TYSABRI (natalizumab) GALAFOLD (migalastat) A prior authorization is a request submitted on your behalf by your health care provider for a particular procedure, test, treatment, or prescription. ; Wegovy contains semaglutide and should . LEQVIO (inclisiran) ALECENSA (alectinib) K ADUHELM (aducanumab-avwa) indigestion, heartburn, or gastroesophageal reflux disease (GERD) fatigue (low energy) stomach flu. 0000003481 00000 n INQOVI (decitabine and cedazuridine) Bevacizumab SKYRIZI (risankizumab-rzaa) Please use the updated forms found below and take note of the fax number referenced within the Drug Authorization Forms. XHANCE (fluticasone proprionate) c OPZELURA (ruxolitinib cream) I SOLARAZE (diclofenac) ZINPLAVA (bezlotoxumab) Angiotensin Receptor Blockers (e.g., Atacand, Atacand HCT, Tribenzor, Edarbi, Edarbyclor, Teveten) 0000092598 00000 n MYALEPT (metreleptin) All Rights Reserved. You can download the Aetna Health app on the App Store (Apple devices) or Google Play (Android devices). <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> F startxref Pre-authorization is a routine process. n Insulin Rapid Acting (Admelog, Apidra, Fiasp, Insulin Lispro [Humalog ABA], Novolog, Insulin Aspart [Novolog ABA], Novolog ReliOn) Your benefits plan determines coverage. TALZENNA (talazoparib) 0000055434 00000 n Indication and Usage. VEMLIDY (tenofovir alafenamide) VYONDYS 53 (golodirsen) MinuteClinic at CVS is a convenient retail clinic that you'll find in select CVS Pharmacyand Target stores. A $25 copay card provided by the manufacturer may help ease the cost but only if . Weve answered some of the most frequently asked questions about the prior authorization process and how we can help. A NURTEC ODT (rimegepant) 0000013058 00000 n ZERVIATE (cetirizine) You can take advantage of a wide range of services across a variety of categories, including: CVS HealthHUBservices BREYANZI (lisocabtagene maraleucel) NPLATE (romiplostim) Has lost at least 5% of baseline (prior to the initiation of Wegovy) body weight (only required once) 4. 0000011005 00000 n PLAQUENIL (hydroxychloroquine) #^=&qZ90>Te o@2 endstream endobj 2544 0 obj <>/Filter/FlateDecode/Index[84 2409]/Length 69/Size 2493/Type/XRef/W[1 1 1]>>stream Visit the secure website, available through www.aetna.com, for more information. 0000008484 00000 n TREMFYA (guselkumab) 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. TURALIO (pexidartinib) Q See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. SYMLIN (pramlintide) POLIVY (polatuzumab vedotin-piiq) U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements. IMCIVREE (setmelanotide) ),)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 If this is the case, our team of medical directors is willing to speak with your health care provider for next steps. ZURAMPIC (lesinurad) KRINTAFEL (tafenoquine) ISTURISA (osilodrostat) OCREVUS (ocrelizumab) Whats the difference? FANAPT (iloperidone) HAEGARDA (C1 Esterase Inhibitor SQ [human]) ERIVEDGE (vismodegib) FIRDAPSE (amifampridine) EMGALITY (galcanezumab-gnlm) 0000002376 00000 n Aetna considers up to a combined limit of 26 individual or group visits by any recognized provider per 12-month period as medically necessary for weight reduction counseling in adults who are obese (as defined by BMI greater than or equal to 30 kg/m 2 ** ). y x=rF?#%=J,9R 0h/t7nH&tJ4=3}_-u~UqT/^Vu]x>W.XUuX/J"IxQbqqB iq(.n-?$bz')m>~H? As an OptumRx provider, you know that certain medications require approval, or M ONFI (clobazam) CHOLBAM (cholic acid) 0000062995 00000 n prescription drug benefit coverage under his/her health insurance plan or call OptumRx. FARXIGA (dapagliflozin) The cash price is even higher, averaging $1,988.22 since August 2021 according to GoodRx . 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. ABECMA (idecabtagene vicleucel) The discussion, analysis, conclusions and positions reflected in the Clinical Policy Bulletins (CPBs), including any reference to a specific provider, product, process or service by name, trademark, manufacturer, constitute Aetna's opinion and are made without any intent to defame. AIMOVIG (erenumab-aooe) endobj Opioid Coverage Limit (initial seven-day supply) No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM. VYNDAQEL (tafamidis meglumine) B MEPSEVII (vestronidase alfa-vjbk) The responsibility for the content of this product is with Aetna, Inc. and no endorsement by the AMA is intended or implied. <> 0000002527 00000 n Amantadine Extended-Release (Gocovri) 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. L 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 . Testosterone oral agents (JATENZO, TLANDO) gym discounts, 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. 0000002567 00000 n RUCONEST (recombinant C1 esterase inhibitor) Fluoxetine Tablets (Prozac, Sarafem) Off-label and Administrative Criteria Reprinted with permission. 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 TEZSPIRE (tezepelumab-ekko) Has anyone been able to jump through this type of hoop? ! 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. RYBREVANT (amivantamab-vmjw) PHEXXI (lactic acid, citric acid, and potassium bitartrate) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. Hyaluronic Acid derivatives (Synvisc, Hyalgan, Orthovisc, Euflexxa, Supartz) VERQUVO (vericiguat) rz^6>)@?v": QCd?Pcu E 2 0 obj ARAKODA (tafenoquine) these guidelines may not apply. We recommend you speak with your patient regarding KORSUVA (difelikefalin) CIBINQO (abrocitinib) Please note also that the ABA Medical Necessity Guidemay be updated and are, therefore, subject to change. . 0000002808 00000 n 0000000016 00000 n 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. endobj NEXLIZET (bempedoic acid and ezetimibe) To ensure that a PA determination is provided to you in a timely Fax: 1-855-633-7673. LEUKINE (sargramostim) MAVENCLAD (cladribine) ONPATTRO (patisiran for intravenous infusion) the determination process. You are now being directed to CVS Caremark site. In some cases, not enough clinical documentation could result in a denial. Were here to help. a State mandates may apply. ULTOMIRIS (ravulizumab) MassHealth Pharmacy Initiatives and Clinical Information. 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. XELJANZ/XELJANZ XR (tofacitinib) 0000004753 00000 n TWIRLA (levonorgestrel and ethinyl estradiol) CALQUENCE (Acalabrutinib) VIMIZIM (elosulfase alfa) Filgrastim agents (Nivestym, Zarxio, Neupogen, Granix, Releuko) Pharmacy Prior Authorization Guidelines Coverage of drugs is first determined by the member's pharmacy or medical benefit. Program Name: BadgerCare Plus and Medicaid: Handbook Area: Pharmacy: 01/15/2023 ILARIS (canakinumab) We stay in touch with providers throughout the prior authorization request. NUPLAZID (pimavanserin) % q MYRBETRIQ (mirabegron granules) 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. If denied, the provider may choose to prescribe a less costly but equally effective, alternative JAKAFI (ruxolitinib) Wegovy This fax machine is located in a secure location as required by HIPAA regulations. RHOPRESSA (netarsudil solution) TEMODAR (temozolomide) TECARTUS (brexucabtagene autoleucel) EYLEA (aflibercept) XTANDI (enzalutamide) 0000002222 00000 n Asenapine (Secuado, Saphris) STELARA (ustekinumab) denied. b Welcome. SOVALDI (sofosbuvir) GAVRETO (pralsetinib) III. We also host webinars, outreach campaigns and educational workshops to help them navigate the process. 0000017217 00000 n HWn8}7#Y 0MCFME"R+$Yrp yN.oHC Dhx4iE$D;NP&+Xi:!WB>|\_ June 4, 2021, the FDA announced the approval of Novo Nordisks Wegovy (semaglutide), as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index (BMI) of 30 kg/m2 or greater (obesity) or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbid condition (eg, hypertension, type 2 diabetes mellitus [T2DM], or dyslipidemia), DPL-Footer Legal And Social Bar Component, Utilization management changes, effective 01/01/23, Fraud, waste, abuse and general compliance, Language Assistance / Non-Discrimination Notice, Asistencia de Idiomas / Aviso de no Discriminacin. FORTAMET ER (metformin) ZYDELIG (idelalisib) AMEVIVE (alefacept) bBZ!A01/a(m:=Ug^@+zDfD|4`vP3hs)l5yb/CLBf;% 2p|~\ie.~z_OHSq::xOv[>vv 0000070343 00000 n NEXLETOL (bempedoic acid) QTERN (dapagliflozin and saxagliptin) LUXTURNA (voretigene neparvovec-rzyl) Wegovy Prior Authorization with Quantity Limit TARGET AGENT(S) Wegovy (semaglutide) Brand (generic) GPI Multisource Code Quantity Limit (per day or as listed) Wegovy (semaglutide) 0.25 mg/0.5 mL pen* 6125207000D520 M, N, O, or Y 8 pens (4 . TREANDA (bendamustine) making criteria** that are developed from clinical evidence from the following sources: *Guidelines are specific to plans utilizing our standard drug lists only. 4 0 obj .!@3g\wbm"/,>it]xJi/VZ1@bL:'Yu]@_B@kp'}VoRgcxBu'abo*vn%H8Ldnk00X ya"3M TM y-$\6mWE y-.ul6kaR 0000004987 00000 n Just enter your mobile number and well text you a link to download the Aetna Health app from the App Store or on Google Play. WINLEVI (clascoterone) Coagulation Factor IX, recombinant human (Ixinity) Applicable FARS/DFARS apply. Alogliptin and Pioglitazone (Oseni) Patient Information SIMPONI, SIMPONI ARIA (golimumab) 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. CPT only Copyright 2022 American Medical Association. In doing so, CVS/Caremark will be able to decide whether or not the requested prescription is included in the patient's insurance plan. KISQALI (ribociclib) Therefore, Arizona residents, members, employers and brokers must contact Aetna directly or their employers for information regarding Aetna products and services. The information you will be accessing is provided by another organization or vendor. 2>7_0ns]+hVaP{}A RECLAST (zoledronic acid-mannitol-water) HALAVEN (eribulin) Tried/Failed criteria may be in place. If you can't submit a request via telephone, please use our general request form or one of the state specific forms below . ZEGERID (omeprazole-sodium bicarbonate) This page includes important information for MassHealth providers about prior authorizations. ASPARLAS (calaspargase pegol) I was just informed by my insurance (UnitedHealthcare) that the Ozempic Rx that Calibrate ordered for me was denied because I am not diabetic. All Rights Reserved. ZORVOLEX (diclofenac) [a=CijP)_(z ^P),]y|vqt3!X X Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna). If needed (prior to cap removal) the pen can be kept from 8C to 30C (46F to 86F) up to 28 days. Prior Authorization Criteria Author: RAVICTI (glycerol phenylbutyrate) 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 . 0000010297 00000 n 3 0 obj Please contact CVS/Caremark at 855-582-2022 with questions regarding the prior authorization process. Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. Go to the American Medical Association Web site. %PDF-1.7 The member's benefit plan determines coverage. SOLOSEC (secnidazole) CAMBIA (diclofenac) Growth Hormone (Norditropin; Nutropin; Genotropin; Humatrope; Omnitrope; Saizen; Sogroya; Skytrofa; Zomacton; Serostim; Zorbtive) Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations. Atypical Antipsychotics, Long-Acting Injectable (Abilify Maintena, Aristata, Aristada Initio, Perseris, Risperdal Consta, Zyprexa Relprevv) BIJUVA (estradiol-progesterone) PCSK9-Inhibitors (Repatha, Praluent) Y If you do not intend to leave our site, close this message. 0000069682 00000 n GAMIFANT (emapalumab-izsg) VERZENIO (abemaciclib) uG4A4O9WbAtfwZj6_[X3 @[gL(vJ2U'=-"g~=G2^VZOgae8JG 2|@sGb 7ow@u"@|)7YRx$nhV;p^\ sAk ;ZM>u~^u)pOq%cB=J zY^4fz{ ; t$ x$nI9N$v\ArN{Jg~,+&*14 jz\-9\j9 LS${ 5qmfU'@Nj,hI)~^ }/ 6ryCUNu 'u ;7`@X. Once a review is complete, the provider is informed whether the PA request has been approved or PEPAXTO (melphalan flufenamide) CVS HealthHUB offers all the same services as MinuteClinic at CVS with some additional benefits. NULOJIX (belatacept) 0000001386 00000 n e 0000004021 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. NINLARO (ixazomib) At a MinuteClinic inside a CVS Pharmacy, you may see nurse practitioners (NPs), physician associates (PAs) and pharmacists. 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. So far, all weight loss drugs are 'excluded' from coverage for my specific employer's contracted plan. PYRUKYND (mitapivat) QUVIVIQ (daridorexant) While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. ZILXI (minocycline 1.5% foam) SLYND (drospirenone) Varicella Vaccine MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate) You are now being directed to the CVS Health site. SCEMBLIX (asciminib) Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. r CEQUA (cyclosporine) Step #2: We review your request against our evidence-based, clinical guidelines.These clinical guidelines are frequently reviewed and updated to reflect best practices. YUPELRI (revefenacin) 0000069452 00000 n PLEGRIDY (peginterferon beta-1a) H QBREXZA (glycopyrronium cloth 2.4%) SUSVIMO (ranibizumab) Please fill out the Prescription Drug Prior Authorization Or Step . LUCENTIS (ranibizumab) authorization (PA) guidelines* to encompass assessment of drug indications, set guideline Conditions Not Covered KEVZARA (sarilumab) 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). EMFLAZA (deflazacort) Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica) 0000008320 00000 n Navitus believes that effective and efficient communication is the key to ensuring a strong working relationship with our prescribers. endobj BENLYSTA (belimumab) All services deemed "never effective" are excluded from coverage. BRUKINSA (zanubrutinib) endobj AEMCOLO (rifamycin delayed-release) ORIAHNN (elagolix, estradiol, norethindrone) COPIKTRA (duvelisib) f t EPSOLAY (benzoyl peroxide cream) If there is a discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of benefits, the benefits plan will govern. 2'izZLW|zg UZFYqo M( YVuL%x=#mF"8<>Tt 9@%7z oeRa_W(T(y%*KC%KkM"J.\8,M FORTEO (teriparatide) EPIDIOLEX (cannabidiol) BRONCHITOL (mannitol) 0000002571 00000 n Also includes the CAR-T Monitoring Program, and Luxturna Monitoring Program . FENORTHO (fenoprofen) AYVAKIT (avapritinib) OCALIVA (obeticholic acid) RYDAPT (midostaurin) Lack of information may delay REVLIMID (lenalidomide) TYRVAYA (varenicline) These clinical guidelines are frequently reviewed and updated to reflect best practices. If a patient does not tolerate the maintenance 2.4 mg once weekly dose, the dose can be temporarily decreased to 1.7 . x=ko?,pHE^rEQ q4'MN89dYuj[%'G_^KRi{qD\p8o7lMv;_,N_Wogv>|{G/foM=?J~{(K3eUrc %,4eRUZJtzN7b5~$%1?s?&MMs&\byQl!x@eYZF`'"N(L6FDX It is only a partial, general description of plan or program benefits and does not constitute a contract. FLEQSUVY, OZOBAX, LYVISPAH (baclofen) Wegovy has not been studied in patients with a history of pancreatitis ~ -The safety . Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. However, I do see the prior authorization requirements for my insurance assuming my employer will remove the weight loss medicine exclusion for 2023 (we shall see, or maybe I appeal!?). 0000069611 00000 n ESBRIET (pirfenidone) Click on "Claims," "CPT/HCPCS Coding Tool," "Clinical Policy Code Search. To request authorization for Leqvio, or to request authorization for Releuko for non-oncology purposes, please contact CVS Health-NovoLogix via phone (844-387-1435) or fax (844-851-0882). FYARRO (sirolimus protein-bound particles) X666q5@E())ix cRJKKCW"(d4*_%-aLn8B4( .e`6@r Dg g`> TAZVERIK (tazematostat) This search will use the five-tier subtype. KESIMPTA (ofatumumab) SPRYCEL (dasatinib) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. no77gaEtuhSGs~^kh_mtK oei# 1\ 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. 0000011411 00000 n Elapegademase-lvlr (Revcovi) CONTRAVE (bupropion and naltrexone) WELIREG (belzutifan) Please select a letter to see drugs listed by that letter, or enter the name of the drug you wish to search for. 0000005021 00000 n COTELLIC (cobimetinib) z@vOK.d CP'w7vmY Wx* SOLIQUA (insulin glargine and lixisenatide) vomiting. LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT"). 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. PROLIA (denosumab) Specialty pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used to treat complex conditions. The prior authorization includes a list of criteria that includes: Individual has attempted to lose weight through a formalized weight management program (hypocaloric diet, exercise, and behavior modification) for at least 6 months prior to requests for drug therapy. A prior approval is required for the procedures listed below for both the FEP Standard and Basic Option plan and the FEP Blue Focus plan. FOTIVDA (tivozanib) ORKAMBI (lumacaftor/ivacaftor) ENBREL (etanercept) XOSPATA (gilteritinib) i ZYFLO (zileuton) NEXVIAZYME (avalglucosidase alfa-ngpt) SYNRIBO (omacetaxine mepesuccinate) 0000039610 00000 n NAPRELAN (naproxen) HEPLISAV-B (hepatitis B vaccine) Antihemophilic factor VIII (Eloctate) BRAFTOVI (encorafenib) 0YjjB \K2z[tV7&v7HiRmHd 91%^X$Kw/$ zqz{i,vntGheOm3|~Z ?IFB8H`|b"X ^o3ld'CVLhM >NQ/{M^$dPR4,I1L@TO4enK-sq}&f6y{+QFXY}Z?zF%bYytm. ZEPATIER (elbasvir-grazoprevir) Propranolol (Inderal XL, InnoPran XL) DELATESTRYL (testosterone cypionate 100mg/ml; 200mg/ml) BELEODAQ (belinostat) An exception can be requested following a denial of a prior authorization or can be submitted at the onset of the request. Valuable and timely information on drug therapy issues impacting today's health care and pharmacy environment. S No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. TARGRETIN (bexarotene) constipation *. The prior authorization process helps ensure that the test, treatment, and/or procedure your provider requests is effective, safe, and medically appropriate. While Clinical Policy Bulletins (CPBs) define Aetna's clinical policy, medical necessity determinations in connection with coverage decisions are made on a case by case basis. TRACLEER (bosentan) 0000002153 00000 n ENDARI (l-glutamine oral powder) which contain clinical information used to evaluate the PA request as part of. The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in Aetna Precertification Code Search Tool. SYLVANT (siltuximab) The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. VFEND (voriconazole) IMLYGIC (talimogene laherparepvec) TUKYSA (tucatinib) Gardasil 9 Coverage for weight loss drugs like Wegovy varies widely depending on the kind of insurance you have and where you live. ZYKADIA (ceritinib) NAYZILAM (midazolam nasal spray) TEPMETKO (tepotinib) SUNOSI (solriamfetol) GLYXAMBI (empagliflozin-linagliptin) APTIOM (eslicarbazepine) TECFIDERA (dimethyl fumarate) VUITY (pilocarpine) 0000002392 00000 n LEMTRADA (alemtuzumab) SUTENT (sunitinib) Treating providers are solely responsible for dental advice and treatment of members. HEMLIBRA (emicizumab-kxwh) Wegovy must be kept in the original carton until time of administration. 2 XPOVIO (selinexor) ORGOVYX (relugolix) XADAGO (safinamide) h ZOMETA (zoledronic acid) ACTIMMUNE (interferon gamma-1b injection) Allergen Immunotherapy Agents (Grastek, Odactra, Oralair, Ragwitek) ZTALMY (ganaxolone suspension) You can review prior authorization criteria for Releuko for oncology indications, as well as any recent coding updates, on the OncoHealth website. LYBALVI (olanzapine/samidorphan) PALYNZIQ (pegvaliase-pqpz) VIZIMPRO (dacomitinib) 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. If providers are unable to submit electronically, we offer the following options: Call 1-800-711-4555 to submit a verbal PA request z HETLIOZ/HETLIOZ LQ (tasimelton) 2. or greater (obese), or 27 kg/m. CARBAGLU (carglumic acid) The maintenance dosage of Wegovy is 2.4 mg injected subcutaneously once weekly. 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 . EYSUVIS (loteprednol etabonate) LYNPARZA (olaparib) The recently passed Prior Authorization Reform Act is helping us make our services even better. Applicable FARS/DFARS apply. RETEVMO (selpercatinib) Low Molecular Weight Heparins (LMWH) - FRAGMIN (dalteparin), INNOHEP (tinzaparin), LOVENOX (enoxaparin), ARIXTRA (fondaparinux) TRIPTODUR (triptorelin extended-release) 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 It does not mean precertification as defined by Texas law, as a reliable representation of payment of care or services to fully insured HMO and PPO members. The OptumRx Pharmacy Utilization Management (UM) Program utilizes drug-specific prior Antihemophilic Factor [recombinant] pegylated-aucl (Jivi) The Food and Drug Administration (FDA) approved Vaxneuvance (pneumococcal 15-valent conjugate vaccine) for active immunization for the prevention of invasive disease caused by Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, 22F, 23F and 33F in adults 18 years of age and older. INBRIJA (levodopa) RANEXA, ASPRUZYO (ranolazine) CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. BESPONSA (inotuzumab ozogamicin IV) JYNARQUE (tolvaptan) CINQAIR (reslizumab) 0000016096 00000 n ACZONE (dapsone) ADLARITY (donepezil hydrochloride patch) interferon peginterferon galtiramer (MS therapy) Type in Wegovy and see what it says. It enables a faster turnaround time of This list is subject to change. UPTRAVI (selexipag) 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. ARIKAYCE (amikacin) VITRAKVI (larotrectinib) XIIDRA (lifitegrast) Under certain plans, if more than one service can be used to treat a covered person's dental condition, Aetna may decide to authorize coverage only for a less costly covered service provided that certain terms are met. 0000001751 00000 n reason prescribed before they can be covered. Coagulation Factor IX, (recombinant), Albumin Fusion Protein (Idelvion) VICTRELIS (boceprevir) OZURDEX (dexamethasone intravitreal implant) GLP-1 Agonists (Bydureon, Bydureon BCise, Byetta, Ozempic, Rybelsus, Trulicity, Victoza, Adlyxin) & GIP/GLP-1 Agonist (Mounjaro) 0000013356 00000 n RECORLEV (levoketoconazole) SENSIPAR (cinacalcet) v NERLYNX (neratinib) UKONIQ (umbralisib) Pancrelipase (Pancreaze; Pertyze; Viokace) 0000055963 00000 n MinuteClinic at CVS services 2545 0 obj <>stream Reauthorization approval duration is up to 12 months . NATPARA (parathyroid hormone, recombinant human) VUMERITY (diroximel fumarate) 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. s NULIBRY (fosdenopterin) 0000007229 00000 n XYOSTED (testosterone enanthate) 0000054934 00000 n hb```b``{k @16=v1?Q_# tY 3. Aetna Inc. and its subsidiary companies are not responsible or liable for the content, accuracy or privacy practices of linked sites, or for products or services described on these sites. STEGLATRO (ertugliflozin) Pretomanid Wegovy should be stored in refrigerator from 2C to 8C (36F to 46F). OPDUALAG (nivolumab/relatlimab) allowed by state or federal law. X xref upQz:G Cs }%u\%"4}OWDw No fee schedules, basic unit, relative values or related listings are included in CPT. 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. 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. AZEDRA (Iobenguane I-131) 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. The request processes as quickly as possible once all required information is together. Wegovy is indicated as an adjunct to a reduced-calorie diet and increased physical activity for weight management, including weight loss and weight maintenance, in adults with an initial Body Mass Index (BMI) of. EMPAVELI (pegcetacoplan) 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. OXLUMO (lumasiran) Antihemophilic Factor VIII, Recombinant (Afstyla) 5JB7P@i`xHKMBueX7{ Lm!vpp ;BfP,(&!lQo;!oDx3 vKC$Uq/.^F`EK!v?f\g b/R8;v dPVmB8z?F'_+,8=;J #)3g;VYv_Rjb$6~:l[`Pl;E1>|5R%C99vf:K^(~hT\`5W}:&5F1uV h`j7)g*Z`W'ON:QR:}f_`/Q&\ ", The five character codes included in the Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology (CPT. This excerpt is provided for use in connection with the review of a claim for benefits and may not be reproduced or used for any other purpose. Disclaimer of Warranties and Liabilities. Blue Shield Medicare plans follow Medicare guidelines for risk allocation and Medicare national and local coverage guideline. This means that based on evidence-based guidelines, our clinical experts agree with your health care providers recommendation for your treatment. PAXLOVID (nirmatrelvir and ritonavir) EUCRISA (crisaborole) Prior Authorization Resources. 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 . If you have questions, you can reach out to your health care provider. Wegovy should be used with a reduced calorie meal plan and increased physical activity. NUBEQA (darolutamide) 0000002756 00000 n The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in Aetna Clinical Policy Bulletins (CPBs). It is sometimes known as precertification or preapproval. 0000004700 00000 n 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. NOCTIVA (desmopressin) Saxenda [package insert]. Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. AKLIEF (trifarotene) ENJAYMO (sutimlimab-jome) Treating providers are solely responsible for medical advice and treatment of members. - 30 kg/m (obesity), or. 0000001076 00000 n RINVOQ (upadacitinib) Copyright 2015 by the American Society of Addiction Medicine. REYVOW (lasmiditan) However, applicable state mandates will take precedence with respect to fully insured plans and self-funded non-ERISA (e.g., government, school boards, church) plans. When conditions are met, we will authorize the coverage of Wegovy. KALYDECO (ivacaftor) 0000003404 00000 n If you would like to view forms for a specific drug, visit the CVS/Caremark webpage, linked below. 0000013029 00000 n Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn) Therapeutic indication. The number of medically necessary visits . endstream endobj 425 0 obj <>/Filter/FlateDecode/Index[21 368]/Length 35/Size 389/Type/XRef/W[1 1 1]>>stream It is . g Testosterone pellets (Testopel) Others have four tiers, three tiers or two tiers. FULYZAQ (crofelemer) The prior authorization includes a list of criteria that includes: Individual has attempted to lose weight through a formalized weight management program (hypocaloric diet, exercise, and behavior modification) for at least 6 months prior to requests for drug therapy. 0000005950 00000 n BCBSKS _ Commercial _ PS _ Weight Loss Agents Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ . Call 1-800-711-4555 to request OptumRx standard drug-specific guideline to be faxed. 0000005705 00000 n The prior authorization process helps ensure that you are receiving quality, effective, safe, and timely care that is medically necessary. 0000005437 00000 n VARUBI (rolapitant) SILIQ (brodalumab) Since Dental Clinical Policy Bulletins (DCPBs) 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. PSG suggests the inclusion of those strategies within prior authorization (PA) criteria. AUBAGIO (teriflunomide) Buprenorphine/Naloxone (Suboxone, Zubsolv, Bunavail) We evaluate each case using clinical criteria to ensure each member receives the right care at the right time in their health care journey. Pharmacy Prior Authorization Guidelines. Treating providers are solely responsible for medical advice and treatment of members. XTAMPZA ER (oxycodone) Z The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. The drug specific criteria and forms found within the (Searchable) lists on the Drug List Search tab are for informational purposes only to assist you in completing the Prescription Drug Prior Authorization Or Step Therapy Exception Request Form if they are helpful to you. Erythropoietin, Epoetin Alpha TIBSOVO (ivosidenib) Antihemophilic Factor VIII, recombinant (Kovaltry) CABLIVI (caplacizumab) 0 stream HUMIRA (adalimumab) ONGLYZA (saxagliptin) MEKTOVI (binimetinib) Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. SOLODYN (minocycline 24 hour) VONVENDI (von willebrand factor, recombinant) SYMTUZA (darunavir, cobicistat, emtricitabine, and tenofovir alafenamide tablet ) iMo::>91}h9 All decisions are backed by the latest scientific evidence and our board-certified medical directors. prior authorization (PA), to ensure that they are medically necessary and appropriate for the XCOPRI (cenobamate) MINOCIN (minocycline tablets) Interferon beta-1a (Avonex, Rebif/Rebif Rebidose) ELIQUIS (apixaban) 0000092908 00000 n KOSELUGO (selumetinib) OXERVATE (cenegermin-bkbj) 0000055600 00000 n 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. Our prior authorization process will see many improvements. AMVUTTRA (vutrisiran) VIJOICE (alpelisib) BONIVA (ibandronate) Subcutaneous Immunoglobulin (SCIG) (Hizentra, HyQvia) ALUNBRIG (brigatinib) 426 0 obj <>stream 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 . VONJO (pacritinib) 0000002704 00000 n XELODA (capecitabine) 0000003577 00000 n AMPYRA (dalfampridine) 0000011178 00000 n Each main plan type has more than one subtype. BRINEURA (cerliponase alfa IV) Unlisted, unspecified and nonspecific codes should be avoided. 0000012735 00000 n CPT is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physicians. Pharmacy General Exception Forms DOPTELET (avatrombopag) 0000008227 00000 n 389 38 Please be sure to add a 1 before your mobile number, ex: 19876543210, Guidelines from nationally recognized health care organizations such as the Centers for Medicare and Medicaid Services (CMS), Peer-reviewed, published medical journals, A review of available studies on a particular topic, Expert opinions of health care professionals. a 0000005011 00000 n VYZULTA (latanoprostene bunod) Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. Do you want to continue? BAFIERTAM (monomethyl fumarate) TRIKAFTA (elexacaftor, tezacaftor, and ivacaftor) VIVLODEX (meloxicam) Other policies and utilization management programs may apply. EPCLUSA (sofosbuvir/velpatasvir) For those who choose to cover Wegovy, PSG recommends the following: Thoroughly evaluate the financial impact of covering weight loss drugs; Better outcomes are expected when Wegovy is combined with other weight management strategies. ANNOVERA (segesterone acetate/ethinyl estradiol) KLISYRI (tirbanibulin) TEGSEDI (inotersen) ** OptumRxs Senior Medical Director provides ongoing evaluation and quality assessment of FDA Approved Indication(s) Wegovy is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index (BMI) of: 30 kg/m. Your patients 3 0 obj Submitting a PA request to OptumRx via phone or fax. VABYSMO (faricimab) CYSTARAN (cysteamine ophthalmic) Optum guides members and providers through important upcoming formulary updates. Discard the Wegovy pen after use. Alogliptin (Nesina) DAKLINZA (daclatasvir) STROMECTOL (ivermectin) gas. ROZLYTREK (entrectinib) XEMBIFY (immune globulin subcutaneous, human klhw) J AUSTEDO (deutetrabenazine) Aetna has reached these conclusions based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). all End of Life Medications SIGNIFOR (pasireotide) GILENYA (fingolimod) TAKHZYRO (lanadelumab) RECARBRIO (imipenem, cilastin and relebactam) 0000009958 00000 n 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 Global Prior Authorization: Auvelity, Macrilen GLP1 Agonist: Adlyxin, Bydureon, Byetta, Mounjaro, Ozempic, Rybelsus, Trulicity, and Victoza Gonadotropin-Releasing Hormone Agonists for Central Precocious Puberty: Fensolvi, Lupron Depot-Ped, Triptodur Gonadotropin-Releasing Hormone Agonists Long-Acting Agents: Lupaneta Pack, Lupron-Depot Growth .

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