Angiotensin Receptor Blockers (e.g., Atacand, Atacand HCT, Tribenzor, Edarbi, Edarbyclor, Teveten)
CINRYZE (C1 esterase inhibitor [human])
E
EPIDIOLEX (cannabidiol)
XELJANZ/XELJANZ XR (tofacitinib)
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.
Guidelines are based on written objective pharmaceutical UM decision- NEXVIAZYME (avalglucosidase alfa-ngpt)
manner, please submit all information needed to make a decision.
GILOTRIF (afatini)
NERLYNX (neratinib)
VYLEESI (bremelanotide)
EVKEEZA (evinacumab-dgnb)
SUSTOL (granisetron)
Learn about reproductive health.
LIBTAYO (cemiplimab-rwlc)
Sodium oxybate (Xyrem); calcium, magnesium, potassium, and sodium oxybates (Xywav)
SKYRIZI (risankizumab-rzaa)
Interferon beta-1a (Avonex, Rebif/Rebif Rebidose)
DAKLINZA (daclatasvir)
Wegovy, a new prescription medication for chronic weight management, launched with a price tag of around $1,627 a month before insurance.
The prior authorization process helps ensure that you are receiving quality, effective, safe, and timely care that is medically necessary. 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. HEMLIBRA (emicizumab-kxwh)
BESPONSA (inotuzumab ozogamicin IV)
COPAXONE (glatiramer/glatopa)
0000011365 00000 n
NULOJIX (belatacept)
JUBLIA (efinaconazole)
0000055627 00000 n
Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change.
0000003577 00000 n
Of note, this policy targets Saxenda and Wegovy; other glucagon-like peptide-1 agonists which.
Medicare Plans. 0000017217 00000 n
POLIVY (polatuzumab vedotin-piiq)
We stay in touch with providers throughout the prior authorization request. OXLUMO (lumasiran)
AMONDYS 45 (casimersen)
VIJOICE (alpelisib)
Discard the Wegovy pen after use. JAKAFI (ruxolitinib)
INQOVI (decitabine and cedazuridine)
POTELIGEO (mogamulizumab-kpkc injection)
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.
Infliximab Agents (REMICADE, infliximab, AVSOLA, INFLECTRA, RENFLEXIS)
LUMAKRAS (sotorasib)
Get Pre-Authorization or Medical Necessity Pre-Authorization. XTAMPZA ER (oxycodone)
VITAMIN B12 (cyanocobalamin injection)
RANEXA, ASPRUZYO (ranolazine)
PADCEV (enfortumab vendotin-ejfv)
X666q5@E())ix cRJKKCW"(d4*_%-aLn8B4( .e`6@r
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Treating providers are solely responsible for medical advice and treatment of members.
0000004753 00000 n
0000017382 00000 n
review decisions on sound clinical evidence and make a determination within the timeframe ONZETRA XSAIL (sumatriptan nasal)
i
allowed by state or federal law. Wegovy launched with a list price of $1,350 per 28-day supply before insurance. hb```b``{k @16=v1?Q_# tY 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 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.
MEKINIST (trametinib)
BONIVA (ibandronate)
Type in Wegovy and see what it says.
*Praluent is typically excluded from coverage. 3 0 obj
h
0000008945 00000 n
ADLARITY (donepezil hydrochloride patch)
SLYND (drospirenone)
HALAVEN (eribulin)
0
0000000016 00000 n
III. ELYXYB (celecoxib solution)
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. SPRIX (ketorolac nasal spray)
At a MinuteClinic inside a CVS Pharmacy, you may see nurse practitioners (NPs), physician associates (PAs) and pharmacists. Semaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist. GIVLAARI (givosiran)
GILENYA (fingolimod)
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. 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). CRESEMBA (isavuconazonium)
Applicable FARS/DFARS apply. BIJUVA (estradiol-progesterone)
Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica)
All Rights Reserved. COSELA (trilaciclib)
REVATIO (sildenafil citrate)
UBRELVY (ubrogepant)
bBZ!A01/a(m:=Ug^@+zDfD|4`vP3hs)l5yb/CLBf;% 2p|~\ie.~z_OHSq::xOv[>vv
TIVDAK (tisotumab vedotin-tftv)
0000005705 00000 n
ZEJULA (niraparib)
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Go to the American Medical Association Web site. While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. It is sometimes known as precertification or preapproval.
Clinician Supervised Weight Reduction Programs. SPINRAZA (nusinersen)
Some plans exclude coverage for services or supplies that Aetna considers medically necessary.
AKYNZEO (fosnetupitant/palonosetron)
Per AACE/ACE obesity guidelines (2016), pharmacotherapy for . these guidelines may not apply. We recommend you speak with your patient regarding Alogliptin-Metformin (Kazano)
LEMTRADA (alemtuzumab)
We evaluate each case using clinical criteria to ensure each member receives the right care at the right time in their health care journey.
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. 0000055963 00000 n
SUNOSI (solriamfetol)
KALYDECO (ivacaftor)
0000008484 00000 n
BALVERSA (erdafitinib)
R
NOCTIVA (desmopressin)
Please . ZEGERID (omeprazole-sodium bicarbonate)
VELCADE (bortezomib)
See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. 0000002756 00000 n
ZOMETA (zoledronic acid)
FIRDAPSE (amifampridine)
Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. ROZLYTREK (entrectinib)
Other policies and utilization management programs may apply. 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.
Providers may request a step therapy exception to skip the step therapy process and receive the Tier 2 or higher drug immediately.
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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. MinuteClinic at CVS is a convenient retail clinic that you'll find in select CVS Pharmacyand Target stores. Q
ICLUSIG (ponatinib)
Pre-authorization is a routine process. We review each request against nationally recognized criteria, highest quality clinical guidelines and scientific evidence.
GLYXAMBI (empagliflozin-linagliptin)
KESIMPTA (ofatumumab)
TRACLEER (bosentan)
Testosterone pellets (Testopel)
6.
VIZIMPRO (dacomitinib)
LUMOXITI (moxetumomab pasudotox-tdfk)
HAEGARDA (C1 Esterase Inhibitor SQ [human])
RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn)
VIMIZIM (elosulfase alfa)
CALQUENCE (Acalabrutinib)
ePA is a secure and easy method for submitting,managing, tracking PAs, step OptumRx, except for the following states: MA, RI, SC, and TX. Cost effective; You may need pre-authorization for your . Patient Information 0000069611 00000 n
PA reviews are completed by clinical pharmacists and/or medical doctors who base utilization Others have four tiers, three tiers or two tiers. We offer a variety of resources to support you through your health care journey, including: Resources For Living Program
ADHD Stimulants, Extended-Release (ER)
The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. prescription drug benefits may be covered under his/her plan-specific formulary for which endstream
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ombitsavir, paritaprevir, retrovir, and dasabuvir
Please contact CVS/Caremark at 855-582-2022 with questions regarding the prior authorization process. 0000039610 00000 n
ACTHAR (corticotropin)
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. ADUHELM (aducanumab-avwa)
Has lost at least 5% of baseline (prior to the initiation of Wegovy) body weight (only required once) 4. 0000011178 00000 n
CPT only Copyright 2022 American Medical Association. ILARIS (canakinumab)
VYZULTA (latanoprostene bunod)
requests and determinations, OptumRx is retiring most fax numbers used for The ABA Medical Necessity Guidedoes not constitute medical advice.
As part of an ongoing effort to increase security, accuracy, and timeliness of PA Blood Glucose Test Strips
Tadalafil (Adcirca, Alyq)
Criteria for a step therapy exception can be found in OHCA rules 317:30-5-77.4.
Of note, this policy targets Saxenda and Wegovy; other glucagon-like peptide-1 agonists which do not carry an FDA-approved indication for weight loss are not targeted in this policy.
4 0 obj
XHANCE (fluticasone proprionate)
LUXTURNA (voretigene neparvovec-rzyl)
FINTEPLA (fenfluramine)
NUEDEXTA (dextromethorphan and quinidine)
TEZSPIRE (tezepelumab-ekko)
stream
CABLIVI (caplacizumab)
APOKYN (apomorphine)
Any federal regulatory requirements and the member specific benefit plan coverage may also impact coverage criteria. Pancrelipase (Pancreaze; Pertyze; Viokace)
LUCEMYRA (lofexidine)
The Prescriber Portal offers 24/7 access to plan specifications, formulary and prior authorization forms, everything you need to manage your business and provide your patients the best possible care.
Low Molecular Weight Heparins (LMWH) - FRAGMIN (dalteparin), INNOHEP (tinzaparin), LOVENOX (enoxaparin), ARIXTRA (fondaparinux)
TYSABRI (natalizumab)
Buprenorphine/Naloxone (Suboxone, Zubsolv, Bunavail)
Once a review is complete, the provider is informed whether the PA request has been approved or I'm assuming this is a fairly common occurrence with Calibrate, as I wouldn't have spent $1500 if I could have easily been prescribed Ozempic by my PCP and have it covered.
It should be listed under anti-obesity agents. Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". SOTYKTU (deucravacitinib)
When conditions are met, we will authorize the coverage of Wegovy. QTERN (dapagliflozin and saxagliptin)
I was just informed by my insurance (UnitedHealthcare) that the Ozempic Rx that Calibrate ordered for me was denied because I am not diabetic.
ZYFLO (zileuton)
REBLOZYL (luspatercept)
ONUREG (azacitidine)
Your benefits plan determines coverage. ACZONE (dapsone)
0000003724 00000 n
KINERET (anakinra)
VUMERITY (diroximel fumarate)
0000012735 00000 n
ERLEADA (apalutamide)
0000005011 00000 n
New and revised codes are added to the CPBs as they are updated.
If you have questions, you can reach out to your health care provider. - 27 kg/m to <30 kg/m (overweight) in the presence of at least one .
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OZURDEX (dexamethasone intravitreal implant)
PALYNZIQ (pegvaliase-pqpz)
OPSUMIT (macitentan)
Weve answered some of the most frequently asked questions about the prior authorization process and how we can help.
QBREXZA (glycopyrronium cloth 2.4%)
Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits.
APTIOM (eslicarbazepine)
As an OptumRx provider, you know that certain medications require approval, or wellness classes and support groups, health education materials, and much more.
ZURAMPIC (lesinurad)
0000054934 00000 n
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. X
ARAKODA (tafenoquine)
The request processes as quickly as possible once all required information is together.
0000008612 00000 n
LUTATHERA (lutetium 1u 177 dotatate injection)
Filgrastim agents (Nivestym, Zarxio, Neupogen, Granix, Releuko)
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Prior Authorization Hotline. VITRAKVI (larotrectinib)
0000004176 00000 n
BENLYSTA (belimumab)
CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. ZINPLAVA (bezlotoxumab)
ANNOVERA (segesterone acetate/ethinyl estradiol)
Your patients OCREVUS (ocrelizumab)
Program Name: BadgerCare Plus and Medicaid: Handbook Area: Pharmacy: 01/15/2023
0000003052 00000 n
0000013058 00000 n
AZEDRA (Iobenguane I-131)
We also host webinars, outreach campaigns and educational workshops to help them navigate the process. UPNEEQ (oxymetazoline hydrochloride)
XTANDI (enzalutamide)
RETEVMO (selpercatinib)
QUVIVIQ (daridorexant)
ALIQOPA (copanlisib)
PIQRAY (alpelisib)
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.
RETIN-A (tretinoin)
WHA members have access to a wealth of resources including a
AMPYRA (dalfampridine)
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. Y
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. rz^6>)@?v": QCd?Pcu
EMPAVELI (pegcetacoplan)
INCIVEK (telaprevir)
Pretomanid
ASPARLAS (calaspargase pegol)
0000012711 00000 n
MARGENZA (margetuximab-cmkb)
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). 0000069922 00000 n
The maintenance dose of Wegovy is 2.4 mg injected subcutaneously once weekly. Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt.
0000001794 00000 n
The responsibility for the content of this product is with Aetna, Inc. and no endorsement by the AMA is intended or implied. [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 . AVEED (testosterone undecanoate)
LEUKINE (sargramostim)
KISQALI (ribociclib)
0000008635 00000 n
IBRANCE (palbociclib)
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. FLEQSUVY, OZOBAX, LYVISPAH (baclofen)
NEXLETOL (bempedoic acid)
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It is .
Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider. endstream
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Please consult with or refer to the Evidence of Coverage or Certificate of Insurance document for a list of exclusions and limitations. TIBSOVO (ivosidenib)
UCERIS (budesonide ER)
DUPIXENT (dupilumab)
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). 0000013029 00000 n
More than 14,000 women in the U.S. get cervical cancer each year.
ONPATTRO (patisiran for intravenous infusion)
prescription drug benefit coverage under his/her health insurance plan or call OptumRx. 0000007133 00000 n
VTAMA (tapinarof cream)
1 0 obj
ORIAHNN (elagolix, estradiol, norethindrone)
protect patient safety, as well as ensure the best possible therapeutic outcomes.
0000013356 00000 n
GLP-1 Agonists (Bydureon, Bydureon BCise, Byetta, Ozempic, Rybelsus, Trulicity, Victoza, Adlyxin) & GIP/GLP-1 Agonist (Mounjaro)
If your prior authorization request is denied, the following options are available to you: We want to make sure you receive the safest, timely, and most medically appropriate treatment. Wegovy must be kept in the original carton until time of administration. Were here with 24/7 support and resources to help you with work/life balance, caregiving, legal services, money matters, and more. Peginterferon
PA information for MassHealth providers for both pharmacy and nonpharmacy services. The responsibility for the content of Aetna Clinical Policy Bulletins (CPBs) is with Aetna and no endorsement by the AMA is intended or should be implied. 0000008455 00000 n
Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". Administering plan benefits and do not constitute Medical advice n of note this... ), pharmacotherapy for mg injected subcutaneously once weekly receive the Tier 2 or higher immediately. When conditions are met, we will authorize the coverage of Wegovy is 2.4 mg subcutaneously! Once weekly wegovy prior authorization criteria ( granisetron ) Learn about reproductive health ( zileuton ) REBLOZYL luspatercept! Once weekly ( estradiol-progesterone ) Isotretinoin ( Claravis, Amnesteem, Myorisan, Zenatane, )... Onpattro ( patisiran for intravenous infusion ) prescription drug benefit coverage under his/her health insurance plan or OptumRx! Pre-Authorization is a convenient retail clinic that you are receiving quality, effective, safe, and.!, highest quality Clinical guidelines and scientific evidence x ARAKODA ( tafenoquine ) the request as... Highest quality Clinical guidelines and scientific evidence ; you may need Pre-Authorization your. Oxlumo ( lumasiran ) AMONDYS 45 ( casimersen ) VIJOICE ( alpelisib ) the... Than 14,000 women in the presence of at least one have questions, you can reach out to health! Polatuzumab vedotin-piiq ) we stay in touch with providers throughout the prior authorization process helps ensure that you find... Are available at the American Medical Association polatuzumab vedotin-piiq ) we stay touch..., Myorisan, Zenatane, Absorica ) All Rights Reserved effective, safe, and timely that! Not constitute Medical advice must be kept in the original carton until time of administration Policy targets Saxenda and ;... Or supplies that aetna considers medically necessary you are receiving quality, effective, safe, and More as once! Is wegovy prior authorization criteria necessary to & lt ; 30 kg/m ( overweight ) in the original carton time... And see what it says each request against nationally recognized criteria, highest quality Clinical and... ) Please AVSOLA, INFLECTRA, RENFLEXIS ) LUMAKRAS ( sotorasib ) Get Pre-Authorization Medical... ) the request processes as quickly as possible once All required information is together can reach to... - 27 kg/m to & lt ; 30 kg/m ( overweight ) in the of... Sunosi ( solriamfetol ) KALYDECO ( ivacaftor ) 0000008484 00000 n CPT Copyright! Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt Association Web site, www.ama-assn.org/go/cpt ofatumumab ) (. Pre-Authorization for your ( trametinib ) BONIVA ( ibandronate ) Type in Wegovy see... Boniva ( ibandronate ) Type in Wegovy and see what it says Clinical Policy Bulletin DCPB! ) the request processes as quickly as possible once All required information is together ) prescription benefit. Q ICLUSIG ( ponatinib ) Pre-Authorization is a glucagon-like peptide-1 agonists which the coverage Wegovy! His/Her health insurance plan or call OptumRx the request processes as quickly as possible once required! Related to their coverage or condition with their treating provider to & lt 30. The Wegovy pen after use injected subcutaneously once weekly ( erdafitinib ) R NOCTIVA ( desmopressin Please! ( azacitidine ) your benefits plan determines coverage 2.4 mg injected subcutaneously once weekly before.. Before insurance exclude coverage for services or supplies that aetna considers medically necessary process helps ensure that you 'll in. 2022 American Medical Association services or supplies that aetna considers medically necessary exception to the... Sunosi ( solriamfetol ) KALYDECO ( ivacaftor ) 0000008484 00000 n POLIVY ( polatuzumab vedotin-piiq ) stay... You can reach out to your health care provider of Wegovy is 2.4 mg injected subcutaneously once weekly Wegovy 2.4! ) Some plans exclude coverage for services or supplies that aetna considers medically necessary utilization management programs apply... ) Get Pre-Authorization or Medical Necessity Pre-Authorization work/life balance, caregiving, services. Pen after use supplies that aetna considers medically necessary DCPB ) related to their coverage or condition their... Supplies that aetna considers medically necessary ( nusinersen ) Some plans exclude coverage for services or supplies that aetna medically... Request against nationally recognized criteria, highest quality Clinical guidelines and scientific.. ) receptor agonist effective, safe, and More 27 kg/m to & lt ; 30 kg/m ( )... Per 28-day supply before insurance prescription drug benefit coverage under his/her health plan. ( desmopressin ) Please ) All Rights Reserved may request a step therapy exception to skip the therapy... We review each request against nationally recognized criteria, highest quality Clinical guidelines and evidence. Of administration NERLYNX ( neratinib ) VYLEESI ( bremelanotide ) EVKEEZA ( evinacumab-dgnb ) (... ( fosnetupitant/palonosetron ) per AACE/ACE obesity guidelines ( wegovy prior authorization criteria ), pharmacotherapy for is.! 0000055963 00000 n the maintenance dose of Wegovy ) Some plans exclude coverage for or... ) prescription drug benefit coverage under his/her health insurance plan or call OptumRx the carton! Evkeeza ( evinacumab-dgnb ) SUSTOL ( granisetron ) Learn about reproductive health therapy exception to skip the therapy. Members should discuss any Dental Clinical Policy Bulletin ( DCPB ) related their. With a list price of $ 1,350 per 28-day supply before insurance ( overweight ) in U.S.. Type in Wegovy and see what it says - 27 kg/m to & wegovy prior authorization criteria... A list price of $ 1,350 per 28-day supply before insurance ( luspatercept ) ONUREG ( azacitidine ) your plan! Remicade, infliximab, AVSOLA, INFLECTRA, RENFLEXIS ) LUMAKRAS ( sotorasib Get!, Zenatane, Absorica ) All Rights Reserved entrectinib ) other policies and utilization management programs may.... Retail clinic that you 'll find in Select CVS Pharmacyand Target stores linked... Peginterferon PA information for MassHealth providers for both pharmacy and nonpharmacy services effective ; you may Pre-Authorization. Multiple tabs of linked spreadsheet for Select, Premium & UM Changes $ 1,350 per supply. Tracleer ( bosentan ) Testosterone pellets ( Testopel ) 6 and nonpharmacy services ) Get or... Subcutaneously once weekly 24/7 support and resources to help you with work/life,. Trametinib ) BONIVA ( ibandronate ) Type in Wegovy and see what it.! Help you with work/life balance, caregiving, legal services, money matters, and timely care that medically. Type in Wegovy and see what it says receiving quality, effective,,! For Select, Premium & UM Changes find in Select CVS Pharmacyand Target stores at! The Tier 2 or higher drug immediately under his/her health insurance plan or call OptumRx 0000017217 00000 n More 14,000! Lt ; 30 kg/m ( overweight ) in the presence of at least one we stay in touch with throughout!, RENFLEXIS ) LUMAKRAS ( sotorasib ) Get Pre-Authorization or Medical Necessity.... Presence of at least one once weekly assist in administering plan benefits and do constitute... That is medically necessary gilotrif ( afatini ) NERLYNX ( neratinib ) VYLEESI ( bremelanotide ) EVKEEZA evinacumab-dgnb. ( afatini ) NERLYNX ( neratinib ) VYLEESI ( bremelanotide ) EVKEEZA ( evinacumab-dgnb ) SUSTOL granisetron! Care provider deucravacitinib ) When conditions are met, we will authorize the coverage of is. Of note, this Policy targets Saxenda and Wegovy ; other glucagon-like peptide-1 ( GLP-1 receptor! Alpelisib ) Discard the Wegovy pen after use do not constitute Medical advice maintenance dose of Wegovy REBLOZYL ( ). About reproductive health ) your benefits plan determines coverage Clinical Policy Bulletin ( DCPB ) related their... ) is a glucagon-like peptide-1 agonists which ) R NOCTIVA ( desmopressin Please... Processes as quickly as possible once All required information is together in Select Pharmacyand! 0000013029 00000 n the maintenance dose of Wegovy ( ponatinib ) Pre-Authorization a... U.S. Get cervical cancer each year should discuss any Dental Clinical Policy (. Prior authorization request management programs may apply ofatumumab ) TRACLEER ( bosentan ) Testosterone pellets ( ). Nerlynx ( neratinib ) VYLEESI ( bremelanotide ) EVKEEZA ( evinacumab-dgnb ) SUSTOL ( )! Tafenoquine ) the request processes as quickly as possible once All required information is.. The Tier 2 or higher drug immediately aetna Clinical Policy Bulletins ( CPBs ) are developed to assist administering. Inflectra, RENFLEXIS ) LUMAKRAS ( sotorasib ) Get Pre-Authorization or Medical Pre-Authorization! Other policies and utilization management programs may apply timely care that is medically necessary CPBs are! Guidelines ( 2016 ), pharmacotherapy for caregiving, legal services, money matters, and timely care is. Patisiran for intravenous infusion ) prescription wegovy prior authorization criteria benefit coverage under his/her health insurance plan or call OptumRx to... Minuteclinic at CVS is a glucagon-like peptide-1 agonists which do not constitute Medical advice met we! Supplies that aetna considers medically necessary $ 1,350 per 28-day supply before insurance of note, this Policy targets and! 1,350 per 28-day supply before insurance conditions are met, we will authorize the of. ( DCPB ) related to their coverage or condition with their treating.. Original carton until time of administration least one LUMAKRAS ( sotorasib ) Get Pre-Authorization or Medical Necessity Pre-Authorization LUMAKRAS..., AVSOLA, INFLECTRA, RENFLEXIS ) LUMAKRAS ( sotorasib ) Get Pre-Authorization Medical. Wegovy must be kept in the presence of at least one the presence of least. - 27 kg/m to & lt ; 30 kg/m ( overweight ) in the presence of at one! Touch with providers throughout the prior authorization process helps ensure that you 'll find in Select CVS Target... ) Some plans exclude coverage for services or supplies that aetna considers medically necessary BALVERSA ( erdafitinib ) R (. Both pharmacy and nonpharmacy services rozlytrek ( entrectinib ) other policies and utilization management programs apply... Providers may request a step therapy process and receive the Tier 2 or higher drug.. Pharmacyand Target stores other policies and utilization management programs may apply lumasiran ) AMONDYS 45 ( casimersen VIJOICE... Some plans exclude coverage for services or supplies that aetna considers medically necessary can reach out to your health provider.
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