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EN
ES

Novologix Part B PA Policies

A

Abecma 4643-A MedB P2022
Abraxane 4817-A MedB P2021
- Abraxane MedB Jurisdiction K (CT, MA, ME, NH, NY, RI, VT) P2021
Actemra MedB P2021
Acthar-Purified Cortrophin Gel 4797-A MedB P2021a
Adagen 4809-A MedB P2021
Adakveo 3416-A MedB P2021
Adcetris MedB 4463-A P2021a
Aduhelm 4777-A MedB P2021b
Aliqopa 2331-A MedB P2021
Alpha1-Proteinase Inhibitors MedB P2021
Alphanate MedB Jurisdiction L (DC, DE, MD, NJ, PA) P2020a
Amondys 45 MedB P2021a
Andexxa Med B P2021
Aranesp 1982-A MedB P2021
- Aranesp 2108-A MedB Jurisdiction N (FL, PR, USVI) P2021
Asparlas 4616-A MedB P2021a
ATryn Med B P2021
Avastin-Mvasi-Zirabev - Oncology MedB P2021
Avastin-Mvasi-Zirabev Ocular & Other 2509-A MedB P2021

B

Bavencio 2130-A MedB P2021
Beleodaq 4727-A MedB P2021
Benlysta 2502-A MedB P2021a
Beovu 3348-A MedB P2021
- Beovu 3828-A MedB Jurisdiction K (CT, MA, ME, NH, NY, RI, VT) P2021
Berinert 4230-A MedB P2021
Besponsa 2265-A MedB P2021
Bevacizumab and biosimilars 3834-A MedB Jurisdiction K (CT MA ME NH NY RI VT) P2021a
BiCNU 4808-A MedB P2022
Blincyto 4231-A MedB P2021
Botulinum Toxins 2624-A MedB P2021
Breyanzi 4514-A MedB P2021a
Brineura MedB P2021

C

Cablivi 4856-A MedB P2021
Camcevi 4764-A MedB P2021
- Camcevi 5133-A MedB Jurisdiction K (CT, MA, ME, NH, RI, VT) P2022
Carvykti 5266-A MedB P2022
Cerezyme MedB 4459-A P2021
Cimzia 4703-A MedB P2021
Cinqair 2065-A MedB P2021
Cinryze 2189-A MedB P2021
Coagadex 4849-A MedB P2021
- Coagadex MedB Jurisdiction L (DC, DE, MD, NJ, PA) P2021
Corifact 4851-A MedB P2021
- Corifact MedB Jurisdiction L (DC, DE, MD, NJ, PA) P2021
Cosela MedB P2021
Crysvita 4234-A MedB P2021
Cyramza MedB P2021

D

Danyelza MedB P2021
Darzalex MedB P2021
- Darzalex Faspro MedB 4465-A P2021a
decitabine-Dacogen MedB P2021
deferoxamine-Desferal MedB P2021
Dysport MedB Jurisdiction N (FL, PR, USVI) P2021

E

Exondys 51 MedB P2021.docx.pdf
Eligard 4712-A MedB P2021
- Eligard MedB Jurisdiction K (CT, MA, ME, NH, NY, RI, VT) P2021
- Eligard MedB Jurisdiction L (DC, DE, MD, NJ, PA) P2021
Elzonris MedB P2021
Empliciti 4858-A MedB P2021
Empaveli 4739-A MedB P2021a
Enjaymo 5201-A MedB P2022
Entyvio MedB P2021
Epogen-Procrit-Retacrit (Epoetin) 1983-A MedB P2021
- Epogen-Procrit-Retacrit 2110-A MedB Jurisdiction N (FL, PR, USVI) P2021
epoprostenol-Flolan-Veletri 4820-A Med B P2021
Erbitux 2626-A MedB P2021
Erwinaze 4199-A MedB P2021
Evenity MedB P2020
Evkeeza MedB P2022
Evomela Med B P2021
Evrysdi MedB P2021
Exondys 51 MedB P2021
Eylea 2507-A MedB P2021
- Eylea 3830-A MedB Jurisdiction K (CT, MA, ME, NH, NY, RI, VT) P2021

F

Fabrazyme 4200-A MedB P2021
Factor IX 4852-A MedB P2021.docx
Factor VIII 4932-A MedB P2021
- Factor VIII MedB Jurisdiction L (DC, DE, MD, NJ, PA) P2021
Fasenra 2419-A MedB P2021.docx
FEIBA 4800-A MedB P2021
- FEIBA MedB Jurisdiction L (DC, DE, MD, NJ, PA) P2021
Fensolvi 4692-A MedB P2021
Filgrastim products 3932-A MedB Jurisdiction K (CT MA ME NH NY RI VT) P2021
- Filgrastim products 4490-A MedB Jurisdiction J (AL, GA, TN) and M (NC, SC, VA, WV) P2021a
Firmagon MedB 4455-A P2021

G

Gazyva 4467-A MedB P2021a
gemcitabine MedB 4469-A P2021a
Givlaari 4235-A MedB P2021
Granix 3920-A MedB Jurisdiction K (CT, MA, ME, NH, NY, RI, VT) P2021
- Granix 4489-A MedB Jurisdiction J (AL, GA, TN) and M (SC, NC, VA, WV) P2021a

H

Hemlibra 4798-A MedB P2021
- Hemlibra MedB Jurisdiction L (DC, DE, MD, NJ, PA) P2021
Hepagam B MedB Jurisdiction L (DC, DE, MD, NJ, PA) P2020
Herceptin and Trastuzumab Biosimilars MedB P2021
- Herceptin Hylecta MedB P2021
Humate-P 4869-A MedB P2021
- Humate-P MedB Jurisdiction L (DC, DE, MD, NJ, PA) P2021a
Hyaluronan Acid Therapies MedB Jurisdiction L (DC, DE, MD, NJ, PA) P2021
Hyaluronans MedB Jurisdiction K (CT, MA, ME, NH, NY, RI, VT) P2021
Hyaluronates MedB P2021

I

icatibant-Sajazir-Firazyr 2192-A M Save edB P2021
Ilaris MedB P2021
Ilumya 4697-A Med B P2022
Imfinzi 2131-A MedB P2021
Imlygic 4468-A MedB P2021
Infliximab MedB P2021
- Infliximab Products MedB Jurisdiction K (CT, MA, ME, NH, NY, RI, VT) P2021
IVIG 1985-A MedB P2021

J

Jelmyto 3870-A MedB P2021
Jemperli 4723-A MedB P2021b

K

Kadcyla MedB P2021
Kalbitor 2193-A MedB P2021
Kanuma MedB P2021
Keytruda 1980-A MedB P2021a
Kimmtrak 5150-A MedB P2022
Krystexxa 2206-A MedB P2022
Kymriah 3061-A MedB P2021
Kyprolis MedB 4470-A P2021b

L

Lemtrada MedB P2021
Leqvio 5120-A MedB P2022
Leukine 4458-A MedB P2021a
- Leukine 4488-A MedB Jurisdiction J (AL, GA, TN) and M (SC, NC, VA, WV) P2021a
Levoleucovorin-Fusilev-Khapzory 4212-A MedB P2021
Libtayo MedB P2022
Lucentis 2508-A MedB P2021
- Lucentis 3831-A MedB Jurisdiction K (CT, MA, ME, NH, NY, RI, VT) P2021
Lumizyme 2690-A MedB P2021
Lumoxiti 4471-A MedB P2021a
Lupron Depot Endometriosis-Fibroid 4728-A MedB P2021
- Lupron Depot MedB Jurisdiction K (CT, MA, ME, NH, NY, RI, VT) P2021
- Lupron Depot MedB Jurisdiction L (DC, DE, MD, NJ, PA) P2021
Lupron Depot Prostate Cancer 4694-A MedB P2021
Lutathera MedB P2020
Luxturna 2457-A MedB P2021
- Luxturna MedB Jurisdiction J (AL,GA,TN) and Jurisdiction M (SC,VA,WV,NC) P2021

M

Macugen MedB 4461-A P2021
Margenza MedB P2021
Marqibo 4815-A MedB P2021
Mepsevii MedB P2021
Miacalcin 4796-A MedB P2021
Mircera 2113-A MedB Jurisdiction N (FL, PR, USVI) P2021
- Mircera 4462-A MedB P2021a
Mylotarg MedB P2021
Myobloc MedB Jurisdiction N (FL, PR, USVI) P2021

N

Naglazyme MedB P2021
Neulasta and biosimilars 4237-A MedB P2021
- Neulasta and pegfilgrastim biosimilars 2114-A MedB Jurisdiction N (FL PR USVI) P2021
Neupogen and filgrastim biosimilars 4758-A MedB P2021a
- Neupogen-Nivestym-Granix-Zarxio 2115-A MedB Jurisdiction N (FL PR USVI) P2021
Nexviazyme 4893-A MedB P2021
Novoseven RT 4799-A MedB P2021
- Novoseven RT MedB Jurisdiction L (DC, DE, MD, NJ, PA) P2021
Nplate 3371-A MedB P2021
Nucala 2063-A MedB P2021a
Nulibry MedB 4582-A P2021

O

Obizur 4850-A MedB P2021
- Obizur MedB Jurisdiction L (DC, DE, MD, NJ, PA) P2021
Ocrevus MedB P2021
Oncaspar 4472-A MedB P2021a
Onivyde MedB P2021a
Onpattro 4238-A MedB P2021
Opdivo MedB Jurisdiction K (CT MA ME NH NY RI VT) P2022a
- Opdivo MedB P2021
Opdualag 5326-A MedB P2022
Orencia MedB P2021
Oxlumo MedB P2020

P

Paclitaxel MedB Jurisdiction K (CT, MA, ME, NH, NY, RI, VT) P2021
Padcev 4473-A MedB P2021b
Pegfilgrastim products 3916-A MedB Jurisdiction K (CT, MA, ME, NH, NY, RI, VT) P2021
- Pegfilgrastim products 4491-A MedB Jurisdiction J (AL, GA, TN) and M (NC, SC, VA, WV) P2021a
Perjeta MedB P2021
Phesgo 4704-A MedB P2021
Photofrin 4827-A MedB P2021
Polivy 3101-A MedB P2021
Portrazza 4724-A MedB P2021
Poteligeo MedB 4474-A P2021
Proleukin 4239-A MedB P2021
Prolia MedB Jurisdiction K (CT, MA, ME, NH, NY, RI, VT) P2020a
- Prolia MedB P2020
Provenge 2409-A MedB P2021

R

Radicava 2066-A MedB P2021
Reblozyl 4717-A MedB P2021
Rituxan Hycela 3869-A MedB Jurisdiction K (CT, MA, ME, NH, NY, RI, VT) P2021
Rituximab 3868-A MedB Jurisdiction K (CT, MA, ME, NH, NY, RI, VT) P2021
- Rituximab products 4452-A Med B Jurisdiction J Jurisdiction M Qset DR 02-2022
Ruconest 2194-A MedB P2021
Rybrevant 4742-A MedB P2021
Rylaze 4824-A MedB P2021
Ryplazim 4782-A MedB P2021

S

Sandostatin LAR MedB P2021
Saphnelo 4878-A MedB P2021
Sarclisa MedB 4718-A P2021
Sevenfact MedB 4695-A P2021
- Sevenfact MedB Jurisdiction L (DC, DE, MD, NJ, PA) P2021
Signifor LAR MedB P2021
Soliris 1632-A MedB P2021a
- Soliris MedB Jurisdiction K (CT, MA, ME, NH, NY, RI, VT) P2021
Somatuline Depot MedB P2021
Spinraza MedB P2021
Stelara MedB P2021a
Subcutaneous Immune Globulins 2541-A MedB P2022a
Supprelin LA MedB Jurisdiction L (DC, DE, MD, NJ, PA) P2021
Sylvant 4476-A MedB P2021

T

Takhzyro 2670-A MedB P2021
Tecartus 4044-A MedB P2021
Tecentriq 2132-A MedB P2021
Tegsedi MedB P2021
Tepezza MedB P2021
Tezspire 5106-A Med B P2022
Thrombate III Med B P2021
Thyrogen 4795-A MedB P2021
Tivdak 4991-A MedB P2021
Trastuzumab-Trastuzumab biologics Med B Jurisdiction N (FL PR USVI) P2021a
Treanda-Bendeka-Belrapzo 2746-A MedB P2021
Trelstar 4204-A MedB P2021
- Trelstar MedB Jurisdiction K (CT, MA, ME, NH, NY, RI, VT) P2021
- Trelstar MedB Jurisdiction L (DC, DE, MD, NJ, PA) P2021
treprostinil-Remodulin 4821-A Med B P2021
Tretten 5002-A Med B P2021
- Tretten MedB Jurisdiction L (DC, DE, MD, NJ, PA) P2021
Triptodur MedB Jurisdiction K (CT, MA, ME, NH, NY, RI, VT) P2021
Trodelvy MedB 4477-A P2021a
Tymlos MedB P2020
Tysabri 1633-A MedB P2021a
Tyvaso 4822-A Med B P2021

U

Ultomiris 2836-A MedB P2021a
Uplizna MedB 4722-A P2021

V

Vabysmo 5160-A MedB P2022
Vantas MedB Jurisdiction K (CT, MA, ME, NH, NY, RI, VT) P2021
- Vantas MedB Jurisdiction L (DC, DE, MD, NJ, PA) P2021
Velcade 4479-A MedB P2021
- Velcade MedB Jurisdiction K (CT, MA, ME, NH, NY, RI, VT) P2021a
Ventavis 4823-A Med B P2021
Viltepso 4835-A MedB P2021
Vimizim MedB P2021
Visudyne 1984-A MedB P2021
Vonvendi 4868-A MedB P2021
VPRIV MedB 4460-A P2021
Vyepti 4388-A MedB P2021
Vyondys 53 4818-A MedB P2021

W

Wilate 4870-A MedB P2021
- Wilate MedB Jurisdiction L (DC, DE, MD, NJ, PA) P2021a
Winrho 4018-A MedB Jurisdiction L (DC, DE, MD, NJ, PA) P2021

X

Xeomin MedB Jurisdiction N (FL, PR, USVI) P2021
Xgeva MedB Jurisdiction K (CT, MA, ME, NH, NY, RI, VT) P2020a
Xiaflex 2309-A MedB P2021
Xolair MedB P2021
- Xolair MedB Jurisdiction K (CT, MA, ME, NH, NY, RI, VT) P2021
- Xolair MedB Jurisdiction N (FL PR USVI) P2021

Y

Yervoy 2437-A MedB P2021a
Yescarta 2386-A MedB P2021

Z

Zepzelca 4726-A MedB P2021a
Zilretta 4816-A MedB P2021
Zoladex MedB 4456-A P2021
- Zoladex MedB Jurisdiction K (CT, MA, ME, NH, NY, RI, VT) P2021
- Zoladex MedB Jurisdiction L (DC, DE, MD, NJ, PA) P2021
zoledronic acid-Reclast MedB P2020
zoledronic acid-Zometa MedB P2020
Zolgensma MedB P2021
Zynlonta 4698-A MedB P2021

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Last Updated: 2022-05-24

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