Injectable Medications Requiring Prior Authorization Updated
The list of injectable medications requiring prior authorization has been updated by TriWest. The new list is effective January 1,
2008, and is available in the Provider Connection area of www.triwest.com. When submitting your prior authorization request, please
indicate the J, C or S code(s) along with the NDC codes.
The following drugs will be added effective January 1, 2008
| Brand Name |
Chemical Name |
| Treanda |
bendamustine |
The following drugs will be removed effective January 1, 2008
| Brand Name |
Chemical Name |
| Herceptin |
trastuzumab |
| Taxol |
paclitaxel |
| Taxotere |
docetaxel |
Complete drug listing effective January 1, 2008
| Brand Name |
Chemical Name |
| Aralast |
alpha 1 proteinase inhibitor |
| Aranesp |
darbepoetinalfa |
| Avastin |
bevacizumab |
| Botox |
botulinum toxin |
| Camptosar |
irinotecan |
| Enbrel |
etanercept |
| Epogen |
epoetinalfa |
| Flolan |
epoprostenol |
| Gemzar |
gemcitabine |
| Myobloc |
botulinum toxin |
| Navelbine |
vinorelbine |
| NovoSeven |
coagulation factor viia |
| Orencia |
abatacept |
| Procrit |
epoetinalfa |
| Prolastin |
alpha 1 proteinase inhibitor |
| Protropin |
somatrem |
| Raptiva |
efalizumab |
| Remicade |
infliximab |
| Remodulin |
treprostinil |
| Rituxan |
rituximab |
| Somavert |
pegvisomant |
| Synagis |
palivizumab |
| Treanda |
bendamustine |
| Vivaglobin |
Immune globulin subcutaneous |
| Xolair |
omalizumab |
| Zemaira |
alpha 1 proteinase inhibitor |
| N/A |
17 alpha-hydroxyprogesteronecaproate (17P) |
| There are multiple brand names for this drug |
hemophilia clotting factor viii |
| There are multiple brand names for this drug |
hemophilia clotting factor ix |
| There are multiple brand names for this drug |
intravenous immune globulin (IVIG) |
| There are multiple brand names for this drug |
somatropin |
| There are multiple brand names for this drug |
von Willebrand factor complex, human |
| There are multiple brand names for this drug |
urofollitropin |
Synagis (palivizumab) and Xolair (omalizumab) require completion of the Clinical Authorization Approval Guideline form, which can
be downloaded at www.triwest.com, under the Find a Form tab.
