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.

A,B,C
Abatacept (such as Orencia)
Adalimumab (such as Humira)
Ado-trastuzumab emtansine (such as Kadcyla)
Alemtuzumab (such as Lemtrada)
Aprepitant (such as Cinvanti)
Aripiprazole lauroxil (such as Aristada)
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)
C-1 esterase inhibitor (such as Haegarda)
Canakinumab (such as Ilaris)
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)
Eculizaumab (Soliris)
Epoetin alfa (such as Epogen, Procrit, Retacrit)
Epoetin beta (such as Mircera)
Epoprostenol (such as Flolan, Veletri, generics)
Filgrastim (such as Neupogen, Zarxio, Nivestym)
Fosnetupitant and Palonosetron (such as Akynzeo)
Fremanezumab-vrfm (such as Ajovy)
GnRH Agonist (such as Lupron, Triptodur, Trelstar)
Golimumab (such as Simponi Aria)
Guselkumab (such as Tremfya)
Granisetron extended release (such as Sustol)
Hyaluronic acid derivatives (such as Durolane, Euflexxa, Gel-One, Gelsyn-3, GenVisc 850, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/Supartz FX, Synojoynt, Synvisc, Synvisc-One, Trivisc)
Hydroxyprogesterone caproate (such as Makena)
I-O
Ibalizumab (such as Trogarzo)
Ibandronate (such as Boniva)
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)
Mepolizumab (such as Nucala)
Natalizumab (such as Tysabri)
Nivolumab (such as Opdivo)
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)
Pegfilgrastim (such as Neulasta, Neulasta Onpro, Fulphila, Udencya)
Pegloticase (such as Krystexxa)
Pembrolizumab (such as Keytruda)
Pemetrexed (such as Alimta)
Pertuzumab (such as Perjeta)
Ramucirumab (such as Cyramza)
Ranibizumab (such as Lucentis)
Reslizumab (such as Cinqair)
Rituximab products (such as Rituxan, Rituxan hycela)
Rolapitant (such as Varubi)
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)
Unclassified Biologics, All
Ustekinumab (such as Stelara)
Vedolizumab (such as Entyvio)
Velaglucerase (such as Vpriv)
Ziv-aflibercept (such as Zaltrap)
Zoledronic acid (such as Reclast, Zometa)

2018 Prior Authorization List

A,B,C
Abatacept (Orencia)
Adalimumab (Humira)
Ado-trastuzumab emtansine (Kadcyla)
Alemtuzumab (Lemtrada)
Aprepitant (Cinvanti)
Aripiprazole lauroxil (Aristada)
Atezolizumab (Tecentriq)
Avelumab (Bavencio)
Belimumab (Benlysta)
Benralizumab (Fasenra)
Botulinum toxins (such as Botox, Myobloc, Dysport, Xeomin)
Brentuximab vedotin (Adcetris)
Canakinumab (Ilaris)
Cetuximab (Erbitux)
D-G
Darbepoetin alfa (Aranesp)
Denosumab (Prolia)
Denosumab (Xgeva)
Durvalumab (Imfinzi)
Ecallantide (Kalbitor)
Epoetin alfa (such as Epogen, Procrit, Retacrit)
Epoetin beta (Mircera)
Epoprostenol (such as Flolan, Veletri, generics)
Filgrastim (such as Neupogen, Zarxio, Nivestym)
Fremanezumab-vrfm (Ajovy)
GnRH Agonist (Lupron)
Golimumab (Simponi Aria)
Granisetron extended release (Sustol)
H,I
Hyaluronic acid derivatives (such as Euflexxa, Gel-One, Gelsyn-3, GenVisc 850, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/Supartz FX, Synvisc, Synvisc-One)
Hydroxyprogesterone caproate (Makena) injection for intramuscular use
Ibandronate (Boniva)
Immune Globulin Intravenous (IVIG) (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 -Remicade (infliximab), Inflectra (infliximab-dyyb), Renflexis (infliximab-abda)
Ipilimumab (Yervoy)
J-N
Mepolizumab (Nucala) injection for subcutaneous use
Nanoparticle albumin bound paclitaxel (Abraxane)
Natalizumab (Tysabri)
Nivolumab (Opdivo)
O,P
Taliglucerase (such as Elelyso)
Ocrelizumab (Ocrevus) injection for intravenous use
Omalizumab (Xolair) injection for subcutaneous use
Paclitaxel (Taxol)
Paliperidone palmitate (Invega Trinza, Invega Sustenna)
Palivizumab (Synagis)
Panitumumab (Vectibix)
Pegfilgrastim (such as Neulasta, Neulasta Onpro)
Pegloticase (Krystexxa)
Pembrolizumab (Keytruda)
Pemetrexed (Alimta)
Pertuzumab (Perjeta)
Q-T
Ramucirumab (Cyramza)
Ranibizumab (Lucentis)
Reslizumab (Cinqair)
Rituximab (Rituxan), Rituximab hyaluronidase (Rituxan hycela)
Romiplostim (Nplate)
Sargramostim (Leukine)
Somatotropin (such as Genotropin, Humatrope,Norditropin, Serostim, Zorbtive)
Tbo-filgrastim (Granix)
Tocilizumab (Actemra)
Trastuzumab (Herceptin)
Treprostinil (Remodulin)
U-Z
Unclassified Biologics, All
Ustekinumab (Stelara)
Vedolizumab (Entyvio)
Zoledronic acid (Reclast)
Zoledronic acid (Zometa)
Ziv-aflibercept (Zaltrap)

Clinical Coverage Criteria

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

DID YOU KNOW...?

DRUG RECALL: Losartan 25mg, 50 mg, 100 mg tablets and all strengths Losartan potassium tablets

Group of doctors and nurses looking to and discussing x-ray image at clinic.On 5/3/2019, Heritage Pharmaceuticals Inc. recalled Losartan 25mg, 50mg, 100mg tablets due the presence of an impurity. The U.S. Food and Drug Administration (FDA) has issued a Recall Class II of the affected medications.

On 4/10/2019, Torrent Pharma, Inc. recalled losartan potassium tablets due to the presence of an impurity. The U.S. Food and Drug Administration (FDA) has issued a Recall Class II of the affected medications.

Recalled drug: Losartan 25mg, 50mg, 100 mg tablets | Losartan Potassium Tablets (all strengths)

READ MORE

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