In case of a conflict between your plan documents and this information, the plan documents will govern. bBZ!A01/a(m:=Ug^@+zDfD|4`vP3hs)l5yb/CLBf;% 2p|~\ie.~z_OHSq::xOv[>vv Service code if available (HCPCS/CPT) To better serve our providers, business partners, and patients, the Cigna Coverage Review Department is transitioning from PromptPA, fax, and phone coverage reviews (also called prior authorizations) to Electronic Prior Authorizations (ePAs). Each main plan type has more than one subtype. Providers may request a step therapy exception to skip the step therapy process and receive the Tier 2 or higher drug immediately. VERZENIO (abemaciclib) KERENDIA (finerenone) FINTEPLA (fenfluramine) Disclaimer of Warranties and Liabilities. CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. VIDAZA (azacitidine) NATPARA (parathyroid hormone, recombinant human) 2 Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. OCALIVA (obeticholic acid) EPSOLAY (benzoyl peroxide cream) UPTRAVI (selexipag) VTAMA (tapinarof cream) Insulin Rapid Acting (Admelog, Apidra, Fiasp, Insulin Lispro [Humalog ABA], Novolog, Insulin Aspart [Novolog ABA], Novolog ReliOn) MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate) Were here to help. CPT only Copyright 2022 American Medical Association. RETIN-A (tretinoin) 0000055434 00000 n ORENITRAM (treprostinil) In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government. These clinical guidelines are frequently reviewed and updated to reflect best practices. RECLAST (zoledronic acid-mannitol-water) RANEXA, ASPRUZYO (ranolazine) your Dashboard to submit your PA request. In the event that a member disagrees with a coverage determination, member may be eligible for the right to an internal appeal and/or an independent external appeal in accordance with applicable federal or state law. - 27 kg/m to <30 kg/m (overweight) in the presence of at least one . Coagulation Factor IX (Alprolix) Type in Wegovy and see what it says. endobj There should also be a book you can download that will show you the pre-authorization criteria, if that is required. INREBIC (fedratinib) COTELLIC (cobimetinib) AIMOVIG (erenumab-aooe) The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna) for a particular member. GIVLAARI (givosiran) Discard the Wegovy pen after use. 0000005437 00000 n constipation *. AMZEEQ (minocycline) End of Life Medications Please . KRINTAFEL (tafenoquine) INQOVI (decitabine and cedazuridine) Coverage of drugs is first determined by the member's pharmacy or medical benefit. Your patients Go to the American Medical Association Web site. In addition, a member may have an opportunity for an independent external review of coverage denials based on medical necessity or regarding the experimental and investigational status when the service or supply in question for which the member is financially responsible is $500 or greater. 0000054864 00000 n XIIDRA (lifitegrast) CIMZIA (certolizumab pegol) 0000055627 00000 n 0000001751 00000 n 2 0 obj SEGLENTIS (celecoxib/tramadol) QELBREE (viloxazine extended-release) BRINEURA (cerliponase alfa IV) Status: CVS Caremark Criteria Type: Initial Prior Authorization POLICY FDA-APPROVED INDICATIONS Saxenda is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight . prior authorization (PA), to ensure that they are medically necessary and appropriate for the ONZETRA XSAIL (sumatriptan nasal) ZEJULA (niraparib) Capsaicin Patch Wegovy is indicated for adults who are obese (body mass index 30) or overweight (body mass index 27), and who also have certain weight-related medical conditions, such as type 2 diabetes . TRIKAFTA (elexacaftor, tezacaftor, and ivacaftor) endobj License to use CPT for any use not authorized herein must be obtained through the American Medical Association, CPT Intellectual Property Services, 515 N. State Street, Chicago, Illinois 60610. VALTOCO (diazepam nasal spray) f TEGSEDI (inotersen) OLYSIO (simeprevir) Call 1-800-711-4555 to request OptumRx standard drug-specific guideline to be faxed. 2'izZLW|zg UZFYqo M( YVuL%x=#mF"8<>Tt 9@%7z oeRa_W(T(y%*KC%KkM"J.\8,M ACTEMRA (tocilizumab) Step #1: Your health care provider submits a request on your behalf. 0000011365 00000 n Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. REVLIMID (lenalidomide) KYLEENA (Levonorgestrel intrauterine device) Valuable and timely information on drug therapy issues impacting today's health care and pharmacy environment. Specialty pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used to treat complex conditions. You, your employees and agents are authorized to use CPT only as contained in Aetna Clinical Policy Bulletins (CPBs) solely for your own personal use in directly participating in healthcare programs administered by Aetna, Inc. You acknowledge that AMA holds all copyright, trademark and other rights in CPT. these guidelines may not apply. We recommend you speak with your patient regarding The prior authorization process helps ensure that the test, treatment, and/or procedure your provider requests is effective, safe, and medically appropriate. ELYXYB (celecoxib solution) of the following: (a) Patient is 18 years of age for Wegovy (b) Patient is 12 years of age for Saxenda (3) Failure to lose > 5% of body weight through at least 6 months of lifestyle modification alone (e.g., dietary or caloric restriction, exercise, behavioral support, community . The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna) for a particular member. 0000007229 00000 n Hepatitis B IG coagulation factor XIII (Tretten) 0000003052 00000 n NUEDEXTA (dextromethorphan and quinidine) EYSUVIS (loteprednol etabonate) STRENSIQ (asfotase alfa) If the submitted form contains complete information, it will be compared to the criteria for . In doing so, CVS/Caremark will be able to decide whether or not the requested prescription is included in the patient's insurance plan. No fee schedules, basic unit, relative values or related listings are included in CPT. CRYSVITA (burosumab-twza) 2545 0 obj <>stream You are now being directed to CVS Caremark site. Growth Hormone (Norditropin; Nutropin; Genotropin; Humatrope; Omnitrope; Saizen; Sogroya; Skytrofa; Zomacton; Serostim; Zorbtive) FANAPT (iloperidone) VYLEESI (bremelanotide) VOXZOGO (vosoritide) Please fill out the Prescription Drug Prior Authorization Or Step . The AMA is a third party beneficiary to this Agreement. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. ENJAYMO (sutimlimab-jome) EUCRISA (crisaborole) RYDAPT (midostaurin) ABECMA (idecabtagene vicleucel) 0000003404 00000 n License to sue CPT for any use not authorized herein must be obtained through the American Medical Association, CPT Intellectual Property Services, 515 N. State Street, Chicago, Illinois 60610. ILUMYA (tildrakizumab-asmn) The Dental Clinical Policy Bulletins (DCPBs) describe Aetna's current determinations of whether certain services or supplies are medically necessary, based upon a review of available clinical information. JAKAFI (ruxolitinib) 0000055600 00000 n No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM. MinuteClinic at CVS is a convenient retail clinic that you'll find in select CVS Pharmacyand Target stores. Wegovy; Xenical; Initial approval criteria for covered drugs with prior authorization: Patient must meet the age limit indicated in the FDA-approved label of the requested drug AND; Documented failure of at least a three-month trial on a low-calorie diet AND; A regimen of increased physical activity unless medically contraindicated by co . LIVTENCITY (maribavir) GLEEVEC (imatinib) Y prescription drug benefits may be covered under his/her plan-specific formulary for which VITRAKVI (larotrectinib) ADUHELM (aducanumab-avwa) As an OptumRx provider, you know that certain medications require approval, or Pre-authorization is a routine process. It is sometimes known as precertification or preapproval. XCOPRI (cenobamate) TECHNIVIE (ombitasvir, paritaprevir, and ritonavir) 6\ !D"'"PN~# yV)GH"4LGAK`h9c&3yzGX/EN5~jx6g"nk!{`=(`\MNUokEfOnJ "1 GAMIFANT (emapalumab-izsg) Long-Acting Muscarinic Antagonists (LAMA) (Tudorza, Seebri, Incruse Ellipta) SYMDEKO (tezacaftor-ivacaftor) If you have questions, you can reach out to your health care provider. Program Name: BadgerCare Plus and Medicaid: Handbook Area: Pharmacy: 01/15/2023 Please consult with or refer to the Evidence of Coverage or Certificate of Insurance document for a list of exclusions and limitations. ORILISSA (elagolix) prescription drug benefit coverage under his/her health insurance plan or call OptumRx. TRACLEER (bosentan) XTAMPZA ER (oxycodone) MINOCIN (minocycline tablets) therapy and non-formulary exception requests. XOSPATA (gilteritinib) Once a review is complete, the provider is informed whether the PA request has been approved or View Medicare formularies, prior authorization, and step therapy criteria by selecting the appropriate plan and county.. Part B Medication Policy for Blue Shield Medicare PPO. Pretomanid Part D drug list for Medicare plans. OPSUMIT (macitentan) NOCTIVA (desmopressin) KYMRIAH (tisagenlecleucel suspension) /wHqy5}r``Tgxkt2&!WKUN|\2KuS/esjlf2y|X*i&YgmL -oxBXWt[]k+E.k6K%,~'nuM Ih authorization (PA) guidelines* to encompass assessment of drug indications, set guideline Links to various non-Aetna sites are provided for your convenience only. TRIPTODUR (triptorelin extended-release) Treating providers are solely responsible for medical advice and treatment of members. ZYKADIA (ceritinib) Your health care provider will communicate with us directly, and generally within 14 days or less, you and your physician will be notified of a decision. XURIDEN (uridine triacetate) ERIVEDGE (vismodegib) stream EXONDYS 51 (eteplirsen) R b CEQUA (cyclosporine) 0000007133 00000 n XPOVIO (selinexor) Or, call us at the number on your ID card. 0000055963 00000 n upQz:G Cs }%u\%"4}OWDw Visit the secure website, available through www.aetna.com, for more information. BOSULIF (bosutinib) CPT is a registered trademark of the American Medical Association. Any use of CPT outside of Aetna Clinical Policy Bulletins (CPBs) should refer to the most current Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. LORBRENA (lorlatinib) Antihemophilic Factor VIII, recombinant (Kovaltry) LEUKINE (sargramostim) DIFFERIN (adapalene) AUBAGIO (teriflunomide) SPINRAZA (nusinersen) STELARA (ustekinumab) . G VIBERZI (eluxadoline) <]/Prev 304793/XRefStm 2153>> Z 0000002567 00000 n This information is neither an offer of coverage nor medical advice. While I await the supply issue to be resolved for Wegovy, I am trying to see if I can get it covered by my insurance so I am ready (my doctor has already prescribed it). In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. GLP-1 Agonists (Bydureon, Bydureon BCise, Byetta, Ozempic, Rybelsus, Trulicity, Victoza, Adlyxin) & GIP/GLP-1 Agonist (Mounjaro) SYMLIN (pramlintide) The member's benefit plan determines coverage. Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider. FLEQSUVY, OZOBAX, LYVISPAH (baclofen) 0000003227 00000 n EGRIFTA SV (tesamorelin) 0000069452 00000 n VUMERITY (diroximel fumarate) ARAKODA (tafenoquine) 2493 53 But there are circumstances where there's misalignment between what is approved by the payer and what is actually . hb```b``mf`c`[ @Q{9 P@`mOU.Iad2J1&@ZX\2 6ttt `D> `g`QJ@ gg`apc7t3N``X tgD?>H7X570}``^ 0C7|^ '2000 G> P^p%JOP*);p/+I56d=:7hT2uovIL~37\K"I@v vI-K\f"CdVqi~a:X20!a94%w;-h|-V4~}`g)}Y?o+L47[atFFs AW %gs0OirL?O8>&y(IP!gS86|)h PENNSAID (diclofenac) ),)W!lD,NrJXB^9L 6ZMb>L+U8x[_a(Yw k6>HWlf>0l//l\pvy]}{&K`%&CKq&/[a4dKmWZvH(R\qaU %8d Hj @`H2i7( CN57+m:#94@.U]\i.I/)"G"tf -5 2. or greater (obese), or 27 kg/m. IMCIVREE (setmelanotide) And we will reduce wait times for things like tests or surgeries. JUBLIA (efinaconazole) CIBINQO (abrocitinib) TAVALISSE (fostamatinib disodium hexahydrate) If patients do not tolerate the maintenance 2.4 mg once-weekly dosage, the dosage can be temporarily decreased to 1.7 mg once weekly, for a maximum of 4 weeks. Filgrastim agents (Nivestym, Zarxio, Neupogen, Granix, Releuko) COPIKTRA (duvelisib) 0000012735 00000 n %%EOF <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> ENTYVIO (vedolizumab) % ULTOMIRIS (ravulizumab) PONVORY (ponesimod) IDHIFA (enasidenib) Unlisted, unspecified and nonspecific codes should be avoided. 0000055177 00000 n The responsibility for the content of this product is with Aetna, Inc. and no endorsement by the AMA is intended or implied. The ABA Medical Necessity Guidedoes not constitute medical advice. Coverage for weight loss drugs like Wegovy varies widely depending on the kind of insurance you have and where you live. OXERVATE (cenegermin-bkbj) B TROGARZO (ibalizumab-uiyk) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. MOZOBIL (plerixafor) ZOSTAVAX (zoster vaccine live) HALAVEN (eribulin) OXLUMO (lumasiran) D Treating providers are solely responsible for dental advice and treatment of members. PEPAXTO (melphalan flufenamide) PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp) While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT"). AKLIEF (trifarotene) s RITUXAN (rituximab) TAVNEOS (avacopan) SUPPRELIN LA (histrelin SC implant) VIZIMPRO (dacomitinib) BRONCHITOL (mannitol) 0000011662 00000 n Prior Authorization Hotline. 0000002527 00000 n VABYSMO (faricimab) VITAMIN B12 (cyanocobalamin injection) 0000013911 00000 n which contain clinical information used to evaluate the PA request as part of. CYRAMZA (ramucirumab) 0000008389 00000 n ONGLYZA (saxagliptin) TREMFYA (guselkumab) 4 0 obj W IMLYGIC (talimogene laherparepvec) Of note, Saxenda (liraglutide subcutaneous injection) and Wegovy (semaglutide subcutaneous injection) are indicated for chronic weight . xref PLEGRIDY (peginterferon beta-1a) What is a "formalized" weight management program? ALUNBRIG (brigatinib) Buprenorphine/Naloxone (Suboxone, Zubsolv, Bunavail) The responsibility for the content of Aetna Precertification Code Search Tool is with Aetna and no endorsement by the AMA is intended or should be implied. AMVUTTRA (vutrisiran) FORTEO (teriparatide) Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica) MARGENZA (margetuximab-cmkb) JUXTAPID (lomitapide) XIAFLEX (collagenase clostridium histolyticum) L endobj Prior review (prior plan approval, prior authorization, prospective review or certification) is the process BCBSNC uses to review the provision of certain medical services and medications against health care management guidelines prior to the services being provided. III. AZEDRA (Iobenguane I-131) MAYZENT (siponimod) MYRBETRIQ (mirabegron granules) BELEODAQ (belinostat) HWn8}7#Y@A I-Zi!8j;)?_i-vyP$9C9*rtTf: p4U9tQM^Mz^71" >({/N$0MI\VUD;,asOd~k&3K+4]+2yY?Da C QULIPTA (atogepant) MEKINIST (trametinib) Pancrelipase (Pancreaze; Pertyze; Viokace) FYARRO (sirolimus protein-bound particles) rz^6>)@?v": QCd?Pcu DELATESTRYL (testosterone cypionate 100mg/ml; 200mg/ml) This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. ", The five character codes included in the Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology (CPT. VICTRELIS (boceprevir) M 0000062995 00000 n LARTRUVO (olaratumab) Please select a letter to see drugs listed by that letter, or enter the name of the drug you wish to search for. B"_?jB+K DAkM5Zq\!rmLlIyn1vH _`a8,hks\Bsr\\MnNLs4d.mp #.&*WS oc>fv 9N58[lF)&9`yE {nW Y &R\qe <> 0000069611 00000 n You, your employees and agents are authorized to use CPT only as contained in Aetna Precertification Code Search Tool solely for your own personal use in directly participating in health care programs administered by Aetna, Inc. You acknowledge that AMA holds all copyright, trademark and other rights in CPT. It should be listed under anti-obesity agents. By clicking on I Accept, I acknowledge and accept that: The Applied Behavior Analysis (ABA) Medical Necessity Guidehelps determine appropriate (medically necessary) levels and types of care for patients in need of evaluation and treatment for behavioral health conditions. In some cases, not enough clinical documentation could result in a denial. Wegovy should be used with a reduced calorie meal plan and increased physical activity. Optum guides members and providers through important upcoming formulary updates. Phone: 1-855-344-0930. Has lost at least 5% of baseline (prior to the initiation of Wegovy) body weight (only required once) 4. Angiotensin Receptor Blockers (e.g., Atacand, Atacand HCT, Tribenzor, Edarbi, Edarbyclor, Teveten) MAVENCLAD (cladribine) INGREZZA (valbenazine) Authorization Duration . MEPSEVII (vestronidase alfa-vjbk) 0000063066 00000 n 0000069922 00000 n SUSTOL (granisetron) ZOLINZA (vorinostat) Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. vomiting. 0000000016 00000 n BREYANZI (lisocabtagene maraleucel) WINLEVI (clascoterone) BRUKINSA (zanubrutinib) LUMAKRAS (sotorasib) Thats why we partner with your provider to accept requests through convenient options like phone, fax or through our online platform. REVATIO (sildenafil citrate) Specialty drugs typically require a prior authorization. VYNDAQEL (tafamidis meglumine) SIGNIFOR (pasireotide) a}'z2~SiCDFr^f0zVdw7 u;YoS]hvo;e`fc`nsm!`^LFck~eWZ]UnPvq|iMr\X,,Ug/P j"vVM3p`{fs{H @g^[;J"aAm1/_2_-~:.Nk8R6sM AKYNZEO (fosnetupitant/palonosetron) ADHD Stimulants, Extended-Release (ER) Aetna's conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna). A prescriber can submit a Prior Authorization Form to Navitus via U.S. Mail or fax, or they can contact our call center to speak to a Prior Authorization Specialist. ZURAMPIC (lesinurad) Tadalafil (Adcirca, Alyq) AMONDYS 45 (casimersen) SYNAGIS (palivizumab) GLUMETZA ER (metformin) KESIMPTA (ofatumumab) TEMODAR (temozolomide) 2493 0 obj <> endobj 1 0 obj PIQRAY (alpelisib) KOMBIGLYZE XR (saxagliptin and metformin hydrochloride, extended release) Tried/Failed criteria may be in place. * For more information about this side effect . manner, please submit all information needed to make a decision. v ZYNLONTA (loncastuximab tesirine-lpyl). Copyright 2023 We offer a variety of resources to support you through your health care journey, including: Resources For Living Program WELIREG (belzutifan) Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. NORTHERA (droxidopa) Infliximab Agents (REMICADE, infliximab, AVSOLA, INFLECTRA, RENFLEXIS) ORTIKOS (budesonide ER) A prior authorization is a request submitted on your behalf by your health care provider for a particular procedure, test, treatment, or prescription. Learn about reproductive health. APOKYN (apomorphine) We use it to make sure your prescription drug is: Safe; Effective; Medically necessary To be medically necessary means it is appropriate, reasonable, and adequate for your condition. NUBEQA (darolutamide) INVELTYS (loteprednol etabonate) ENBREL (etanercept) DUPIXENT (dupilumab) The most efficient way to initiate a prior authorization is to ask your physician to contact Express Scripts' prior authorization hotline at 1-800-753-2851. STEGLUJAN (ertugliflozin and sitagliptin) AJOVY (fremanezumab-vfrm) [Document the weight prior to Wegovy therapy and the weight after Wegovy therapy, including the date the weights were taken:_____] Yes No 3 Does the patient have a body mass index (BMI) greater than or equal to 30 kilogram per . To ensure that a PA determination is provided to you in a timely UBRELVY (ubrogepant) RYBREVANT (amivantamab-vmjw) Inpatient admissions, services and procedures received on an outpatient basis, such as in a doctor's office, If providers are unable to submit electronically, we offer the following options: Call 1-800-711-4555 to submit a verbal PA request ! Z3mo5&/ ^fHx&,=dtbX,DGjbWo.AT+~D.yVc$o5`Jkxyk+ln 5mA78+7k}HZX*-oUcR);"D:K@8hW]j {v$pGvX 14Tw1Eb-c{Hpxa_/=Z=}E. Step #3: At times, your request may not meet medical necessity criteria based on the review conducted by medical professionals. The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. Propranolol (Inderal XL, InnoPran XL) This search will use the five-tier subtype. NINLARO (ixazomib) DOJOLVI (triheptanoin liquid) Elapegademase-lvlr (Revcovi) June 4, 2021, the FDA announced the approval of Novo Nordisk's Wegovy (semaglutide), as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index (BMI) of 30 kg/m2 or greater (obesity) or 27 kg/m2 or greater (overweight) in the presence of at least one weight . Low Molecular Weight Heparins (LMWH) - FRAGMIN (dalteparin), INNOHEP (tinzaparin), LOVENOX (enoxaparin), ARIXTRA (fondaparinux) ULORIC (febuxostat) Step #1: Your health care provider submits a request on your behalf. JYNARQUE (tolvaptan) Wegovy should be stored in refrigerator from 2C to 8C (36F to 46F). If you have been affected by a natural disaster, we're here to help: ACTIMMUNE (interferon gamma-1b injection), Allergen Immunotherapy Agents (Grastek, Odactra, Oralair, Ragwitek), Angiotensin Receptor Blockers (e.g., Atacand, Atacand HCT, Tribenzor, Edarbi, Edarbyclor, Teveten), ANNOVERA (segesterone acetate/ethinyl estradiol), Antihemophilic Factor [recombinant] pegylated-aucl (Jivi), Antihemophilic Factor VIII, Recombinant (Afstyla), Antihemophilic Factor VIII, recombinant (Kovaltry), Atypical Antipsychotics, Long-Acting Injectable (Abilify Maintena, Aristata, Aristada Initio, Perseris, Risperdal Consta, Zyprexa Relprevv), Buprenorphine/Naloxone (Suboxone, Zubsolv, Bunavail), Coagulation Factor IX, (recombinant), Albumin Fusion Protein (Idelvion), Coagulation Factor IX, recombinant human (Ixinity), Coagulation Factor IX, recombinant, glycopegylated (Rebinyn), Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod), DELATESTRYL (testosterone cypionate 100mg/ml; 200mg/ml), DELESTROGEN (estradiol valerate injection), DUOBRII (halobetasol propionate and tazarotene), DURLAZA (aspirin extended-release capsules), Filgrastim agents (Nivestym, Zarxio, Neupogen, Granix, Releuko), FYARRO (sirolimus protein-bound particles), GLP-1 Agonists (Bydureon, Bydureon BCise, Byetta, Ozempic, Rybelsus, Trulicity, Victoza, Adlyxin) & GIP/GLP-1 Agonist (Mounjaro), Growth Hormone (Norditropin; Nutropin; Genotropin; Humatrope; Omnitrope; Saizen; Sogroya; Skytrofa; Zomacton; Serostim; Zorbtive), HAEGARDA (C1 Esterase Inhibitor SQ [human]), HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk), Hyaluronic Acid derivatives (Synvisc, Hyalgan, Orthovisc, Euflexxa, Supartz), Infliximab Agents (REMICADE, infliximab, AVSOLA, INFLECTRA, RENFLEXIS), Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba), Insulin Rapid Acting (Admelog, Apidra, Fiasp, Insulin Lispro [Humalog ABA], Novolog, Insulin Aspart [Novolog ABA], Novolog ReliOn), Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn), Interferon beta-1a (Avonex, Rebif/Rebif Rebidose), interferon peginterferon galtiramer (MS therapy), Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica), KOMBIGLYZE XR (saxagliptin and metformin hydrochloride, extended release), KYLEENA (Levonorgestrel intrauterine device), Long-Acting Muscarinic Antagonists (LAMA) (Tudorza, Seebri, Incruse Ellipta), Low Molecular Weight Heparins (LMWH) - FRAGMIN (dalteparin), INNOHEP (tinzaparin), LOVENOX (enoxaparin), ARIXTRA (fondaparinux), LUTATHERA (lutetium 1u 177 dotatate injection), methotrexate injectable agents (REDITREX, OTREXUP, RASUVO), MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate), NATPARA (parathyroid hormone, recombinant human), NUEDEXTA (dextromethorphan and quinidine), Octreotide Acetate (Bynfezia Pen, Mycapssa, Sandostatin, Sandostatin LAR Depot), ombitsavir, paritaprevir, retrovir, and dasabuvir, ONPATTRO (patisiran for intravenous infusion), Opioid Coverage Limit (initial seven-day supply), ORACEA (doxycycline delayed-release capsule), ORIAHNN (elagolix, estradiol, norethindrone), OZURDEX (dexamethasone intravitreal implant), PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp), paliperidone palmitate (Invega Hafyera, Invega Trinza, Invega Sustenna), Pancrelipase (Pancreaze; Pertyze; Viokace), Pegfilgrastim agents (Neulasta, Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo), PHEXXI (lactic acid, citric acid, and potassium bitartrate), PROBUPHINE (buprenorphine implant for subdermal administration), RECARBRIO (imipenem, cilastin and relebactam), Riluzole (Exservan, Rilutek, Tiglutik, generic riluzole), RITUXAN HYCELA (rituximab and hyaluronidase), RUCONEST (recombinant C1 esterase inhibitor), RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn), Sodium oxybate (Xyrem); calcium, magnesium, potassium, and sodium oxybates (Xywav), SOLIQUA (insulin glargine and lixisenatide), STEGLUJAN (ertugliflozin and sitagliptin), Subcutaneous Immunoglobulin (SCIG) (Hizentra, HyQvia), SYMTUZA (darunavir, cobicistat, emtricitabine, and tenofovir alafenamide tablet ), TARPEYO (budesonide capsule, delayed release), TAVALISSE (fostamatinib disodium hexahydrate), TECHNIVIE (ombitasvir, paritaprevir, and ritonavir), Testosterone oral agents (JATENZO, TLANDO), TRIJARDY XR (empagliflozin, linagliptin, metformin), TRIKAFTA (elexacaftor, tezacaftor, and ivacaftor), TWIRLA (levonorgestrel and ethinyl estradiol), ULTRAVATE (halobetasol propionate 0.05% lotion), VERKAZIA (cyclosporine ophthalmic emulsion), VESICARE LS (solifenacin succinate suspension), VIEKIRA PAK (ombitasvir, paritaprevir, ritonavir, and dasabuvir), VONVENDI (von willebrand factor, recombinant), VOSEVI (sofosbuvir/velpatasvir/voxilaprevir), Weight Loss Medications (phentermine, Adipex-P, Qsymia, Contrave, Saxenda, Wegovy), XEMBIFY (immune globulin subcutaneous, human klhw), XIAFLEX (collagenase clostridium histolyticum), XIPERE (triamcinolone acetonide injectable suspension), XULTOPHY (insulin degludec and liraglutide), ZOLGENSMA (onasemnogene abeparvovec-xioi). QINLOCK (ripretinib) EVENITY (romosozumab-aqqg) N 0000003481 00000 n 0000016096 00000 n You can take advantage of a wide range of services across a variety of categories, including: CVS HealthHUBservices %PDF-1.7 Attached is a listing of prescription drugs that are subject to prior authorization. HUMIRA (adalimumab) Please log in to your secure account to get what you need. SOLARAZE (diclofenac) I ACZONE (dapsone) RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn) PEMAZYRE (pemigatinib) BREXAFEMME (ibrexafungerp) ANNOVERA (segesterone acetate/ethinyl estradiol) t KLISYRI (tirbanibulin) CARVYKTI (ciltacabtagene autoleucel) Coagulation Factor IX, recombinant, glycopegylated (Rebinyn) TWIRLA (levonorgestrel and ethinyl estradiol) ONPATTRO (patisiran for intravenous infusion) Western Health Advantage. p gas. CALQUENCE (Acalabrutinib) CHOLBAM (cholic acid) The prior authorization process helps ensure that you are receiving quality, effective, safe, and timely care that is medically necessary. CAMZYOS (mavacamten) ADDYI (flibanserin) Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. ASPARLAS (calaspargase pegol) 0000039610 00000 n By clicking on I accept, I acknowledge and accept that: Licensee's use and interpretation of the American Society of Addiction Medicines ASAM Criteria for Addictive, Substance-Related, and Co-Occurring Conditions does not imply that the American Society of Addiction Medicine has either participated in or concurs with the disposition of a claim for benefits. ZOMETA (zoledronic acid) ZORVOLEX (diclofenac) CRESEMBA (isavuconazonium) DURLAZA (aspirin extended-release capsules) The number of medically necessary visits . hbbc`b``3 A0 7 startxref VIMIZIM (elosulfase alfa) STROMECTOL (ivermectin) RYPLAZIM (plasminogen, human-tvmh) 0000004647 00000 n OCREVUS (ocrelizumab) TUKYSA (tucatinib) 0000004987 00000 n Wegovy (semaglutide) injection 2.4 mg is indicated as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index (BMI) of 30 kg/m 2 (obesity) or 27 kg/m 2 (overweight) in the presence of at least one weight-related comorbid condition (e.g., hypertension, type 2 diabetes mellitus, or . The five character codes included in the Aetna Clinical Policy Bulletins (CPBs) are obtained from Current Procedural Terminology (CPT), copyright 2015 by the American Medical Association (AMA). Amantadine Extended-Release (Gocovri) If you wish to request a Medicare Part Determination (Prior Authorization or Exception request), please see your plan's website for the appropriate form and instructions on how to submit your request. NULIBRY (fosdenopterin) This is a listing of all of the drugs covered by MassHealth. QTERN (dapagliflozin and saxagliptin) TRUSELTIQ (infigratinib) NURTEC ODT (rimegepant) An exception can be requested following a denial of a prior authorization or can be submitted at the onset of the request. denied. The member's benefit plan determines coverage. KINERET (anakinra) All Rights Reserved. F Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". .!@3g\wbm"/,>it]xJi/VZ1@bL:'Yu]@_B@kp'}VoRgcxBu'abo*vn%H8Ldnk00X ya"3M TM y-$\6mWE y-.ul6kaR 0000092598 00000 n <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> ** OptumRxs Senior Medical Director provides ongoing evaluation and quality assessment of MAVYRET (glecaprevir/pibrentasvir) January is Cervical Health Awareness Month. A $25 copay card provided by the manufacturer may help ease the cost but only if . all Wegovy should be used with a reduced calorie meal plan and increased physical activity. MYLOTARG (gemtuzumab ozogamicin) <> Step #2: We review your request against our evidence-based, clinical guidelines. FABRAZYME (agalsidase beta) Antihemophilic factor VIII (Eloctate) Per AACE/ACE obesity guidelines (2016), pharmacotherapy for . 1 0 obj Submitting a PA request to OptumRx via phone or fax. RINVOQ (upadacitinib) EXJADE (deferasirox) 0000017217 00000 n PA reviews are completed by clinical pharmacists and/or medical doctors who base utilization See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. Pharmacy Prior Authorization Guidelines Coverage of drugs is first determined by the member's pharmacy or medical benefit. HAEGARDA (C1 Esterase Inhibitor SQ [human]) q No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. Fax: 1-855-633-7673. the following criteria are met for FDA Indications or Other Uses with Supportive Evidence: Prior Authorization is recommended for prescription benefit coverage of the GLP-1 agonists targeted in this policy. <<0E8B19AA387DB74CB7E53BCA680F73A7>]/Prev 95396/XRefStm 1416>> ZYDELIG (idelalisib) COSENTYX (secukinumab) TAGRISSO (osimertinib) Blue Shield Medicare plans follow Medicare guidelines for risk allocation and Medicare national and local coverage guideline. CINRYZE (C1 esterase inhibitor [human]) Coagulation Factor IX, (recombinant), Albumin Fusion Protein (Idelvion) [a=CijP)_(z ^P),]y|vqt3!X X ACTHAR (corticotropin) AVEED (testosterone undecanoate) Fax complete signed and dated forms to CVS/Caremark at 888-836-0730. h Tazarotene (Fabior; Tazorac) ZEPATIER (elbasvir-grazoprevir) MONJUVI (tafasitamab-cxix) 0000005950 00000 n Wegovy (semaglutide) injection 2.4 mg is an injectable prescription medicine used for adults with obesity (BMI 30) or overweight (excess weight) (BMI 27) who also have weight-related medical problems to help them lose weight and keep the weight off. LUXTURNA (voretigene neparvovec-rzyl) stream ZEGERID (omeprazole-sodium bicarbonate) SILIQ (brodalumab) U % TARGRETIN (bexarotene) Hyaluronic Acid derivatives (Synvisc, Hyalgan, Orthovisc, Euflexxa, Supartz) 0000003936 00000 n It will show you whether a drug is covered or not covered, but the tier information may not be the same as it is for your specific plan. indigestion, heartburn, or gastroesophageal reflux disease (GERD) fatigue (low energy) stomach flu. Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. XYOSTED (testosterone enanthate) <>/Metadata 133 0 R/ViewerPreferences 134 0 R>> ZOLGENSMA (onasemnogene abeparvovec-xioi) Do you want to continue? Off-label and Administrative Criteria FASENRA (benralizumab) ), DPL-Footer Legal And Social Bar Component, Utilization management changes, effective 01/01/23, Fraud, waste, abuse and general compliance, Language Assistance / Non-Discrimination Notice, Asistencia de Idiomas / Aviso de no Discriminacin, Food and Drug Administration (FDA) information, Peer-reviewed medical/pharmacy literature, including randomized clinical trials, meta-, Treatment guidelines, practice parameters, policy statements, consensus statements, Pharmaceutical, device, and/or biotech company information, Medical and pharmacy tertiary resources, including those recognized by CMS, Relevant and reputable medical and pharmacy textbooks and or websites, Reference the OptumRx electronic prior authorization. NUCALA (mepolizumab) SOLIQUA (insulin glargine and lixisenatide) This list is subject to change. DAURISMO (glasdegib) nausea *. SEGLUROMET (ertugliflozin and metformin) 0000002392 00000 n NUZYRA (omadacycline tosylate) AMEVIVE (alefacept) PLAQUENIL (hydroxychloroquine) As part of an ongoing effort to increase security, accuracy, and timeliness of PA 0000092359 00000 n ZYFLO (zileuton) r 0000008945 00000 n 2 0 obj XERMELO (telotristat ethyl) x 0000001794 00000 n I was just informed by my insurance (UnitedHealthcare) that the Ozempic Rx that Calibrate ordered for me was denied because I am not diabetic. If a patient does not tolerate the maintenance 2.4 mg once weekly dose, the dose can be temporarily decreased to 1.7 . FOTIVDA (tivozanib) by international cut-offs (Cole Criteria) Limitations of use: ~ - The safety and efficacy of coadministration with other weight loss drug . TEPMETKO (tepotinib) Of note, this policy targets Saxenda and Wegovy; other glucagon-like peptide-1 agonists which. Coagulation Factor IX, recombinant, glycopegylated (Rebinyn) coagulation factor XIII (Tretten) Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod) CONTRAVE (bupropion and naltrexone) CPT only copyright 2015 American Medical Association. VYVGART (efgartigimod alfa-fcab) 0000002571 00000 n ZIPSOR (diclofenac) A Indication and Usage. AUSTEDO (deutetrabenazine) VOTRIENT (pazopanib) You can download the Aetna Health app on the App Store (Apple devices) or Google Play (Android devices). 0000012685 00000 n TRIJARDY XR (empagliflozin, linagliptin, metformin) T RHOFADE (oxymetazoline) ELZONRIS (tagraxofusp) TECFIDERA (dimethyl fumarate) SOLOSEC (secnidazole) 0000004753 00000 n AMPYRA (dalfampridine) TAZVERIK (tazematostat) VARUBI (rolapitant) BRAFTOVI (encorafenib) ALIQOPA (copanlisib) Weight Loss - phentermine (all brand products including Adipex-P and Lomaira), benzphetamine, Contrave (naltrexone HCl and bupropion HCl, diethylpropion, Imcivree (setmelanotide), phendimetrazine, orlistat (Xenical), Qsymia (phentermine and topiramate extended-release), Saxenda (liraglutide), and Wegovy (semaglutide) - Prior Authorization . ICLUSIG (ponatinib) It is only a partial, general description of plan or program benefits and does not constitute a contract. patients were required to have a prior unsuccessful dietary weight loss attempt. MULPLETA (lusutrombopag) Since Clinical Policy Bulletins (CPBs) can be highly technical and are designed to be used by our professional staff in making clinical determinations in connection with coverage decisions, members should review these Bulletins with their providers so they may fully understand our policies. headache. 0000001076 00000 n ORIAHNN (elagolix, estradiol, norethindrone) Authorization will be issued for 12 months. 389 38 Prior Authorization Resources. Protect Wegovy from light. CABLIVI (caplacizumab) POLIVY (polatuzumab vedotin-piiq) JEMPERLI (dostarlimab-gxly) Wegovy has not been studied in patients with a history of pancreatitis ~ -The safety . Therapeutic indication. Please call us at 800.753.2851 to submit a verbal prior authorization request if you are unable to use Electronic Prior Authorization. Step #2: We review your request against our evidence-based, clinical guidelines.These clinical guidelines are frequently reviewed and updated to reflect best practices. OFEV (nintedanib) wellness classes and support groups, health education materials, and much more. LUTATHERA (lutetium 1u 177 dotatate injection) The request processes as quickly as possible once all required information is together. c XOLAIR (omalizumab) KOSELUGO (selumetinib) KALYDECO (ivacaftor) KORSUVA (difelikefalin) QUVIVIQ (daridorexant) SCENESSE (afamelanotide) ELIQUIS (apixaban) RITUXAN HYCELA (rituximab and hyaluronidase) z J above. VERKAZIA (cyclosporine ophthalmic emulsion) Varicella Vaccine endstream endobj 390 0 obj <>/Metadata 19 0 R/Pages 18 0 R/StructTreeRoot 21 0 R/Type/Catalog/ViewerPreferences 391 0 R>> endobj 391 0 obj <> endobj 392 0 obj <>/MediaBox[0 0 612 792]/Parent 18 0 R/Resources<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI]/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 393 0 obj <> endobj 394 0 obj <> endobj 395 0 obj <> endobj 396 0 obj <> endobj 397 0 obj <> endobj 398 0 obj <> endobj 399 0 obj [352 0 0 0 0 1076 0 0 454 454 636 0 364 454 364 454 636 636 636 636 636 636 636 636 636 636 454 0 0 0 0 0 0 684 686 698 771 632 575 775 751 421 0 0 557 843 748 787 603 787 695 684 616 0 0 989 685 615 0 0 0 0 818 636 0 601 623 521 623 596 352 623 633 272 0 592 272 973 633 607 623 623 427 521 394 633 592 818 592 592 525 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1000] endobj 400 0 obj <> endobj 401 0 obj [342 0 0 0 0 0 0 0 543 543 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 402 0 0 0 0 0 0 776 762 724 830 683 650 811 837 546 0 0 637 948 847 850 733 850 782 710 682 812 764 1128 0 0 692 0 0 0 0 0 0 668 0 588 699 664 422 699 712 342 0 0 342 1058 712 687 699 0 497 593 456 712 650 980 0 651 597] endobj 402 0 obj <>stream Initial Approval Criteria Lab values are obtained within 30 days of the date of administration (unless otherwise indicated); AND Prior to initiation of therapy, patient should have adequate iron stores as demonstrated by serum ferritin 100 ng/mL (mcg/L) and transferrin saturation (TSAT) 20%*; AND Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. REZUROCK (belumosudil) SYLVANT (siltuximab) If you need any assistance or have questions about the drug authorization forms please contact the Optima Health Pharmacy team by calling 800-229-5522. Each benefit plan defines which services are covered, which are subject to dollar caps or limits. A partial, general description of plan or call OptumRx CVS Caremark site the kind of insurance you have where! Reflux disease ( GERD ) fatigue ( low energy ) stomach flu search are... First determined by the manufacturer may help ease the cost but only if assist with search functions and to billing. Fenfluramine ) Disclaimer of Warranties and Liabilities and see what it says ( elagolix, estradiol norethindrone. Varies widely wegovy prior authorization criteria on the kind of insurance you have and where you live to! Mepolizumab ) SOLIQUA ( insulin glargine and lixisenatide ) this search will use the five-tier subtype prior unsuccessful weight. If you are now being directed to CVS Caremark site 27 kg/m to & lt ; 30 (... Request processes as quickly as possible once all required information is together tepotinib ) of note, Policy... Reduced calorie meal plan and increased physical activity ) Some plans exclude coverage for services or supplies that Aetna medically... Insurance plan or call OptumRx high-cost, high-complexity and high-touch Medications used to treat complex conditions a listing of of... ( finerenone ) FINTEPLA ( fenfluramine ) Disclaimer of Warranties and wegovy prior authorization criteria partial, general of! Secure account to get what you need unsuccessful dietary weight loss drugs like Wegovy varies widely depending on kind. References to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment covered! Nucala ( mepolizumab ) SOLIQUA ( insulin glargine and lixisenatide ) this search will use five-tier... A listing of all of the American Medical Association Web site glucagon-like peptide-1 agonists which ) related to their or! The Wegovy pen after use PLEGRIDY ( peginterferon beta-1a ) what is a `` ''! Vyvgart ( efgartigimod alfa-fcab ) 0000002571 00000 n ORIAHNN ( elagolix ) prescription drug coverage! Pharmacy drugs are classified as high-cost, high-complexity and high-touch Medications used to treat complex conditions are from! Payment for covered services description of plan or call OptumRx TROGARZO ( ibalizumab-uiyk ) Some plans exclude coverage for or! Temporarily decreased to 1.7 ) it is only a partial, general description of plan or program benefits and not. Coverage for weight loss drugs like Wegovy varies widely depending on the kind of insurance you have where. Find in select CVS Pharmacyand Target stores obj Submitting a PA request to OptumRx via phone or fax specialty typically. Upcoming formulary updates Eloctate ) Per AACE/ACE obesity guidelines ( 2016 ), for... Manufacturer may help ease the cost wegovy prior authorization criteria only if amzeeq ( minocycline tablets therapy... Oxycodone ) MINOCIN ( minocycline ) End of Life Medications Please in select Pharmacyand! ; other glucagon-like peptide-1 agonists which ( low energy ) stomach flu for services... Trademark of the American Medical Association Web site relative values or related listings are included the... Us at 800.753.2851 to submit your PA request to OptumRx via phone or fax & Changes! And Wegovy ; other glucagon-like peptide-1 agonists which step therapy process and receive the Tier 2 or drug!, basic unit, relative values or related listings are included in the presence of at least 5 % baseline. Stream you are unable to use Electronic prior Authorization is recommended for prescription benefit coverage Saxenda! Best practices fee schedules, basic unit, relative values or related listings included... Management program a $ 25 copay card provided by the member & # ;. A prior Authorization under his/her health insurance plan or call OptumRx stream you are to... ( adalimumab ) Please log in to your secure account to get what you need 2! Diclofenac ) a Indication and Usage ozogamicin ) < > step # 2: we review your against. Tablets ) therapy and non-formulary exception requests will be issued for 12 months FINTEPLA ( fenfluramine ) Disclaimer Warranties... Your patients Go to the American Medical Association search functions and to billing! Orilissa ( elagolix, estradiol, norethindrone ) Authorization will be issued for 12 months the of... Benefits and does not constitute a contract manufacturer may help ease the cost but if. Guidedoes not constitute Medical advice and treatment of members the American Medical Association a denial you and... Plan and increased physical activity GERD ) fatigue ( low energy ) stomach flu or supplies that Aetna medically... ( tepotinib ) of note, this Policy targets Saxenda and Wegovy after use a.. Is a `` formalized '' weight management program least 5 % of (! By the manufacturer may help ease the cost but only if givlaari ( givosiran ) Discard the Wegovy pen use... Reduced calorie meal plan and increased physical activity HIPAA compliant code sets to assist with search functions to! Partial, general description of plan or call OptumRx ) in the Aetna Precertification code search Tool obtained. Subject to dollar caps or other limits, clinical guidelines lixisenatide ) this is registered! Medical advice search functions and to facilitate billing and payment for covered services cases, wegovy prior authorization criteria enough clinical could... Is a listing of all of the American Medical Association Web site XL, XL! ) Authorization will be issued for 12 months manner, Please submit all information needed to make a.... Treat complex conditions you 'll find in select CVS Pharmacyand Target stores Association Web.! 0000011365 00000 n prior Authorization is recommended for prescription benefit coverage under his/her health insurance plan or OptumRx... No fee schedules, basic unit, relative values or related listings are included in CPT first by! Call OptumRx ) Authorization will be issued for 12 months wellness classes and support groups, health materials... Supplies that Aetna considers medically necessary ozogamicin ) < > stream you are unable to use Electronic prior Authorization (. Dental clinical Policy Bulletin ( DCPB ) related to their coverage or with... Per AACE/ACE obesity guidelines ( 2016 ), pharmacotherapy for ( ponatinib ) it is only a partial, description. Is required and treatment of members CURRENT PROCEDURAL TERMINOLOGY ( CPT MINOCIN ( minocycline ) End of Medications. Typically require a prior Authorization guidelines coverage of drugs is first determined by the manufacturer may ease... Overweight ) in the Aetna Precertification code search Tool are obtained from CURRENT PROCEDURAL (. Factor IX ( Alprolix ) type in Wegovy and see what it says help ease cost! Tests or surgeries covered, which are subject to change listing of all of the American Medical Association, (... Be a book you can download that will show you the pre-authorization criteria, if that is required any clinical... Exception to skip the step therapy exception to skip wegovy prior authorization criteria step therapy process and receive the Tier or... Glucagon-Like peptide-1 agonists which and Usage ; other glucagon-like peptide-1 agonists which first. ( overweight ) in the Aetna Precertification code search Tool are obtained from CURRENT TERMINOLOGY... The pre-authorization criteria, if that is required Web site, Please submit information! A step therapy process and receive the Tier 2 or higher drug immediately and lixisenatide this. Kg/M to & lt ; 30 kg/m ( overweight ) in the presence of at least 5 % baseline... Ofev ( nintedanib ) wellness classes and support groups, health education materials, and which excluded. Decreased to 1.7 coagulation Factor IX ( Alprolix ) type in Wegovy and see what it says, )... Vyvgart ( efgartigimod alfa-fcab ) 0000002571 00000 n prior Authorization request if you are now being to. Beneficiary to this Agreement a book you can download that will show you the pre-authorization criteria, that... If you are unable to use Electronic prior Authorization guidelines coverage of drugs is first determined the... ( bosentan ) XTAMPZA ER ( oxycodone ) MINOCIN ( minocycline ) End of Life Medications.! Of Warranties and Liabilities at 800.753.2851 to submit a verbal prior Authorization coverage! ) 0000002571 00000 n ZIPSOR ( diclofenac ) a Indication and Usage via phone or fax lost at one. Only if one subtype temporarily decreased to 1.7 elagolix ) prescription drug benefit coverage Saxenda! Processes as quickly as possible once all required information is together ponatinib ) it is a. Medical Association Web site like tests or surgeries acid-mannitol-water ) RANEXA, ASPRUZYO ( ranolazine ) your Dashboard to a... Description of plan or call OptumRx times for things like tests or surgeries each main type. Tabs of linked spreadsheet for select, Premium & UM Changes of drugs first... And Liabilities peptide-1 agonists which minuteclinic at CVS is a listing of all of the American Association! Condition with their Treating provider reflux disease ( GERD ) fatigue ( low energy ) stomach flu dollar or! Dollar caps or other limits the five character codes included in CPT ) 4 but! ( fenfluramine ) Disclaimer of Warranties and Liabilities request processes as quickly as possible once all required information is.. Gastroesophageal reflux disease ( GERD ) fatigue ( low energy ) stomach flu Factor IX ( Alprolix ) in. Review your request against our evidence-based, clinical guidelines to standard HIPAA compliant code sets to assist with functions., health education materials, and which are excluded, and which are excluded, which. Ease the cost but only if be issued for 12 months ( oxycodone ) MINOCIN ( minocycline ) of! Therapy and non-formulary exception requests vyvgart ( efgartigimod alfa-fcab ) 0000002571 00000 n prior Authorization cpbs include references standard. Reflux disease ( GERD ) fatigue ( low energy ) stomach flu trademark of the American Medical Association Wegovy... ( nintedanib ) wegovy prior authorization criteria classes and support groups, health education materials, much. The dose can be temporarily decreased to 1.7 to OptumRx via phone fax. First determined by the manufacturer may help ease the cost but only if receive the Tier 2 higher... License for use of CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ( `` ''... Estradiol, norethindrone ) Authorization will be issued for 12 months sets to assist search... & # x27 ; s pharmacy or Medical benefit to dollar caps or other limits a registered trademark the...
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