2020 Prior Authorization List and Utilization Guidelines COMMUNITY HEALTH PLAN Professional Adminstered Medications of WashingtonTM Effective: January 1, 2020 MEDICARE ADVANTAGE
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Professionally-administered • Eptinezumab (Vyepti) • Pemetrexed (such as Alimta) medications requiring prior • Fam-trastuzumab deruxtecan (Enhertu) • Pertuzumab (such as Perjeta) authorization (2020) • Filgrastim (such as Neupogen, Zarxio, Nivestym) • Ramucirumab (such as Cyramza) • Fosnetupitant and Palonosetron (such as Akynzeo) • Ranibizumab (such as Lucentis) • All experimental or investigational drugs • Fremanezumab-vrfm (such as Ajovy) • Ravulizumab (such as Ultomiris) and services. • Fulvestrant (such as Faslodex) • Reslizumab (such as Cinqair) • All unlisted codes with a charge greater • GnRH Agonist (such as Eligard, Lupron, Supprelin LA, • Rilonacept (such as Arcalyst) than $250. Triptodur, Trelstar, Vantas, Zoladex) • Rituximab products (such as Rituxan, Rituxan hycela) • All unclassified biologics. • Golimumab (such as Simponi Aria) • Rolapitant (such as Varubi) • Granisetron extended release (such as Sustol) • Romidepsin (such as Istodax) • Abatacept (such as Orencia) • Guselkumab (such as Tremfya) • Romiplostim (such as Nplate) • Adalimumab (such as Humira) • Hyaluronic acid derivatives (such as Euflexxa, Gel-One, • Sacituzumab govitecan (Trodelvy) • Ado-trastuzumab emtansine (such as Kadcyla) Synvisc) • Sargramostim (such as Leukine) • Afamelanotide (Scenesse) • Hydroxyprogesterone caproate (such as Makena) • Somatotropin (such as Genotropin, • Alemtuzumab (such as Lemtrada) • Ibalizumab (such as Trogarzo) Humatrope,Norditropin, Serostim, Zorbtive) • Alglucosidase alfa (such as Lumizyme) • Ibandronate (such as Boniva) • Taliglucerase (such as Elelyso) • Alpha-1 Proteinase Inhibitor human (such as • Icatibant (such as Firazyr) • Tbo-filgrastim (such as Granix) Glassia) • Imiglucerase (such as Cerezyme) • Teprotumumab (Tepezza) • Aprepitant (such as Cinvanti) • Immune Globulin Intravenous (IVIG)(such as Bivigam, • Tildrakizumab (such as Ilumya) • Aripiprazole lauroxil (such as Aristada) Carimune NF Nanofiltered, Flebogamma DIF, • Tocilizumab (such as Actemra) Gammagard Liquid, Gammagard S/D < 1 mcg/dL in 5% • Asparaginase (such as Erwinaze) • Trastuzumab (such as Herceptin) solution, Gammaked, Gammaplex, Gamunex-C, • Treprostinil (such as Remodulin) • Atezolizumab (such as Tecentriq) Octagam, Privigen Liquid) • Triamcinolone ace xr 1mg (such as Zilretta) • Avelumab (such as Bavencio) • Immune globulin subcutaneous • Belimumab (such as Benlysta) (such as Cuvitru, Hizentra) • Ustekinumab (such as Stelara) • Benralizumab (such as Fasenra) • Infliximab products for IV infusion • Vedolizumab (such as Entyvio) • Botulinum toxins (such as Botox, Myobloc, (such as Remicade, Inflectra, Renflexis, Ixifi) • Velaglucerase (such as Vpriv) Dysport, Xeomin) • Inotuzumab ozogam (such as Besponsa) • Vestronidase (such as Mepsevii) • Brentuximab vedotin (such as Adcetris) • Ipilimumab (such as Yervoy) • Ziv-aflibercept (such as Zaltrap) • Brexanolone (Zulresso) • Isatuximab (Sarclisa) • Zoledronic acid (such as Reclast, Zometa) • Buprenorphine injectables (such as Probuphine, • Lanadelumab (such as Takhzyro) DOCUMENTATION REQUIRED TO SUPPORT Sublocade) • Mepolizumab (such as Nucala) DECISION-MAKING • C-1 esterase inhibitor (such as Haegarda, • Mogamulizumab (such as Poteligeo) Ruconest) Please provide documentation with the request to • Natalizumab (such as Tysabri) • Caplacizumab (Cablivi) support medical necessity. Examples of appropriate • Nivolumab (such as Opdivo) documents include: • Canakinumab (such as Ilaris) • Obinutuzumab (such as Gazyva) • Certolizumab pegol (such as Cimzia) • Ocrelizumab (such as Ocrevus) • Current (within 6 months, or more recent • Cetuximab (such as Erbitux) depending on condition) history and/or physician • Omalizumab (such as Xolair) • Copanlisib (such as Aliqopa) examination notes that address the problem and • Paclitaxel (such as Taxol) need for services requested • Corticotropin repository (such as Acthar) • Paclitaxel protein-bound (such as Abraxane) • Relevant medication history, lab, and/or • Darbepoetin alfa (such as Aranesp) • Paliperidone palmitate (such as Invega Trinza, Invega radiology results • Daunorubicin and Cytarabine Liposome (such Sustenna) • Relevant specialty consultation notes as Vyxeos) • Palivizumab (such as Synagis) • Other pertinent information • Denosumab (such as Prolia, Xgeva) • Panitumumab (such as Vectibix) • Durvalumab (such as Imfinzi) BENEFIT and COVERAGE LIMITATIONS • Patisiran (Onpattro) • Ecallantide (such as Kalbitor) This PA list is not all-inclusive. Please refer to the • Pegfilgrastim (all products) HCA Provider Billing Guidelines Manual and/or Fee • Eculizumab (Soliris) • Pegloticase (such as Krystexxa) Schedule. For Medicare coverage, limitations, • Enfortumab vedotin (Padcev) please refer to the National Coverage Guidelines • Pembrolizumab (such as Keytruda • Epoetin alfa (such as Epogen, Procrit, Retacrit) and/or Local Coverage Guidelines. Failure to obtain the required prior authorization may result in a • Epoetin beta (such as Mircera) denied claim. Services are subject to benefit • Esketamine (Spravato) coverage, limitations and exclusions as described in • Epoprostenol (such as Flolan, Veletri, generics) plan coverage guidelines. • P