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.

➔ 2022 Prior Authorization List for Professionally-Administrated Medications

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.

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 $250.
  • All unclassified biologics.

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)
• Advate (factor VIII [antihemophilic factor, recombinant]) CHNW and MA
• Adynovate (factor VIII [antihemophilic factor, recombinant], pegylated) CHNW and MA
• Afamelanotide (Scenesse)
• Afstyla (factor VIII [antihemophilic factor, recombinant]) CHNW and MA
• Agalsidase (such as Fabrazyme) CHNW and MA
• Alemtuzumab (such as Lemtrada)
• Alglucosidase alfa (such as Lumizyme) CHNW and MA
• Alpha-1 Proteinase Inhibitor human (such as Glassia)
• Alphanate (antihemophilic factor VIII/von Willebrand factor complex [human]) CHNW and MA
• Alphanine (factor IX [antihemophilic factor, purified, non-recombinant]) CHNW and MA
• Aprepitant (such as Cinvanti)
• Alprolix (factor IX, fc fusion protein [recombinant]) CHNW and MA
• Aripiprazole lauroxil (such as Aristada)
• Asparaginase (such as Erwinaze)
• Atezolizumab (such as Tecentriq)
• Avelumab (such as Bavencio)
• AVXS-101/ Onasemnogene abeparvovec (such as Zolgensma) CHNW and MA
• Axicabtagene ciloleucel (such as Yescarta) CHNW and MA
• Bebulin (factor IX, complex) CHNW and MA
• Belantamab Mafodotin (such as Blenrep)
• Beleodaq (belinostat)
• Belimumab (such as Benlysta)
• BeneFIX (factor IX [antihemophilic factor, recombinant]) CHNW and MA
• 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)
• Burosumab-twza (such as Crysvita) CHNW and MA
• C1 esterase inhibitor (human) (such as Berinert, Cinryze, Haegarda, Ruconest) CHNW and MA
• Cabazitaxel (such as Jevtana)
• Caplacizumab (Cablivi)
• Canakinumab (such as Ilaris)
• CEMIPLIMAB-RWLC (such as Libtayo)
• Cerliponase alfa (such as Brineura) CHNW and MA
• Certolizumab pegol (such as Cimzia)
• Cetuximab (such as Erbitux)
• Coagadex (factor X [human]) CHNW and MA
• Collagenase – Clostridium Histolyticum (such as Xiaflex)
• Copanlisib (such as Aliqopa)
• Corifact (factor XIII [antihemophilic factor, human]) CHNW and MA
• Corticotropin repository (such as Acthar)
• Crizanlizumab-tmca (such as Adakveo) CHNW and MA

Line of Business (LOB) Legend:
WAH = Washington Apple Health IMC
MA = Medicare Advantage
CHNW = Cascade Select

If no LOB is highlighted next to the service, then Notification or Authorization applies across all LOBs for that service.

D-H

• Darbepoetin alfa (such as Aranesp)
• Darzalex (daratumumab)
• Daunorubicin and Cytarabine Liposome (such as Vyxeos)
• Denosumab (such as Prolia, Xgeva)
• Durvalumab (such as Imfinzi)
• Durysta (bimatoprost)
• Ecallantide (such as Kalbitor) CHNW and MA
• Eculizumab (Soliris) CHNW and MA
• Edavarone (such as Radicava) CHNW and MA
• Eloctate (factor VIII, fc fusion protein [recombinant]) CHNW and MA
• Elosulfase (such as Vimizim) CHNW and MA
• Emapalumab-lzsg (such as Gamifant) CHNW and MA
• Enfortumab vedotin (Padcev)
• Epoetin alfa (such as Epogen, Procrit, Retacrit)
• Epoetin beta (such as Mircera)
• Esketamine (Spravato)
• Epoprostenol (such as Flolan, Veletri, generics)
• Eptinezumab (Vyepti)
• Eterplirsen (such as Exondys 51)
• Factor VIII (antihemophilic factor, porcine) CHNW and MA
• Fam-trastuzumab deruxtecan (Enhertu)
• Feiba NF (anti-inhibitor coagulant complex) CHNW and MA
• Filgrastim (such as Neupogen, Zarxio, Nivestym)
• Fosnetupitant and Palonosetron (such as Akynzeo)
• Fremanezumab-vrfm (such as Ajovy)
• Fulvestrant (such as Faslodex)
• Galsulfase (such as Naglazyme) CHNW and MA
• Gemtuzumab Ozogamicin (such as Mylotarg)
• Givosiran (such as Givlaari) CHNW and MA
• Golimumab (such as Simponi Aria)
• Golodirsen (such as Vyondys 53) CHNW and MA
• Goserelin Acetate (such as Zoladex)
• Granisetron extended release (such as Sustol)
• Guselkumab (such as Tremfya)
• Helixate FS (factor VIII [antihemophilic factor, recombinant]) CHNW and MA
• Hemlibra (emicizumab) CHNW and MA
• Hemofil M (factor VIII [antihemophilic factor, human]) CHNW and MA
• Histrelin Acetate (such as Supprelin LA, Vantas)
• Humate-P (von Willebrand factor complex) CHNW and MA
• Hyaluronic acid derivatives (such as Euflexxa, Gel-One, Synvisc)
• Hydroxyprogesterone caproate (such as Makena)

Line of Business (LOB) Legend:
WAH = Washington Apple Health IMC
MA = Medicare Advantage
CHNW = Cascade Select

If no LOB is highlighted next to the service, then Notification or Authorization applies across all LOBs for that service.

I-O

• Ibalizumab (such as Trogarzo)
• Ibandronate (such as Boniva)
• Icatibant (such as Firazyr) CHNW and MA
• Idelvion (factor IX, fc fusion protein [recombinant]) CHNW and MA
• Idursulfase (such as Elaprase) CHNW and MA
• Iluvien (fluocinolone acetonide)
• 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)
• Inebilizumab (such as Uplizna) CHNW and MA
• Infliximab products for IV infusion (such as Remicade, Inflectra, Renflexis, Ixifi)
• Inotuzumab ozogam (such as Besponsa)
• Ipilimumab (such as Yervoy)
• Isatuximab (Sarclisa)
• Ixinity (factor IX [antihemophilic factor, recombinant]) CHNW and MA
• Jivi (factor VIII [antihemophilic factor, recombinant], pegylated-aucl) CHNW and MA
• Koate (factor VIII [antihemophilic factor, human]) CHNW and MA
• Koate-DVI (factor VIII [antihemophilic factor, human]) CHNW and MA
• Kogenate (factor VIII [antihemophilic factor, recombinant]) CHNW and MA
• Kovaltry (factor VIII [antihemophilic factor, recombinant]) CHNW and MA
• Lanadelumab (such as Takhzyro) CHNW and MA
• Lanreotide (such as Somatuline Depot)
• Laronidase (such as Aldurazyme) CHNW and MA
• Leuprolide Acetate (such as Eligard, Fensolvi, Lupron Deopt, Lupron Depot-Ped)
• Luspatercept-aamt (such as Reblozyl) CHNW and MA
• Lutetium Lu 177 dotatate (such as Lutathera) CHNW and MA
• Mepolizumab (such as Nucala)
• Mogamulizumab (such as Poteligeo)
• Mononine (factor IX [antihemophilic factor, purified, non-recombinant]) CHNW and MA
• Natalizumab (such as Tysabri)
• Nelarabine (such as Arranon)
• Nivolumab (such as Opdivo)
• Novoeight (factor VIII [antihemophilic factor, recombinant]) CHNW and MA
• NovoSeven RT (factor VIIa [antihemophilic factor, recombinant]) CHNW and MA
• Nusinersen (such as Spinraza) CHNW and MA
• Nuwiq (factor VIII [antihemophilic factor, recombinant]) CHNW and MA
• Obinutuzumab (such as Gazyva)
• Obizur (factor VIII [antihemophilic factor, recombinant]) CHNW and MA
• Ocrelizumab (such as Ocrevus)
• Octreotide-Depot Form For Intramuscular Injection (such as Sandostatin)
• Omalizumab (such as Xolair)
• Oncaspar (pegaspargase)
• Ozurdex (dexamethasone)

Line of Business (LOB) Legend:
WAH = Washington Apple Health IMC
MA = Medicare Advantage
CHNW = Cascade Select

If no LOB is highlighted next to the service, then Notification or Authorization applies across all LOBs for that service.

P-S

• 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)
• Pertuzumab (such as Perjeta)
• Pertuzumab/Trastuzumab/Hyaluronidase (Phesgo)
• Polatuzumab Vedotin-piiq (such as Polivy)
• Profilnine SD (factor IX, complex) CHNW and MA
• Provenge (sipuleucel-T)
• Ramucirumab (such as Cyramza)
• Ravulizumab (such as Ultomiris) CHNW and MA
• Rebinyn (factor IX [antihemophilic factor, recombinant], glycopegylated) CHNW and MA
• Recombinante (factor VIII [antihemophilic factor, recombinant]) CHNW and MA
• Reslizumab (such as Cinqair)
• Retisert (fluocinolone acetonide)
• Rilonacept (such as Arcalyst)
• Rituximab products (such as Rituxan, Rituxan hycela)
• Rixubis (factor IX [antihemophilic factor, recombinant]) CHNW and MA
• Rolapitant (such as Varubi)
• Romidepsin (such as Istodax)
• Romiplostim (such as Nplate)
• Sacituzumab govitecan (Trodelvy)
• Sargramostim (such as Leukine)
• Sebelipase (such as Kanuma) CHNW and MA
• Somatotropin (such as Genotropin, Humatrope, Norditropin, Serostim, Zorbtive)

Line of Business (LOB) Legend:
WAH = Washington Apple Health IMC
MA = Medicare Advantage
CHNW = Cascade Select

If no LOB is highlighted next to the service, then Notification or Authorization applies across all LOBs for that service.

T-Z

• Tafasitamab (such as Monjuvi)
• Taliglucerase (such as Elelyso)
• Tbo-filgrastim (such as Granix)
• Teprotumumab (Tepezza) CHNW and MA
• Tildrakizumab (such as Ilumya)
• Tisagenlecleucel-t (such as Kymriah) CHNW and MA
• Tocilizumab (such as Actemra)
• Trastuzumab (such as Herceptin)
• Treprostinil (such as Remodulin)
• Tretten (factor XIII a-subunit [recombinant]) CHNW and MA
• Triamcinolone ace xr 1mg (such as Zilretta)
• Triptorelin Pamoate (such as Trelstar, Triptodur)
• Ustekinumab (such as Stelara)
• Vedolizumab (such as Entyvio)
• Velaglucerase (such as Vpriv)
• Vestronidase (such as Mepsevii)
• Vonvendi (von Willebrand factor [recombinant]) CHNW and MA
• Voretigene neparvovec-rzyl (such as Luxterna) CHNW and MA
• Wilate (von Willebrand factor complex [human]) CHNW and MA
• Xyntha (factor VIII [antihemophilic factor, recombinant]) CHNW and MA
• Yutiq (fluocinolone acetonide)
• Ziv-aflibercept (such as Zaltrap)

Line of Business (LOB) Legend:
WAH = Washington Apple Health IMC
MA = Medicare Advantage
CHNW = Cascade Select

If no LOB is highlighted next to the service, then Notification or Authorization applies across all LOBs for that service.

 

Clinical Coverage Criteria

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

Formularies

To view the current Medicare formularies, please visit our Prescription Drug Coverage 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.

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