Professionally Administered Medications - Washington State Local Health Insurance - CHPW

Professionally Administered Medications

Community Health Plan of Washington (CHPW) 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 that are listed as requiring prior authorization but do not have CHPW Clinical Coverage Criteria, MCG guidelines will be used to determine medical necessity.

Prior authorization for self-administered medication

Any pharmaceutical not listed on our formulary requires prior authorization. For self-administered drugs requiring prior authorization, please contact Express Scripts at 1-844-605-8168 or use CoverMyMeds.com to start the prior authorization process.

Any drug not listed in the formulary will require prior authorization.

Medicaid Formulary
Medicare Formularies

Submitting a Prior Authorization Request for professionally administered drugs

ONLINE (preferred) through the Care Management Portal (JIVA)
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.

Professionally-administered medication requiring prior authorization (2020)

2020 Prior Authorization List and Utilization Guidelines

Professionally-administered medication requiring prior authorization (2019)

All experimental or investigational drugs and services.

All unlisted codes with a charge greater than $500.

All unclassified biologics.

A, B, C
  • Abatacept (such as Orencia)
  • Adalimumab (such as Humira)
  • Ado-trastuzumab emtansine (such as Kadcyla)
  • Alemtuzumab (such as Lemtrada)
  • Alpha-1 Proteinase Inhibitor human (such as Glassia)
  • 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)
  • Brexanolone (Zulresso)
  • Buprenorphine injectables (such as Probuphine, Sublocade)
  • 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)
  • Esketamine (Spravato)
  • Filgrastim (such as Neupogen, Zarxio, Nivestym)
  • Fosnetupitant and Palonosetron (such as Akynzeo)
  • Fremanezumab-vrfm (such as Ajovy)
  • GnRH Agonist (such as Eligard, Lupron, Supprelin LA, Triptodur, Trelstar, Vantas)
  • 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)
  • Lanadelumab (such as Takhzyro)
  • Mepolizumab (such as Nucala)
  • Mogamulizumab (such as Poteligeo)
  • 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)
  • Patisiran (Onpattro)
  • 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)
  • Ravulizumab (such as Ultomiris)
  • 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)
  • Vestronidase (such as Mepsevii)
  • Ziv-aflibercept (such as Zaltrap)
  • Zoledronic acid (such as Reclast, Zometa)

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