Professionally Administered Medication - Community Health Plan of Washington - Medicare Advantage

Prior Authorization for Professionally Administered Medication

The professionally administered drugs listed below require prior authorization. For medications which are listed as requiring prior authorization, CHPW uses national coverage determinations (NCDs) and local coverage determinations (LCDs) when available. NCDs and LCDs are established by the Centers for Medicare and Medicare Services (CMS) and are accessible on the CMS website or through Noridian, Washington’s Medicare Fee-for-Service contractor. If CMS criteria is not available, MCG guidelines or CHPW Clinical Coverage Criteria will be used to determine medical necessity. For self-administered drugs requiring prior authorization, please contact Express Scripts at 1-844-605-8168 or use https://www.CoverMyMeds.com to start the prior authorization process.

View the current Medicare formularies

Any drug that fits the following criteria also requires prior authorization:

All experimental or investigational drugs and services.
All unlisted codes with a charge greater than $500.
All unclassified biologics.

List of Drugs that Require Approval

Below is a list of professionally administered medications requiring prior authorization. Please note that this may not reflect the most up-to-date list of medications.

Click to expand each section. Drugs are listed by generic name, but brand name references are given. For example, if you are looking for Orencia, you will need to search for its generic name, abatacept, in the list instead. In this case, you will need to expand titles A-C, not I-O.

2020 Prior Authorization List

• All experimental or investigational drugs and services.
• All unlisted codes with a charge greater than $250.
• All unclassified biologics.

→ Click to download 2020 professionally-administrated medications.

A,B,C

• Abatacept (such as Orencia)
• Adalimumab (such as Humira)
• Ado-trastuzumab emtansine (such as Kadcyla)
• Alemtuzumab (such as Lemtrada)
• Alglucosidase alfa (such as Lumizyme)
• Alpha-1 Proteinase Inhibitor human (such as
Glassia)
• Aprepitant (such as Cinvanti)
• Aripiprazole lauroxil (such as Aristada)
• Asparaginase (such as Erwinaze)
• Atezolizumab (such as Tecentriq)
• Avelumab (such as Bavencio)
• Belimumab (such as Benlysta)
• Benralizumab (such as Fasenra)
• Botulinum toxins (such as Botox, Myobloc,
Dysport, Xeomin)
• Brentuximab vedotin (such as Adcetris)
• Brexanolone (Zulresso)
• Buprenorphine injectables (such as Probuphine,
Sublocade)
• C-1 esterase inhibitor (such as Haegarda,
Ruconest)
• Canakinumab (such as Ilaris)
• Certolizumab pegol (such as Cimzia)
• Cetuximab (such as Erbitux)
• Copanlisib (such as Aliqopa)
• Corticotropin repository (such as Acthar)

D-H
• Darbepoetin alfa (such as Aranesp)
• Daunorubicin and Cytarabine Liposome (such
as Vyxeos)
• Denosumab (such as Prolia, Xgeva)
• Durvalumab (such as Imfinzi)
• Ecallantide (such as Kalbitor)
• Eculizumab (Soliris)
• Epoetin alfa (such as Epogen, Procrit, Retacrit)
• Epoetin beta (such as Mircera)
• Epoprostenol (such as Flolan, Veletri, generics)
• Esketamine (Spravato)
• Filgrastim (such as Neupogen, Zarxio, Nivestym)
• Fosnetupitant and Palonosetron (such as Akynzeo)
• Fremanezumab-vrfm (such as Ajovy)
• Fulvestrant (such as Faslodex)
• GnRH Agonist (such as Eligard, Lupron, Supprelin LA,
Triptodur, Trelstar, Vantas, Zoladex)
• Golimumab (such as Simponi Aria)
• Granisetron extended release (such as Sustol)
• Guselkumab (such as Tremfya)
• Hyaluronic acid derivatives (such as Euflexxa, Gel-One,
Synvisc)
• Hydroxyprogesterone caproate (such as Makena)

I-O
• Ibalizumab (such as Trogarzo)
• Ibandronate (such as Boniva)
• Icatibant (such as Firazyr)
• Imiglucerase (such as Cerezyme)
• Immune Globulin Intravenous (IVIG)(such as Bivigam,
Carimune NF Nanofiltered, Flebogamma DIF,
Gammagard Liquid, Gammagard S/D < 1 mcg/dL in 5%
solution, Gammaked, Gammaplex, Gamunex-C,
Octagam, Privigen Liquid)
• Immune globulin subcutaneous
(such as Cuvitru, Hizentra)
• Infliximab products for IV infusion
(such as Remicade, Inflectra, Renflexis, Ixifi)
• Inotuzumab ozogam (such as Besponsa)
• Ipilimumab (such as Yervoy)
• Lanadelumab (such as Takhzyro)
• Mepolizumab (such as Nucala)
• Mogamulizumab (such as Poteligeo)
• Natalizumab (such as Tysabri)
• Nivolumab (such as Opdivo)
• Obinutuzumab (such as Gazyva)
• Ocrelizumab (such as Ocrevus)
• Omalizumab (such as Xolair)
P-S
• Paclitaxel (such as Taxol)
• Paclitaxel protein-bound (such as Abraxane)
• Paliperidone palmitate (such as Invega Trinza, Invega
Sustenna)
• Palivizumab (such as Synagis)
• Panitumumab (such as Vectibix)
• Patisiran (Onpattro)
• Pegfilgrastim (all products)
• Pegloticase (such as Krystexxa)
• Pembrolizumab (such as Keytruda
Pemetrexed (such as Alimta)Pemetrexed (such as
Alimta)
• Pertuzumab (such as Perjeta)
• Ramucirumab (such as Cyramza)
• Ranibizumab (such as Lucentis)
• Ravulizumab (such as Ultomiris)
• Reslizumab (such as Cinqair)
• Rilonacept (such as Arcalyst)
• Rituximab products (such as Rituxan, Rituxan hycela)
• Rolapitant (such as Varubi)
• Romidepsin (such as Istodax)
• Romiplostim (such as Nplate)
• Sargramostim (such as Leukine)
• Somatotropin (such as Genotropin,
Humatrope,Norditropin, Serostim, Zorbtive)

T-Z
• Taliglucerase (such as Elelyso)
• Tbo-filgrastim (such as Granix)
• Tildrakizumab (such as Ilumya)
• Tocilizumab (such as Actemra)
• Trastuzumab (such as Herceptin)
• Treprostinil (such as Remodulin)
• Triamcinolone ace xr 1mg (such as Zilretta)
• Ustekinumab (such as Stelara)
• Vedolizumab (such as Entyvio)
• Velaglucerase (such as Vpriv)
• Vestronidase (such as Mepsevii)
• Ziv-aflibercept (such as Zaltrap)
• Zoledronic acid (such as Reclast, Zometa)

 

Clinical Coverage Criteria

To view Utilization Management Policies for Medical Drug Benefits, please visit the Prior Authorization page.

DID YOU KNOW...?

Required Training

Providers are required to complete a Fraud, Waste, and Abuse training within 90 days of contracting with CHPW and annually thereafter. All clinic staff – including CEOs, senior leaders, managers, clerical/admin staff, physicians, and other clinical staff – are required to receive this training. Training courses are available on the CMS Medicare Learning Network website.

More information can be found in our Provider Manual.

☏ HAVE QUESTIONS ?

Sales Team

Get real answers
from real people

Phone: 1-800-944-1247
Email: Sales@chpw.org

x