Community Health Plan of Washington requires prior authorization for certain professionally administered medications. 

These professionally administered drugs require prior authorization. Review CHPW's Clinical Coverage Criteria for these drugs. For medications which are listed as requiring prior authorization but do not have CHPW Clinical Coverage Criteria, MCG guidelines will be used to determine medical necessity. For prior authorization requirements for self-administered drugs, please search our online formulary. For self-administered drugs requiring a prior authorization, please contact Express Scripts at 1-844-605-8168 or use https://www.CoverMyMeds.com to start the prior authorization process.

A, B, C

  • Abatacept (Orencia)
  • Adalimumab (Humira)
  • Ado-trastuzumab emtansine (Kadcyla)
  • Alemtuzumab (Lemtrada)
  • Aripiprazole lauroxil (Aristada)
  • Atezolizumab (Tecentriq)
  • Avelumab (Bavencio)
  • Belimumab (Benlysta)
  • Benralizumab (Fasenra)
  • Botulinum toxin (Botox, Mybloc, Dysport, Xeomin)
  • Brentuximab vedotin (Adcetris)
  • Canakinumab (Ilaris)
  • Cetuximab (Erbitux) 

D-G

  • Darbepoetin alfa (Aranesp)
  • Denosumab (Prolia)
  • Denosumab (Xgeva)
  • Durvalumab (Imfinzi)
  • Ecallantide (Kalbitor)
  • Epoetin alfa (Epogen, Procrit)
  • Epoprostenol (Flolan, Veletri, generics)
  • Filgrastim (Neupogen, Zarxio)
  • GnRH Agonist (Lupron)
  • Golimumab (Simponi Aria)
  • Granisetron extended release (Sustol)

H, I

  • Hyaluronic acid derivatives (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 (Cuvitru, Hizentra)
  • Infliximab products - Inflectra (infliximab-dyyb) injection for intravenous use; Remicade (infliximab) for intravenous infusion
  • Ipilimumab (Yervoy) 

J-N

  • Mepolizumab (Nucala) injection for subcutaneous use
  • Nanoparticle albumin bound paclitaxel (Abraxane)
  • Natalizumab (Tysabri)
  • Nivolumab (Opdivo)

O, P

  • Ocrelizumab (Ocrevus) injection for intravenous use
  • Omalizumab (Xolair) injection for subcutaneous use
  • Paclitaxel (Taxol)
  • Paliperidone palmitate (Invega Trinza, Invega Sustenna)
  • Palivizumab (Synagis)
  • Panitumumab (Vectibix)
  • Pegloticase (Krystexxa)
  • Pembrolizumab (Keytruda)
  • Pemetrexed (Alimta)
  • Pertuzumab (Perjeta) 

Q-T

  • Ramucirumab (Cyramza)
  • Ranibizumab (Lucentis)
  • Rituximab (Rituxan)
  • Sargramostim (Leukine)
  • Somatotropin (Genotropin, Humatrope,Norditropin, Serostim, Zorbtive) 
  • Tbo-filgrastim (Granix)
  • Tocilizumab (Actemra)
  • Trastuzumab (Herceptin)
  • Treprostinil (Remodulin)

U-Z

  • Ustekinumab (Stelara)
  • Vedolizumab (Entyvio)
  • Zoledronic acid (Reclast)
  • Zoledronic acid (Zometa)
  • Ziv-aflibercept (Zaltrap)

Submitting a Prior Authorization Request

ONLINE (preferred) through the Care Management Portal
Request a Care Management Portal account to check eligibility and authorization status, print approval letters, and submit requests online 24/7.

Fax: Fill out the Prior Authorization Request Form and fax it, with supporting documentation, to the number listed on the form

Please contact CHPW with any questions or concerns.