™ (gemcitabine)
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Intravenous Immune Globulin
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Subcutaneous Immune Globulin
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Itvisma® (onasemnogene abeparvovec-brve)
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Ixempra® (ixabepilone)
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Izervay™ (avacincaptad pegol intravitreal )
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Jelmyto® (mitomycin)
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Jemperli™ (dostarlimab-gxly)
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Jevtana® (cabazitaxel) COMMERCIAL POLICY ONLY
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Jobevne™ (bevacizumab-nwgd)
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Kadcyla® (ado-trastuzumab emtansine)
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Kalbitor® (ecallantide )
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Kanjinti™ (trastuzumab-anns)
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Kanuma® (sebelipase alfa)
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Keytruda® (pembrolizumab)
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Keytruda Qlex™ (pembrolizumab and berahyaluronidase alfa-pmph)
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Khapzory™ (levoleucovorin sodium)
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Kimmtrak® (tebentafusp-tebn)
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Kisunla® (donanemab-azbt)
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Kresladi™ (marnetegragene autotemcel)
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Krystexxa® (pegloticase)
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Kymriah® (tisagenlecleucel)
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Kyprolis® (carfilzomib)
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Kyxata™ (carboplatin)
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Lamzede® (velmanase alfa-tycv)
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Lanreotide (Cipla)
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Lemtrada® (alemtuzumab )
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Lenmeldy™ (atidarsagene autotemcel)
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LeqembI® (lecanemab-irmb )
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Leqvio® (inclisiran subcutaneous injection – Novartis)
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Leukine® (sargramostim)
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Leuprolide Depot (leuprolide acetate 22.5 mg for depot suspension)
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Libtayo® (cemiplimab-rwlc)
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Loargys® (pegzilarginase-nbln)
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Loqtorzi™ (toripalimab-tpzi)
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Lucentis® (ranibizumab)
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Lumizyme® (alglucosidase)
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Lunsumio™ (mosunetuzumab-axgb)
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Lunsumio Velo™ (mosunetuzumab-axgb)
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Lupron® (leuprolide acetate)
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Lupron Depot® (leuprolide acetate)
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Lupron Depot® (leuprolide acetate (for depot suspension), 7.5 mg)
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Lutrate Depot® (leuprolide acetate (for depot suspension), 22.5 mg)
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Lutathera® (lutetium Lu 177 dotatate )
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Luxturna® (voretigene neparvovec-rzyl )
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Lyfgenia® (lovotibeglogene autotemcel)
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Lymphir® (denileukin difitox-cxdl)
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Lynozyfic™ (linvoseltamab-gcpt intravenous infusion)
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Margenza® (margetuximab-cmkb)
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Mepsevii® (vestronidase alfa-vjbk)
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Modeyso™ (dordaviprone)
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Monjuvi® (tafasitamab-cxix)
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Monoferric® (ferric derisomaltose )
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Mvasi™ (bevacizumab-awwb)
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Mylotarg™ (gemtuzumab ozogamicin)
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Myobloc® (rimabotulinumtoxin b)
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Naglazyme® (galsulfase)
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Neulasta® (pegfilgrastim)
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Neupogen® (filgrastim)
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Nexviazyme® (avalglucosidase alfa-ngpt)
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Niktimvo™ (axatilimab-csfr)
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Nivestym® (filgrastim-aafi, biosimilar)
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Nplate® (romiplostim)
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Nucala® (mepolizumab)
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Nufymco® (Intravitreal)
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Nulibry™ (fosdenopterin )
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Nypozi™ (filgrastim-txid)
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Nyvepria® (pegfilgrastim-apgf)
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Ocrevus® (ocrelizumab)
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Ocrevus Zunovo® (ocrelizumab/hyaluronidase-ocsq)
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Octagam® (intravenous immune globulin)
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Ogivri® (trastuzumab-dkst)
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Omisirge® (omidubicel-onlv)
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Omlyclo
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Omvoh® IV (mirikizumab-mrkz)
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Omvoh® SQ (mirikizumab-mrkz)
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Oncaspar® (pegaspargase)
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Onivyde® (irinotecan liposome) COMMERCIAL POLICY ONLY
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Onpattro® (patisiran)
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Ontruzant® (trastuzumab-dttb)
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Opdivo® (nivolumab)
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Opdivo Qvantig™ (nivolumab and hyaluronidase-nvhy)
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Opdualag® (nivolumab/relatlimab-rmbw)
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Opuviz (aflibercept-yszy)
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Orencia® (abatacept )
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Otarmeni™ (lunsotogene parvec-cwha)
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Otulfi™ (ustekinumab-aauz)
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Oxlumo™ (lumasiran subcutaneous injection )
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Paclitaxel Albumin-Bound (paclitaxel albumin-bound (Teva))
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Padcev® (enfortumab vedotin-ejfv)
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Panzyga® (intravenous immune globulin)
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Papzimeos™ (zopapogene imadenovec-drba)
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Pavblu® (aflibercept-ayyh)
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Pegfilgrastim
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Pemetrexed (pemetrexed (accord))
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Pemetrexed (pemetrexed (avyxa))
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Pemetrexed (pemetrexed (bluepoint))
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Pemetrexed (pemetrexed (hospira))
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Pemetrexed (pemetrexed (sandoz))
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Pemetrexed (pemetrexed (teva))
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Pemetrexed (pemetrexed (various))
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Pemetrexed (pemetrexed ditromethamine (Hospira))
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Pemfexy® (pemetrexed)
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Pemrydi RTU™ (pemetrexed disodium)
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Perjeta® (pertuzumab)
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Phesgo® (pertuzumab, trastuzumab, hyaluronidase-zzxf)
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Piasky® (crovalimab-akkz)
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Pluvicto™
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Polivy® (polatuzumab vedotin-piiq)
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Pombiliti® (cipaglucosidase alfa-atga)
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Portrazza® (necitumumab)
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Poteligeo® (mogamulizumab-kpkc)
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Privigen® (intravenous immune globulin)
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Procrit/Epogen® (epoetin alfa)
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Prolastin-C® (alpha-1 proteinase inhibitor (human)) COMMERCIAL POLICY ONLY
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Prolastin®-C Liquid (alpha1-proteinase inhibitor [human]) COMMERCIAL POLICY ONLY
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Provenge® (sipuleucel-t)
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Pyzchiva™ IV (ustekinumab-ttwe) MEDICARE POLICY ONLY
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Pyzchiva™ SQ (ustekinumab-ttwe subcutaneous injection) MEDICARE POLICY ONLY
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Qalsody® (tofersen)
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Radicava® (edaravone )
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Reblozyl® (luspatercept-aamt)
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Releuko® (filgrastim-ayow, biosimilar)
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Remicade® (infliximab)
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Renflexis® (infliximab-abda)
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Retacrit® (epoetin alfa-epbx)
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Rethymic® (allogenic processed thymus tissue-agdc)
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Revcovi® (elapegademase-lvlr)
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Riabni® (rituximab-arrx)
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Rituxan® (rituximab)
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Rituxan Hycela® (rituximab and hyaluronidase human)
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Roctavian® (valoctocogene roxaparvovec-rvox)
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Rolvedon® (eflapegrastim-xnst)
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Ruconest® (C1 esterase inhibitor )
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Ruxience® (rituximab-pvvr)
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Rybrevant® (amivantamab-vmjw)
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Rybrevant Faspro™ (amivantamab and hyaluronidase-lpuj).
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Rylaze® (asparaginase erwinia chrysanthemi recombinant-rywn)
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Ryoncil® (remestemcel-l-rknd/ td)
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Ryplazim® (plasminogen, human-tvmh)
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Rystiggo® (rozanolixizumab-noli)
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Rytelo® (imetelstat)
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Ryzneuta® (efbemalenograstim alfa-vuxw)
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Sajazir™ (icatibant )
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Sandostatin® LAR Depot (octreotide acetate )
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Saphnelo™ (anifrolumab-fnia )
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Sarclisa® (isatuximab-irfc)
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Scenesse® (afamelanotide)
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Selarsdi™ IV (ustekinumab-aekn)
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Selarsdi™ SQ (ustekinumab-aekn subcutaneous injection)
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Simponi Aria® (golimumab )
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Skyrizi® IV (risankizumab-rzaa )
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Skysona® (elivaldogene autotemcel )
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Soliris® (eculizumab intravenous infusion)
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Somatuline® Depot (lanreotide )
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Spevigo® (spesolimab) (Intravenous)
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Spevigo® (spesolimab) (Subcutaneous)
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Spinraza® (nusinersen intrathecal injection )
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Spravato® (esketamine nasal spray)
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Starjemza™
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Stelara® IV (ustekinumab )
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Stelara® SQ (ustekinumab subcutaneous injection)
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Steqeyma® (ustekinumab-stba)
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Stimufend® (pegfilgrastim-fpgk)
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Supprelin LA® (histrelin implant)
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Sustol® (granisetron extended-release)
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Susvimo™ (ranibizumab intravitreal injection)
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Syfovre™ (pegcetacoplan intravitreal injection)
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Sylvant® (siltuximab)
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Synagis® (palivizumab) COMMERCIAL POLICY ONLY
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Takhzyro® (lanadelumab-flyo)
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Talvey® (talquetamab-tgvs)
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Tecartus® (brexucabtagene autoleucel)
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Tecelra® (afamitresgene autoleucel)
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Tecentriq® (atezolizumab)
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Tecentriq Hybreza™ (atezolizumab-hyaluronidase-tqjs)
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Tecvayli® (teclistamab-cqyv)
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Tegsedi® (inotersen)
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Tepezza™ (teprotumumab )
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Testopel® (testosterone pellets)
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Tevimbra® (tislelizumab-jsgr)
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Tezspire® (tezepelumab-ekko)
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Tivdak® (tisotumab vedotin-tftv)
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Tofidence™ (tocilizumab-bavi)
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Trastuzumab-pkrb (Intravenous/Intrathecal/Intraventricular)
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Trazimera™ (trastuzumab-qyyp)
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Treanda® (bendamustine)
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Trelstar® (triptorelin pamoate)
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Tremfya® IV (guselkumab)
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Tremfya® SQ (guselkumab)
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Tretten® (coagulation Factor XIII A-Subunit)
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Triptodur® (triptorelin, extended-release)
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Trodelvy® (sacituzumab govitecan-hziy)
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Trogarzo® (ibalizumab-uiyk )
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Truxima® (rituximab-abbs)
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Tyenne® (tocilizumab-aazg)
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Tyruko® (natalizumab-sztn)
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Tysabri® (natalizumab )
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Tzield® (teplizumab-mzwv)
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Udenyca® (pegfilgrastim-jmdb)
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Ultomiris® (ravulizumab-cwvz)
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Unloxcyt™ (cosibelimab-ipdl intravenous infusion)
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Uplizna® (inebilizumab-cdon)
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Ustekinumab
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Vabrinty (leuprolide acetate subcutaneous)
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Vabysmo™ (faricimab-svoa intravitreal )
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Vectibix® (panitumumab)
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Vegzelma™ (bevacizumab-adcd)
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Veopoz® (pozelimab-bbfg)
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Viltepso™ (viltolarsen )
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Vimizim® (elosulfase alfa)
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Visudyne® (verteporfin)
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Vivimusta® (bendamustine)
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Vonvendi® (von Willebrand factor)
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Vpriv® (velaglucerase)
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Vyepti® (eptinezumab-jjmr)
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Vyjuvek™ (beremagene geperpavec-svdt)
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Vyloy® (zolbetuximab-clzb)
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Vyondys 53™ (golodirsen )
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Vyvgart® (efgartigimod alfa-fcab)
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Vyvgart Hytrulo® (efgartigimod alfa-fcab and hyaluronidase-qvfc)
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Vyxeos® (daunorubicin; cytarabine liposomal)
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Wainua® (eplontersen)
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Waskyra™ (etuvetidigene autotemcel)
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Wezlana™ IV (ustekinumab-auub)
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Wezlana™ SQ (ustekinumab-auub subcutaneous injection)
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Xembify® (subcutaneous immune globulin)
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Xenpozyme™ (olipudase alfa-rpcp)
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Xeomin® (incobotulinumtoxin a)
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Xiaflex® (collagenase clostridium histolyticum intralesional injection)
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Xipere® (injection, triamcinolone acetonide)
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Xolair® (omalizumab)
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Yartemlea® (narsoplimab-wuug)
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Yervoy® (ipilimumab)
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Yesafili (aflibercept-jbvfv)
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Yescarta® (axicabtagene ciloleucel)
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Yesintek® (ustekinumab-kfce)
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Yimmugo® (intravenous immune globulin)
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Yondelis® (trabectedin)
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Zaltrap® (ziv-aflibercept)
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Zarxio® (filgrastim-sndz, biosimilar)
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Zemaira® (alpha-1 proteinase inhibitor) - COMMERCIAL POLICY ONLY
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Zepzelca™ (lurbinectedin)
-
Zevaskyn™ (prademagene zamikeracel)
-
Ziextenzo® (pegfilgrastim-bmez)
-
Ziihera® (zanidatamab-hrii)
-
Zirabev™ (bevacizumab-bvzr)
-
Zoladex® (goserelin acetate implant, per 3.6 mg)
-
Zolgensma® (onasemnogene abeparvovec-xioi )
-
Zusduri™ (mitomycin intravesical)
-
Zynlonta® (loncastuximab tesirine-lpyl)
-
Zynteglo™ (betibeglogene autotemcel)
-
Zynyz™ (retifanlimab-dlwr)