Medical Prior Authorization List (For Drugs Administered in an Office, Home or Outpatient Setting) Effective August 1, 2021 THIS LIST APPLIES TO ALL COMMERCIAL FULLY-INSURED MEMBERS Certain drugs require prior authorization in order to be covered under your health plan. Prior authorization review is the process of determining the medical necessity of a proposed procedure, surgery or treatment (including prescribed drug intervention) relative to approved criteria. Prior authorization is required to ensure that the drug is medically necessary and you will receive the benefits to which you are entitled. Requests for prior authorization must be received before the services or drugs are provided/ administered. Failure of a network provider to contact SummaCare for required authorization of items covered under your benefit plan will relieve the health plan and you from any financial responsibility for the service if those services are rendered before notifying the plan. Certain drugs that require prior authorization may also be subject to SummaCare’s Site of Care Policy. These drugs are noted with “++”. For more information refer to the policy on our website at: https://www.summacare.com/providers/provider-policies/pharmacy-policies NOTE: Your in-network providers are responsible for obtaining authorization 48 hours prior to administering these prescription drugs. If you use a provider that is not in your network, it is your responsibility to obtain any required prior authorization. For Providers: Network providers are responsible for obtaining authorization at least 48 hours before rendering these prescription drugs. How to request prior authorization for drugs covered under the medical benefit: • Fax submission of requests for prior authorization should be used for non-urgent requests. • Routine requests: Fax 234-231-7082 • Urgent requests: Call 330-996-8710 or 888-996-8710 (TTY 800-750-0750) • Oncology requests: For all drugs marked with “*” Call 855-774-1315 SummaCare provides coverage under the medical benefit for many drugs that are administered in an office, home or outpatient setting. We require certain drugs to receive prior authorization before being administered. The following drugs may require prior authorization: 5FU (fluorouracil) * ADRIAMYCIN (doxorubicin) * ABILIFY MAINTENA (aripiprazole) ADVATE (factor product) ABRAXANE (paclitaxel) * ADYNOVATE (factor product) ACTEMRA (tocilizumab) * ++ AFSTYLA (factor product) ACTHAR GEL (corticotropin) AKYNZEO (fosnetupitant/palonosetron) * ACTIMMUNE (interferon gamma-1b) * ALDURAZYME (laronidase) ++ ADAGEN (pegademase) ALIMTA (premetrexed disodium) * ADAKVEO (crizanlizumab-tmca) ALIQOPA (copsnlidib) * ADCETRIS (brentuximab vedotin) * ALKERAN (melphalan) * 1 Medical Prior Authorization List (For Drugs Administered in an Office, Home or Outpatient Setting) ALOXI (palonosetron) * CEREZYME (imiglucerase) ++ ALPHANATE (antihemophilic factor) CERUBIDINE (daunorubicin) * ALPHANINE SD (antihemophilic factor) CIMZIA (certolizumab pegol) ++ ALPROLIX (factor product) CINRYZE (C1 inhibitor) ++ AMONDYS (casimersen) CINQAIR (reslizumab) ANDEXXA (andexanet alfa) CINVANTI (aprepitant) * ARA-C (cytarabine) * CLOLAR (clofarabine) * ARALAST (alpha proteinase inhibitor) ++ COAGADEX (factor product) ARANESP (darbepoetin alfa) * CORIFACT (factor product) ARCALYST (rilonacept) COSELA (trilaciclib) * AREDIA (pamidronate disodium) * COSMEGEN (dactinomycin) * ARISTADA/ARISTADA INITIO (aripiprazole lauroxil) CRYSVITA (burosumab-twza) * ARRANON (nelarabine) * CUVITRU (immune globulin) ARZERRA (ofatumumab) * CYRAMZA (ramucirumab) * ASCENIV (immune globulin) ++ CYTOGAM (cytomegalovirus immune globulin) ++ ASPARLAS (calaspargase pegol-mknl) * CYTOXAN (cyclophosphamide) * ATGAM (antithymocyte globulin) ++ DACOGEN (decitabine)* AVASTIN (bevacizumab) * DANYELZA (naxitamab-gqgk) * AVONEX (interferon beta-1a) DARZALEX (daratumumab) * AVSOLA (infliximab-axxq)++ DARZALEX FASPRO (daratumumab-hyaluronidase) * AZEDRA (iobenguane I 131) DEPOCYT (cytarabine-liposome) * BAVENCIO (avelumab) * DOJOLVI (triheptanoin) BCNU (carmustine)* DOXIL (doxorubicin-liposome) * BEBULIN/BEBULIN VH (factor product) DTIC-DOME (dacarbazine) * BELEODAQ (belinostat) * DUROLANE (hyaluronate and derivatives) BELRAPZO (bendamustine hcl)* DYSPORT (abobotulinumtoxin A) BENDEKA (bendamustine hcl) * ELAPRASE (idursulfase) ++ BENEFIX (factor product) ELELYSO (taliglucerase–alfa) BENLYSTA IV (belimumab) ELIGARD (leuprolide acetate)* BERINERT (c1 esterase inhibitor) ++ ELLENCE (epirubicin) * BESPONSA (inotuzumab ozogamicin) * ELOCTATE (factor product) BIVIGAM (immune globulin) ++ ELOXATIN (oxaliplatin) * BLENOXANE (bleomycin) * ELZONRIS (tagraxofusp-erzs) * BLENREP (belantamab mafodotin-blmf) * EMPLICITI (elotuzumab) * BLINCYTO (blinatumomab) * EMPAVELI (pegcetacoplan) BONIVA IV (ibandronate) ENHERTU (fam-trastuzumab deruxtecan-nxki) * BOTOX (onabotulinumtoxin A) ENTYVIO (vedolizumab) ++ BRINEURA (cerliponase) EPOGEN (epoetin alfa) * CABENUVA (cabotegravir/rilpivirine) ERBITUX (cetuximab) * CABLIVI (caplacizumab-yhdp) ERWINAZE (asparaginase) * CAMPTOSAR (irinotecan) * ESPEROCT (factor product) CARIMUNE (immune globulin) EVENITY (romosozumab-aqqg) CAYSTON (aztreonam) inhalation EVKEEZA (evinacumab-dgnb) 2 Medical Prior Authorization List (For Drugs Administered in an Office, Home or Outpatient Setting) EVOMELA (melphalan)* IDAMYCIN (idarubicin) * EXONDYS 51 (eteplirsen) IDELVION (factor product) EXCLUDED FROM COVERAGE IFEX (ifosfamide) * FABRAZYME (agalsidase) ++ ILARIS (canakinumab) FASENRA (benralizumab) ILUMYA (tildrakizumab-asmn) FASLODEX (fluvestrant) * IMFINZI (durvalumab) * FEIBA NF (factor product) IMLYGIC (talimogene laherparepvec) * FENSOLVI (leuprolide acetate) * INFLECTRA (infliximab-dyyb) ++ FIRMAGON (degarelix) * INFUGEM (gemcitabine) * FLEBOGAMMA (immune globulin) ++ INTRON A (interferon alfa-2b) * FLOLAN (epoprostenol) INVEGA SUSTENNA (paliperidone palmitate ER) FLUDARA (fludarabine) * INVEGA TRINZA (paliperidone palmitate) FOLOTYN (pralatrexate) * ISTODAX (romidepsin)* FUDR (floxuridine) * IXEMPRA (ixabepilone) * FULPHILA (pegfilgrastim-jmbd) * IXINITY (factor product) FUSILEV (levoleucovorin) * JELMYTO (mitomycin)* GAMASTAN (immune globulin) ++ JEMPERLI (dostarlimab-gxly) * GAMIFANT (emapalumab-lzsg) JEVTANA (cabazitaxel) * GAMMAGARD (immune globulin) ++ JIVI (factor product) GAMMAKED (immune globulin) ++ KADCYLA (trastuzumab emtansine) * GAMMAPLEX (immune globulin) ++ KANJINTI (trastuzumab-anns) * GAMUNEX-C (immune globulin) ++ KANUMA (sebelipase) ++ GAZYVA (obinutuzumab) * KCENTRA (factor product) GEL-ONE (hyaluronate and derivatives) KEYTRUDA (pembrolizumab) * GELSYN (hyaluronate and derivatives) KHAPZORY (levoleucovorin) * GENVISC (hyaluronate and derivatives) KOATE (factor product) GEMZAR (gemcitabine) * KOGENATE FS (factor product) GIVLAARI (givosiran) KOVALTRY (factor product) GLASSIA (proteinase inhibitor) ++ KRYSTEXXA (pegloticase) GRANIX (tbo-filgrastim) * KYMRIAH (tisagenleceucel) HALAVEN (eribulin mesylate) * KYPROLIS (carfilzomib) * HELIXATE FS (factor product) LARTRUVO (olaratumab)* HEMLIBRA (emicizumab-kxwh) LEMTRADA (alemtuzumab) HEMOFIL M (antihemophilic factor) LEUCOVORIN * HERCEPTIN (trastuzumab) * LEUKINE (sargramostim) * HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk) * LEUSTATIN (cladribine) * HERZUMA (trastuzumab-pkrb) * LIBTAYO (cemiplimab-rwic) * HIZENTRA (immune globulin) LUMIZYME (alglucosidase) ++ HUMATE-P (factor product) LUMOXITI (moxetumomab psaudotox-tdfk) * HYALGAN (hyaluronate and derivatives) LUPRON DEPOT (leuprolide acetate) * HYCAMTIN (topotecan) * LUTATHERA (lutetium lu177 dotatate) HYMOVIS (hyaluronate and derivatives) LUXTURNA (voretigene neparvovec-rzyl) HYQVIA (immune globulin) MARGENZA (margetuximab) 3 Medical Prior Authorization List (For Drugs Administered in an Office, Home or Outpatient Setting) MARQIBO (vincristine sulfate liposome) * PADCEV (enfortumab vedotin-piiq) * MEPSEVII (vestronidase alfa-vjbk) PANZYGA (immune globulin-ifas) ++ MESNEX (mesna) * PARAPLATIN (carboplatin) * METHOTREXATE * PARSABIV (etelcalcetide) MIRCERA (methoxy polyethylene glycol-epoetin beta) PEGASYS (peginterferon alfa-2a) * MONJUVI (tafasitamb-cxix) * PEGINTRON (peginterferon alfa-2b) * MONOCLATE-P (factor product) PEPAXTO (melphalan flufenamide) * MONONINE (factor product) PERJETA (pertuzumab) * MONOVISC (hyaluronate and derivatives) PERSERIS (risperidone) PHESGO (pertuzumab, trastuzumab, and MOZOBIL (plerixafor) hyaluronidase) * MUSTRAGEN (mechlorethamine) * PHOTOFRIN (porfimer) * MUTAMYCIN (mitomycin) * PLATINOL (cisplatin) * MVASI (bevacizumab-awwb) * POLIVY (polatuzumab vedotin-piiq) * MYLOTARG (gemtuzumab ozogamicin) * PORTRAZZA (necitumumab) * MYOBLOC (rimabotulinumtoxin B) POTELIGEO (mogamulizumab-kpkc) * NAGLAZYME (galsulfase) PRIVIGEN (immune globulin) ++ NAVELBINE (vinorelbine) * PROBUPHINE IMPLANT (buprenorphine) NEULASTA (pegfilgrastim) * PROCRIT (epoetin alfa) * NEUPOGEN (filgrastim) * PROFILNINE SD (factor product) NIPENT (pentostatin) * PROLASTIN (alpha proteinase inhibitor) ++ NIVESTYM (filgrastim-aafi) * PROLEUKIN (aldesleukin) * NOVANTRONE (mitoxantrone) * PROLIA (denosumab) NOVOEIGHT (factor product) PROVENGE (sipuleucel-T) * NOVOSEVEN RT (factor product) QUTENZA (capsaicin 8% patch) NPLATE (romiplostim) QUZYTTIR (cetirizine hcl) NUCLALA (mepolizumab) RADICAVA (edaravone) ++ NULOJIX (belatacept) REBINYN (factor product) NUWIQ (factor product) REBLOZYL (luspatercept-aamt) * NYVEPRIA (pegfilgrastim-apgf) * RECLAST (zoledronic acid) OBIZUR (antihemophilic factor) RECOMBINATE (factor