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 $250.
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.

2021 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 2021 professionally-administrated 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)
• Afamelanotide (Scenesse)
• Aflibercept (such as Eylea)
• Agalsidase (such as Fabrazyme)
• 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)
• AVXS-101/ Onasemnogene abeparvovec
(such as Zolgensma) CHNW and MA
• Axicabtagene ciloleucel (such as Yescarta)
• Belantamab Mafodotin (such as Blenrep)
• Belimumab (such as Benlysta)
• Benralizumab (such as Fasenra)
• Botulinum toxins (such as Botox, Myobloc, Dysport, Xeomin)
• Brentuximab vedotin (such as Adcetris)
• Brexanolone (Zulresso)
• Brolucizumab–dbll (such as Beovu)
• Buprenorphine injectables
(such as Probuphine, Sublocade)
• Burosumab-twza (such as Crysvita)
• C1 esterase inhibitor (human) (such as Berinert, Cinryze, Haegarda, Ruconest)
• Cabazitaxel (such as Jevtana)
• Caplacizumab (Cablivi)
• Canakinumab (such as Ilaris)
• CEMIPLIMAB-RWLC (such as Libtayo)
• Cerliponase alfa (such as Brineura)
• Certolizumab pegol (such as Cimzia)
• Cetuximab (such as Erbitux)
• Collagenase – Clostridium Histolyticum (such as Xiaflex)
• Copanlisib (such as Aliqopa)
• Corticotropin repository (such as Acthar)
• Crizanlizumab-tmca (such as Adakveo)

D-H

• Daratumumab (such as Darzalex)
• 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)
• Edavarone (such as Radicava)
• Elosulfase (such as Vimizim)
• Emapalumab-lzsg (such as Gamifant)
• 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)
• Fam-trastuzumab deruxtecan (Enhertu)
• 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)
• Gemtuzumab Ozogamicin (such as Mylotarg)
• Givosiran (such as Givlaari) CHNW and MA
• Golimumab (such as Simponi Aria)
• Golodirsen (such as Vyondys 53)
• Goserelin Acetate (such as Zoladex)
• Granisetron extended release (such as Sustol)
• Guselkumab (such as Tremfya)
• Histrelin Acetate (such as Supprelin LA,Vantas)
• 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)
• Idursulfase (such as Elaprase)
• 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)
• Isatuximab (Sarclisa)
• Lanadelumab (such as Takhzyro)
• Lanreotide (such as Somatuline Depot)
• Laronidase (such as Aldurazyme)
• Leuprolide Acetate (such as Eligard,
Fensolvi, Lupron Deopt, Lupron Depot-Ped)
• Luspatercept-aamt (such as Reblozyl)
• Lutetium Lu 177 dotatate (such as Lutathera)
• Mepolizumab (such as Nucala)
• Mogamulizumab (such as Poteligeo)
• Natalizumab (such as Tysabri)
• Nelarabine (such as Arranon)
• Nivolumab (such as Opdivo)
• Nusinersen (such as Spinraza)
• Obinutuzumab (such as Gazyva)
• Ocrelizumab (such as Ocrevus)
• Octreotide-Depot Form For Intramuscular Injection (such as Sandostatin)
• Omalizumab (such as Xolair)

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)
• 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)
• Sacituzumab govitecan (Trodelvy)
• Sargramostim (such as Leukine)
• Sebelipase (such as Kanuma)
• Somatotropin (such as Genotropin,
Humatrope, Norditropin, Serostim, Zorbtive)

T-Z
• Tafasitamab (such as Monjuvi)
• Taliglucerase (such as Elelyso)
• Tbo-filgrastim (such as Granix)
• Teprotumumab (Tepezza)
• Tildrakizumab (such as Ilumya)
• Tisagenlecleucel-t (such as Kymriah)
• Tocilizumab (such as Actemra)
• Trastuzumab (such as Herceptin)
• Treprostinil (such as Remodulin)
• 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)
• Voretigene neparvovec-rzyl (such as Luxterna)
• 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.

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