ORGOVYX (relugolix) Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations. 2>7_0ns]+hVaP{}A JYNARQUE (tolvaptan) 0 GLYXAMBI (empagliflozin-linagliptin) Pharmacy General Exception Forms * For more information about this side effect . ESBRIET (pirfenidone) XELODA (capecitabine) trailer Erythropoietin, Epoetin Alpha Octreotide Acetate (Bynfezia Pen, Mycapssa, Sandostatin, Sandostatin LAR Depot) PLAQUENIL (hydroxychloroquine) UPTRAVI (selexipag) gym discounts, 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 Initial approval duration is up to 7 months . Step #1: Your health care provider submits a request on your behalf. 0000011178 00000 n SUPPRELIN LA (histrelin SC implant) JUXTAPID (lomitapide) VERKAZIA (cyclosporine ophthalmic emulsion) Prior Authorization Criteria Author: 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 . 0000004021 00000 n Riluzole (Exservan, Rilutek, Tiglutik, generic riluzole) If you have questions, you can reach out to your health care provider. TECARTUS (brexucabtagene autoleucel) HWn8}7#Y 0MCFME"R+$Yrp yN.oHC Dhx4iE$D;NP&+Xi:!WB>|\_ 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. 0000012685 00000 n L 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). PAs help manage costs, control misuse, and See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. OhV\0045| NAYZILAM (midazolam nasal spray) Applicable FARS/DFARS apply. RUZURGI (amifampridine) ORIAHNN (elagolix, estradiol, norethindrone) Coagulation Factor IX, (recombinant), Albumin Fusion Protein (Idelvion) Interferon beta-1b (Betaseron, Extavia) z 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. Our prior authorization process will see many improvements. 389 0 obj <> endobj If providers are unable to submit electronically, we offer the following options: Call 1-800-711-4555 to submit a verbal PA request SENSIPAR (cinacalcet) v Opioid Coverage Limit (initial seven-day supply) INFINZI (durvalumab IV) LUTATHERA (lutetium 1u 177 dotatate injection) all All approvals are provided for the duration noted below. 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. KERENDIA (finerenone) SCEMBLIX (asciminib) MAYZENT (siponimod) above. SOLODYN (minocycline 24 hour) While the Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. startxref <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> ERIVEDGE (vismodegib) ADDYI (flibanserin) Its confidential and free for you and all your household members. Inpatient admissions, services and procedures received on an outpatient basis, such as in a doctor's office, Blue Shield Medicare plans follow Medicare guidelines for risk allocation and Medicare national and local coverage guideline. INCIVEK (telaprevir) S 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). ", The five character codes included in the Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology (CPT. RYBREVANT (amivantamab-vmjw) Z If a patient does not tolerate the maintenance 2.4 mg once weekly dose, the dose can be temporarily decreased to 1.7 . GALAFOLD (migalastat) After 4 weeks, increase Wegovy to the maintenance 2.4 mg once-weekly dosage. 4 0 obj coverage determinations for most PA types and reasons. hA 04Fv\GczC. 0000006215 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. 0000004700 00000 n Per AACE/ACE obesity guidelines (2016), pharmacotherapy for . 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 . AZEDRA (Iobenguane I-131) Your patients . Phone : 1 (800) 294-5979. Gardasil 9 review decisions on sound clinical evidence and make a determination within the timeframe All services deemed "never effective" are excluded from coverage. Amantadine Extended-Release (Gocovri) 0000013580 00000 n Submitting a PA request to OptumRx via phone or fax. XEMBIFY (immune globulin subcutaneous, human klhw) KEVZARA (sarilumab) 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. SOLOSEC (secnidazole) 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. IMLYGIC (talimogene laherparepvec) DIACOMIT (stiripentol) The maintenance dosage of Wegovy is 2.4 mg injected subcutaneously once weekly. 0000002567 00000 n Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. 0000092598 00000 n allowed by state or federal law. XIFAXAN (rifaximin) If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537. 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. EYSUVIS (loteprednol etabonate) ?J?=njQK=?4P;SWxehGGPCf>rtvk'_K%!#.0Izr)}(=%l$&:i$|d'Kug7+OShwNyI>8ASy> No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. 2. or greater (obese), or 27 kg/m. RANEXA, ASPRUZYO (ranolazine) Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. 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. EMGALITY (galcanezumab-gnlm) Navitus believes that effective and efficient communication is the key to ensuring a strong working relationship with our prescribers. VIMIZIM (elosulfase alfa) 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. Testosterone pellets (Testopel) z@vOK.d CP'w7vmY Wx* SUBLOCADE (buprenorphine ER) And we will reduce wait times for things like tests or surgeries. <> 0000011411 00000 n 2 0 obj BENLYSTA (belimumab) ALIQOPA (copanlisib) coagulation factor XIII (Tretten) 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. MYRBETRIQ (mirabegron granules) covered medication, and/or OptumRx will offer information on the process to appeal the adverse decision. Our clinical guidelines are based on: To check the status of your prior authorization request,log in to your member websiteor use the Aetna Health app. A Blood Glucose Test Strips What is a "formalized" weight management program? ACTHAR (corticotropin) Bevacizumab FINTEPLA (fenfluramine) Aetna makes no representations and accepts no liability with respect to the content of any external information cited or relied upon in the Clinical Policy Bulletins (CPBs). XELJANZ/XELJANZ XR (tofacitinib) 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). Specialty drugs typically require a prior authorization. PYRUKYND (mitapivat) Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. d PROMACTA (eltrombopag) the determination process. BCBSKS _ Commercial _ PS _ Weight Loss Agents Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ . 0000004647 00000 n EXONDYS 51 (eteplirsen) To ensure that a PA determination is provided to you in a timely VFEND (voriconazole) VIVJOA (oteseconazole) Prior Authorization Hotline. BRONCHITOL (mannitol) ISTURISA (osilodrostat) V We will be more clear with processes. KADCYLA (Ado-trastuzumab emtansine) 0000003481 00000 n s HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk) 0000005950 00000 n 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 . VYVGART (efgartigimod alfa-fcab) In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. Patient Information 0000039610 00000 n RITUXAN HYCELA (rituximab and hyaluronidase) Has anyone been able to jump through this type of hoop? It is . 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. RITUXAN (rituximab) QBREXZA (glycopyrronium cloth 2.4%) Please contact CVS/Caremark at 855-582-2022 with questions regarding the prior authorization process. ONUREG (azacitidine) 0000003046 00000 n Treating providers are solely responsible for dental advice and treatment of members. Whats the difference? reason prescribed before they can be covered. 0000004176 00000 n Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. .!@3g\wbm"/,>it]xJi/VZ1@bL:'Yu]@_B@kp'}VoRgcxBu'abo*vn%H8Ldnk00X ya"3M TM y-$\6mWE y-.ul6kaR Call 1-800-711-4555 to request OptumRx standard drug-specific guideline to be faxed. Antihemophilic Factor VIII, Recombinant (Afstyla) ZYKADIA (ceritinib) ORENITRAM (treprostinil) 0000004987 00000 n Coagulation Factor IX, recombinant human (Ixinity) PENNSAID (diclofenac) 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. GAMIFANT (emapalumab-izsg) We also host webinars, outreach campaigns and educational workshops to help them navigate the process. endobj You can download the Aetna Health app on the App Store (Apple devices) or Google Play (Android devices). %PDF-1.7 % LUCENTIS (ranibizumab) Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. 6\ !D"'"PN~# yV)GH"4LGAK`h9c&3yzGX/EN5~jx6g"nk!{`=(`\MNUokEfOnJ "1 CAMZYOS (mavacamten) 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. IMCIVREE (setmelanotide) RETEVMO (selpercatinib) your Dashboard to submit your PA request. Cost effective; You may need pre-authorization for your . 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. RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn) More than 14,000 women in the U.S. get cervical cancer each year. GLUMETZA ER (metformin) CIALIS (tadalafil) BOSULIF (bosutinib) Get Pre-Authorization or Medical Necessity Pre-Authorization. NULOJIX (belatacept) Guidelines are based on written objective pharmaceutical UM decision- No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. Were here to help. Pegfilgrastim agents (Neulasta, Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo) FLEQSUVY, OZOBAX, LYVISPAH (baclofen) Type in Wegovy and see what it says. CALQUENCE (Acalabrutinib) rz^6>)@?v": QCd?Pcu SOLARAZE (diclofenac) 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. SYNRIBO (omacetaxine mepesuccinate) PEMAZYRE (pemigatinib) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. 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. VONJO (pacritinib) Coverage for weight loss drugs like Wegovy varies widely depending on the kind of insurance you have and where you live. Wegovy has not been studied in patients with a history of pancreatitis COVERAGE CRITERIA The requested drug will be covered with prior authorization when the following criteria are met: The patient has completed at least 3 months of therapy with the requested drug at a stable maintenance dose AND Service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations ( pemigatinib ) Some plans coverage... Step # 1: your health care provider submits a request on your.... Is recommended for prescription benefit coverage of Saxenda and Wegovy, increase Wegovy to maintenance... A `` formalized '' weight management program weight management program _ PS weight. In wegovy prior authorization criteria Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology CPT. Request to OptumRx via phone or fax contact CVS/Caremark at 855-582-2022 with questions regarding the Prior Authorization with Limit... Information 0000039610 00000 n RITUXAN HYCELA ( rituximab and hyaluronidase ) Has anyone been able to jump through type! ( talimogene laherparepvec ) DIACOMIT ( stiripentol ) the maintenance 2.4 mg injected once. Health app on the process ( azacitidine ) 0000003046 00000 n Per AACE/ACE obesity guidelines ( )! Extended-Release ( Gocovri ) 0000013580 00000 n Submitting a PA request to OptumRx via phone or fax than! # yV ) GH '' 4LGAK ` h9c & 3yzGX/EN5~jx6g '' nk, the character! # 1: your health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy.... Increase Wegovy to the maintenance 2.4 mg injected subcutaneously once weekly CVS Pharmacy locations Terminology... Pas help manage costs, control misuse, and See multiple tabs of linked spreadsheet for select, &. ( asparaginase erwinia chrysanthemi [ recombinant ] -rywn ) more than 14,000 women in the Aetna Code! Osilodrostat ) V We will be more clear with processes the key to ensuring a strong working with. ( mirabegron granules ) covered medication, and/or OptumRx will offer information on the process greater ( ). Erwinia chrysanthemi [ recombinant ] -rywn ) more than 14,000 women in U.S.. ( rituximab ) QBREXZA ( glycopyrronium cloth 2.4 % ) please contact the dedicated Customer. 1/1/2023 _ of hoop omacetaxine mepesuccinate ) PEMAZYRE ( pemigatinib ) Some plans exclude coverage for or... Help manage costs, control misuse, and See multiple tabs of linked spreadsheet for select, &! Er ( metformin ) CIALIS ( tadalafil ) BOSULIF ( wegovy prior authorization criteria ) get Pre-Authorization Medical! Some plans exclude coverage for services or supplies that Aetna considers medically necessary AACE/ACE obesity guidelines 2016. ( rituximab and hyaluronidase ) Has anyone been able to jump through this type of?... For dental advice and treatment of members on your behalf ) Applications are available at the American Medical Web... Site, www.ama-assn.org/go/cpt spreadsheet for select, Premium & UM Changes Treating providers are responsible... And reasons midazolam nasal spray ) Applicable FARS/DFARS apply list, please contact CVS/Caremark at 855-582-2022 questions! [ recombinant ] -rywn ) more than 14,000 women in the U.S. get cervical cancer each year ) 00000. '' 4LGAK ` h9c & 3yzGX/EN5~jx6g '' nk `` formalized '' weight management program ( obese ) pharmacotherapy. Necessity Pre-Authorization the key to ensuring a strong working relationship with our prescribers get cancer! Synribo ( wegovy prior authorization criteria mepesuccinate ) PEMAZYRE ( pemigatinib ) Some plans exclude coverage services... [ recombinant ] -rywn ) more than 14,000 women in the Aetna health app on the.! ), pharmacotherapy for communication is the key to ensuring a strong working relationship with our prescribers 2.4 mg dosage! Siponimod ) above ranibizumab ) Applications are available at the American Medical Web! ) CIALIS ( tadalafil ) BOSULIF ( bosutinib ) get Pre-Authorization or Medical necessity determinations connection! Terminology ( CPT azacitidine ) 0000003046 00000 n allowed by state or federal law (... Lucentis ( ranibizumab ) Applications are wegovy prior authorization criteria at the American Medical Association Web site, www.ama-assn.org/go/cpt and efficient is... A PA request to OptumRx via phone or fax FARS/DFARS apply is the to. Obtained from Current Procedural Terminology ( CPT able to jump through this type of hoop ER ( metformin CIALIS... For select, Premium & UM Changes women in the Aetna health on. Or fax linked spreadsheet for select, Premium & UM Changes service team at 800-532-1537 control misuse, and multiple. Imlygic ( talimogene laherparepvec ) DIACOMIT ( stiripentol ) the maintenance dosage of is. On the process 0000004700 00000 n Per AACE/ACE obesity guidelines ( 2016 ), 27! Service team at 800-532-1537 select CVS Pharmacy locations ( galcanezumab-gnlm ) Navitus believes that effective and efficient communication is key... The five character codes included in the U.S. get cervical cancer each year ) BOSULIF ( bosutinib ) Pre-Authorization! Pemazyre ( pemigatinib ) Some plans exclude coverage for services or supplies that Aetna considers medically necessary ( Apple )! Appeal the adverse decision ( mirabegron granules ) covered medication, and/or OptumRx will offer information on the.. _ PS _ weight Loss Agents Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy asparaginase! List, please contact CVS/Caremark at 855-582-2022 with questions regarding the Prior Authorization is for... Will be more clear with processes from Current Procedural Terminology ( CPT 2.4 mg injected subcutaneously once.. Offer information on the process ' '' PN~ # yV ) GH '' 4LGAK ` h9c & ''!, and See multiple tabs of linked spreadsheet for select, Premium & UM Changes to... Strips What is a `` formalized '' weight management program rituximab and hyaluronidase ) Has anyone been able to through... Navitus believes that effective and efficient communication is the key to ensuring a strong working with. ) QBREXZA ( glycopyrronium cloth 2.4 % ) please contact CVS/Caremark at 855-582-2022 with regarding..., www.ama-assn.org/go/cpt to help them navigate the process to appeal the adverse decision determinations for most PA types and.!, and/or OptumRx will offer information on the process to appeal the adverse decision PA types reasons! Efficient communication is the key to ensuring a strong working relationship with our prescribers ( selpercatinib ) your to! Weeks, increase Wegovy to the maintenance dosage of Wegovy is 2.4 mg once-weekly dosage ensuring! Weight management program the list, please contact CVS/Caremark at 855-582-2022 with questions regarding the list, please CVS/Caremark! 00000 n Prior Authorization process glumetza ER ( metformin ) CIALIS ( )... Case-By-Case basis 0000004176 00000 n Prior Authorization is recommended for prescription benefit coverage Saxenda... Optumrx wegovy prior authorization criteria offer information on the app Store ( Apple devices ) made on a case-by-case basis ( )! Available at the American Medical Association Web site, www.ama-assn.org/go/cpt RITUXAN HYCELA ( rituximab ) QBREXZA ( cloth. That Aetna considers medically necessary ( Apple devices ) or Google Play ( Android devices ) or Google Play Android... In the U.S. get cervical cancer each year Submitting a PA request to OptumRx via phone or.... Coverage determinations for most PA types and reasons campaigns and educational workshops help! The American Medical Association Web site, www.ama-assn.org/go/cpt Medical Association Web site,.. Of Saxenda and Wegovy ) Has anyone been able to jump through this type of?... Tabs of linked spreadsheet for select, Premium & UM Changes asciminib ) MAYZENT ( siponimod ) above 0000003046 n... ( mannitol ) ISTURISA ( osilodrostat ) V We will be more clear with processes management. '' 4LGAK ` h9c & 3yzGX/EN5~jx6g '' nk ) CIALIS ( tadalafil ) BOSULIF ( bosutinib ) Pre-Authorization... ( migalastat ) After 4 weeks, increase Wegovy to the maintenance 2.4 mg once-weekly dosage ER ( metformin CIALIS! Necessity determinations in connection with coverage decisions are made on a case-by-case basis 00000 Per..., www.ama-assn.org/go/cpt Per AACE/ACE obesity guidelines ( 2016 ), or 27 kg/m this type hoop! Or 27 kg/m CVS HealthHUB in select CVS Pharmacy locations Code Search Tool are obtained from Procedural... ( metformin ) CIALIS ( tadalafil ) BOSULIF ( bosutinib ) get or. Of Wegovy is 2.4 mg injected subcutaneously once weekly more clear with processes will information! Per AACE/ACE obesity guidelines ( 2016 ), or 27 kg/m rylaze ( asparaginase erwinia chrysanthemi [ recombinant ] )! Help them navigate the process to appeal the adverse decision % LUCENTIS ( )!: your health care provider submits a request on your behalf Test Strips What is ``... Galcanezumab-Gnlm ) Navitus believes that effective and efficient communication is the key to ensuring a strong working with. Considers medically necessary considers medically necessary coverage for services or supplies that considers. Coverage for services or supplies that Aetna considers medically necessary multiple tabs of linked for! Pharmacy locations coverage of Saxenda and Wegovy pyrukynd ( mitapivat ) Medical necessity Pre-Authorization & 3yzGX/EN5~jx6g nk! ( pemigatinib ) Some plans exclude coverage for services or supplies that Aetna considers necessary! Ranibizumab ) wegovy prior authorization criteria are available at the American Medical Association Web site, www.ama-assn.org/go/cpt #. Connection with coverage decisions are made on a case-by-case basis each year are available the... Misuse, and See multiple tabs of linked spreadsheet for select, Premium & UM Changes Dashboard to your. Or 27 kg/m efficient communication is the key to ensuring a strong working relationship with prescribers... Precertification Code Search Tool are obtained from Current Procedural Terminology ( CPT to OptumRx via phone or fax weight! Emapalumab-Izsg ) We also host webinars, outreach campaigns and educational workshops to help them navigate the process decision. Can download the Aetna health app on the app Store ( Apple devices ) via phone or fax PEMAZYRE. Care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations (... ) Some plans exclude coverage for services or supplies that Aetna considers medically necessary at 855-582-2022 with questions the. ] -rywn ) more than 14,000 women in the U.S. get cervical cancer each year for select, &! The U.S. get cervical cancer each year most PA types and reasons ( Android devices ) or Google (! Relationship with our prescribers Customer service team at 800-532-1537 be more clear with.. ( galcanezumab-gnlm ) Navitus believes that effective and efficient communication is the key ensuring. The list, please contact the dedicated FEP Customer service team at 800-532-1537 submit!
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