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

Utilization Management Policies for Medical Drug Benefits
PM101 Hydroxyprogesterone caproate (Makena) injection for intramuscular use
PM103 Ipilimumab (Yervoy)
PM104 Pemetrexed (Alimta)
PM105 Brentuximab vedotin (Adcetris) for injection, for intravenous use
PM106 Ecallantide (Kalbitor)
PM108 Pertuzumab (Perjeta)
PM109 Palivizumab (Synagis)
PM110 Nanoparticle albumin bound paclitaxel (Abraxane)
PM112 Ramucirumab (Cyramza)
PM114 Epoprostenol (Flolan, Veletri, generics)
PM115 Cetuximab (Erbitux)
PM116 Ado-trastuzumab emtansine (Kadcyla)
PM117 Pembrolizumab (Keytruda)
PM118 Alemtuzumab (Lemtrada)
PM119 Nivolumab (Opdivo) 
PM121 Zoledronic acid (Reclast)
PM122 Treprostinil (Remodulin)
PM124 Zoledronic acid (Zometa)
PM126 Natalizumab (Tysabri)
PM127 Panitumumab (Vectibix)
PM128 Pegfilgrastim (Neulasta)
PM129 Rituximab (Rituxan)
PM130 Sargramostim (Leukine)
PM131 Tbo-filgrastim (Granix)
PM132 Trastuzumab (Herceptin)
PM133 Ziv-aflibercept (Zaltrap)
PM134 Denosumab (Prolia)
PM135 Denosumab (Xgeva)
PM136 Epoetin Products
PM137 Filgrastim Products
PM138 Ibandronate (Boniva)
PM139 Immune globulin subcutaneous
PM140 Darbepoetin alfa (Aranesp)
PM141 Omalizumab (Xolair) injection for subcutaneous use
PM142 Ocrelizuman (Ocrevus) injection for intravenous use
PM144 Hyaluronic acid derivatives (Euflexxa, Gel-One, Gelsyn-3, GenVisc 850, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/Supartz FX, Synvisc, Synvisc-One)
PM145 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)
PM147 Cytokine & CAM Antagonists
PM149 Antiasthmatic Monoclonal Antibodies-IL-5 Antagonists
PM150 Soliris (eculizumab injection for intravenous use – Alexion)
PM151 Buprenorphine for subcutaneous use
PM152 Enzymes for Gaucher Disease
PM153 Romiplostim (Nplate)
PM154 Corticotropin (H.P. Acthar Gel)
PM567 Hereditary Angioedema Agents
PM568 Patisiran (Onpattro) intravenous injection
PM569 Triamcinolone ER (Zilretta)
PM570 OnabotulinumtoxinA (Botox) for Migraine

DID YOU KNOW...?

DRUG RECALL: VALSARTAN, VALSARTAN-HYDROCLOROTHIAZIDE & AMLODIPINE – VALSARTAN

Group of doctors and nurses looking to and discussing x-ray image at clinic.On 12/31/2018, Aurobindo Pharma USA, Inc. recalled Amlodipine-Valsartan, Valsartan-HCTZ, and Valsartan tablets due to the detection of trace amounts of an unexpected impurity found in the finished drug product.   To date, Aurobindo Pharma USA, Inc. has not received any reports of adverse events related to this recall.

Recalled Drug: Valsartan 320mg tablets, Amlodipine-Valsartan 5/160mg, 5/320mg, 10/160mg,    10/320mg tablets , and Valsartan & Hydrochlorothiazide 80/12.5mg, 160/12.5mg, 160/25mg, 320/12.5mg and 320/25mg tablets

Lot Numbers: Aurobindo Pharma USA, Inc. has 80 different lots of medications affected in this recall. Please refer to the link above for more information on the National Drug Code (NDC), expiration date and lot number that corresponds with your medication. More information about the recall is available at: http://www.fda.gov/Safety/Recalls/EnforcementReports/default.htm.

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