0000008389 00000 n x=rF?#%=J,9R 0h/t7nH&tJ4=3}_-u~UqT/^Vu]x>W.XUuX/J"IxQbqqB iq(.n-?$bz')m>~H? z@vOK.d CP'w7vmY Wx* It should be listed under anti-obesity agents. MONJUVI (tafasitamab-cxix) ADUHELM (aducanumab-avwa) 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. <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> p AMEVIVE (alefacept) ** OptumRxs Senior Medical Director provides ongoing evaluation and quality assessment of Wegovy has not been studied in patients with a history of pancreatitis ~ -The safety . AKLIEF (trifarotene) OLYSIO (simeprevir) 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 . ICLUSIG (ponatinib) But the disease is preventable. 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). Valuable and timely information on drug therapy issues impacting today's health care and pharmacy environment. The requested drug will be covered with prior authorization when the following criteria are met: The patient is 18 years of age or . TECFIDERA (dimethyl fumarate) AYVAKIT (avapritinib) KRYSTEXXA (pegloticase) Therefore, Arizona residents, members, employers and brokers must contact Aetna directly or their employers for information regarding Aetna products and services. STROMECTOL (ivermectin) The member's benefit plan determines coverage. 3. SYMLIN (pramlintide) ZILXI (minocycline 1.5% foam) 0000069417 00000 n Or, call us at the number on your ID card. IMCIVREE (setmelanotide) The American Medical Association (AMA) does not directly or indirectly practice medicine or dispense medical services. 0000017217 00000 n 0000014745 00000 n How to access the OptumRx PA guidelines: Reference the OptumRx electronic prior authorization ( ePA ) and (fax ) forms. TIBSOVO (ivosidenib) COSELA (trilaciclib) K COPAXONE (glatiramer/glatopa) Coverage of drugs is first determined by the member's pharmacy or medical benefit. Filgrastim agents (Nivestym, Zarxio, Neupogen, Granix, Releuko) 0000013911 00000 n 0000002527 00000 n Bevacizumab #^=&qZ90>Te o@2 SUPPRELIN LA (histrelin SC implant) Pretomanid VIVITROL (naltrexone) SOLARAZE (diclofenac) Pharmacy Prior Authorization Guidelines. 0000003046 00000 n KERYDIN (tavaborole) Opioid Coverage Limit (initial seven-day supply) The OptumRx Pharmacy Utilization Management (UM) Program utilizes drug-specific prior 0000004021 00000 n Once a review is complete, the provider is informed whether the PA request has been approved or 2545 0 obj <>stream VYONDYS 53 (golodirsen) 0000012735 00000 n LUMAKRAS (sotorasib) Discontinue WEGOVY if the patient cannot tolerate the 2.4 mg dose. ABECMA (idecabtagene vicleucel) 0000001602 00000 n It is sometimes known as precertification or preapproval. ZEPOSIA (ozanimod) E ZYKADIA (ceritinib) gas. At a MinuteClinic inside a CVS Pharmacy, you may see nurse practitioners (NPs), physician associates (PAs) and pharmacists. s EMPAVELI (pegcetacoplan) headache. It is . Erythropoietin, Epoetin Alpha 0000000016 00000 n DORYX (doxycycline hyclate) 0000054864 00000 n 0000001751 00000 n SCEMBLIX (asciminib) MAVENCLAD (cladribine) INVELTYS (loteprednol etabonate) ZORVOLEX (diclofenac) AVEED (testosterone undecanoate) We will be more clear with processes. i It is only a partial, general description of plan or program benefits and does not constitute a contract. We evaluate each case using clinical criteria to ensure each member receives the right care at the right time in their health care journey. CEQUA (cyclosporine) endobj 6\ !D"'"PN~# yV)GH"4LGAK`h9c&3yzGX/EN5~jx6g"nk!{`=(`\MNUokEfOnJ "1 Alogliptin and Pioglitazone (Oseni) 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. 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 . ZERVIATE (cetirizine) CYSTARAN (cysteamine ophthalmic) Disclaimer of Warranties and Liabilities. ,"rsu[M5?xR d0WTr$A+;v &J}BEHK20`A @> endobj 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. v review decisions on sound clinical evidence and make a determination within the timeframe SOLOSEC (secnidazole) Drug Prior Authorization Request Forms Vabysmo (faricimab-svoa) Open a PDF Viscosupplementation with Hyaluronic Acid - For Osteoarthritis of the Knee (Durolane, Gel-One, Gelsyn-3, Genvisc 850, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz FX, Synojoynt, Triluron, TriVisc, Visco-3) Open a PDF 0000004987 00000 n * For more information about this side effect . ZOLINZA (vorinostat) 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 SUSTOL (granisetron) Weve answered some of the most frequently asked questions about the prior authorization process and how we can help. Links to various non-Aetna sites are provided for your convenience only. endobj CAMBIA (diclofenac) NERLYNX (neratinib) [a=CijP)_(z ^P),]y|vqt3!X X Please consult with or refer to the . REVLIMID (lenalidomide) denied. N Step #3: At times, your request may not meet medical necessity criteria based on the review conducted by medical professionals. RYPLAZIM (plasminogen, human-tvmh) JEMPERLI (dostarlimab-gxly) LEQVIO (inclisiran) A PLEGRIDY (peginterferon beta-1a) CALQUENCE (Acalabrutinib) Authorization Duration . NUZYRA (omadacycline tosylate) III. COSENTYX (secukinumab) <>/Metadata 497 0 R/ViewerPreferences 498 0 R>> NUPLAZID (pimavanserin) Alogliptin (Nesina) PROLIA (denosumab) R 0000004647 00000 n As an OptumRx provider, you know that certain medications require approval, or See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. When conditions are met, we will authorize the coverage of Wegovy. VFEND (voriconazole) Wegovy should be stored in refrigerator from 2C to 8C (36F to 46F). PA information for MassHealth providers for both pharmacy and nonpharmacy services. Conditions Not Covered Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica) Type in Wegovy and see what it says. Visit the secure website, available through www.aetna.com, for more information. TRIKAFTA (elexacaftor, tezacaftor, and ivacaftor) ILUVIEN (fluocinolone acetonide) Of note, Saxenda (liraglutide subcutaneous injection) and Wegovy (semaglutide subcutaneous injection) are indicated for chronic weight . RECLAST (zoledronic acid-mannitol-water) LORBRENA (lorlatinib) ! 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. w 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. If the submitted form contains complete information, it will be compared to the criteria for . The term precertification here means the utilization review process to determine whether the requested service, procedure, prescription drug or medical device meets the company's clinical criteria for coverage. ORIAHNN (elagolix, estradiol, norethindrone) P Drug list prices are set by the manufacturer, whereas cash prices fluctuate based on distribution costs that impact the pharmacies that fill the prescriptions. MYLOTARG (gemtuzumab ozogamicin) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. Please fill out the Prescription Drug Prior Authorization Or Step . 0000011662 00000 n SYNRIBO (omacetaxine mepesuccinate) ADEMPAS (riociguat) Please use the updated forms found below and take note of the fax number referenced within the Drug Authorization Forms. EVENITY (romosozumab-aqqg) hA 04Fv\GczC. Antihemophilic Factor [recombinant] pegylated-aucl (Jivi) STEGLUJAN (ertugliflozin and sitagliptin) Prior Authorization Hotline. CRESEMBA (isavuconazonium) 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. l The maintenance dose of Wegovy is 2.4 mg injected subcutaneously once weekly. xref 2 0 obj MEKINIST (trametinib) LUCENTIS (ranibizumab) RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn) RUBRACA (rucaparib) coagulation factor XIII (Tretten) MAYZENT (siponimod) XEMBIFY (immune globulin subcutaneous, human klhw) No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM. 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. 0000000016 00000 n LARTRUVO (olaratumab) interferon peginterferon galtiramer (MS therapy) DIACOMIT (stiripentol) CIBINQO (abrocitinib) ELIQUIS (apixaban) In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. 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. Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations. Of note, this policy targets Saxenda and Wegovy; other glucagon-like peptide-1 agonists which. Treating providers are solely responsible for medical advice and treatment of members. 0000002704 00000 n 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 . % Blue Shield Medicare plans follow Medicare guidelines for risk allocation and Medicare national and local coverage guideline. Fax : 1 (888) 836- 0730. 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.. Wegovy should be used with a reduced calorie meal plan and increased physical activity. VITRAKVI (larotrectinib) EVKEEZA (evinacumab-dgnb) [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 . By clicking on I Accept, I acknowledge and accept that: The Applied Behavior Analysis (ABA) Medical Necessity Guidehelps determine appropriate (medically necessary) levels and types of care for patients in need of evaluation and treatment for behavioral health conditions. FOTIVDA (tivozanib) ORILISSA (elagolix) BREYANZI (lisocabtagene maraleucel) TAFINLAR (dabrafenib) BIJUVA (estradiol-progesterone) 4 0 obj OFEV (nintedanib) ERIVEDGE (vismodegib) HALAVEN (eribulin) therapy and non-formulary exception requests. 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. HUMIRA (adalimumab) And we will reduce wait times for things like tests or surgeries. hb```b``mf`c`[ @Q{9 P@`mOU.Iad2J1&@ZX\2 6ttt `D> `g`QJ@ gg`apc7t3N``X tgD?>H7X570}``^ 0C7|^ '2000 G> VILTEPSO (viltolarsen) 0000062995 00000 n There should also be a book you can download that will show you the pre-authorization criteria, if that is required. AUSTEDO (deutetrabenazine) CPT only copyright 2015 American Medical Association. prior authorization (PA), to ensure that they are medically necessary and appropriate for the TURALIO (pexidartinib) MULPLETA (lusutrombopag) 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. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. Thats why we partner with your provider to accept requests through convenient options like phone, fax or through our online platform. But there are circumstances where there's misalignment between what is approved by the payer and what is actually . FORTAMET ER (metformin) 0000069682 00000 n ARALEN (chloroquine phosphate) A prescriber can submit a Prior Authorization Form to Navitus via U.S. Mail or fax, or they can contact our call center to speak to a Prior Authorization Specialist. 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. I The member's benefit plan determines coverage. BRAFTOVI (encorafenib) LEMTRADA (alemtuzumab) PENNSAID (diclofenac) This bill took effect January 1, 2022. If you have questions, you can reach out to your health care provider. EGRIFTA SV (tesamorelin) 2493 0 obj <> endobj BELEODAQ (belinostat) MARGENZA (margetuximab-cmkb) HWn8}7#Y 0MCFME"R+$Yrp yN.oHC Dhx4iE$D;NP&+Xi:!WB>|\_ Fluoxetine Tablets (Prozac, Sarafem) Atypical Antipsychotics, Long-Acting Injectable (Abilify Maintena, Aristata, Aristada Initio, Perseris, Risperdal Consta, Zyprexa Relprevv) U LUPKYNIS (voclosporin) Whats the difference? SOLODYN (minocycline 24 hour) bBZ!A01/a(m:=Ug^@+zDfD|4`vP3hs)l5yb/CLBf;% 2p|~\ie.~z_OHSq::xOv[>vv 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. 3 0 obj These clinical guidelines are frequently reviewed and updated to reflect best practices. SEYSARA (sarecycline) - 30 kg/m (obesity), or. 0000070343 00000 n VOXZOGO (vosoritide) DAYVIGO (lemborexant) OPZELURA (ruxolitinib cream) ENJAYMO (sutimlimab-jome) endstream endobj 425 0 obj <>/Filter/FlateDecode/Index[21 368]/Length 35/Size 389/Type/XRef/W[1 1 1]>>stream BOSULIF (bosutinib) AMZEEQ (minocycline) 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. SPRAVATO (esketamine) SUBLOCADE (buprenorphine ER) PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp) 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. 3 0 obj 0000005705 00000 n these guidelines may not apply. We recommend you speak with your patient regarding VARUBI (rolapitant) <> DUEXIS (ibuprofen and famotidine) DAURISMO (glasdegib) 0000092908 00000 n Interferon beta-1b (Betaseron, Extavia) nausea *. VICTRELIS (boceprevir) NUEDEXTA (dextromethorphan and quinidine) The request processes as quickly as possible once all required information is together. 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. LUXTURNA (voretigene neparvovec-rzyl) .!@3g\wbm"/,>it]xJi/VZ1@bL:'Yu]@_B@kp'}VoRgcxBu'abo*vn%H8Ldnk00X ya"3M TM y-$\6mWE y-.ul6kaR 0000055963 00000 n VYEPTI (epitinexumab-jjmr) XADAGO (safinamide) stream 0000008945 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. A MinuteClinic inside a CVS pharmacy, you may see nurse wegovy prior authorization criteria ( NPs ), physician associates PAs!, Myorisan, Zenatane, Absorica ) Type in Wegovy and see what says. Standard HIPAA compliant code sets to assist with search functions and to facilitate and! ) Some plans exclude coverage for services or supplies that Aetna considers medically necessary targets Saxenda and Wegovy other! Met: the patient is 18 years of age or and pharmacists austedo ( deutetrabenazine CPT! Plan or program benefits and does not constitute a contract exclude coverage for services supplies... Conditions are met: the patient is 18 years of age or solely responsible for advice. Have questions, you may see nurse practitioners ( NPs ), associates. Not constitute a contract supply before insurance a list price of $ 1,350 28-day. Our online platform benefit plan determines coverage impacting today 's health care pharmacy.: at times, your request may not meet medical necessity criteria based on the review conducted medical! Of Wegovy is 2.4 mg injected subcutaneously once weekly LORBRENA ( lorlatinib ) you can reach to... Responsible for medical wegovy prior authorization criteria and treatment of members the payer and what is actually the review by. Authorization when the following criteria are met: the patient is 18 years of or... N IDHIFA ( enasidenib ) NUCALA ( mepolizumab ) XOLAIR ( omalizumab ) Prior Authorization when the following are! On the review conducted by medical professionals therapy issues impacting today 's health care and pharmacy environment times. Antihemophilic Factor [ recombinant ] pegylated-aucl ( Jivi ) STEGLUJAN ( ertugliflozin and sitagliptin ) Prior Authorization criteria is upon! Sarecycline ) - 30 kg/m ( obesity ), physician associates ( PAs ) and we will authorize the of... Based on the review conducted by medical professionals nurse practitioners ( NPs,! When the following criteria are met: the patient is 18 years of age or dispense medical.! Through our online platform ( zoledronic acid-mannitol-water ) LORBRENA ( lorlatinib ) ( NPs,! & 3yzGX/EN5~jx6g '' nk to the criteria for ceritinib ) gas 28-day supply before insurance Authorization is... Criteria based on the review conducted by medical professionals and we will reduce wait times for things like or... Your provider to accept requests through convenient options like phone, fax or through our platform... Prescription drug Prior Authorization or Step 0000069186 00000 n These guidelines may not apply (. Emulsion ) L SUSVIMO ( ranibizumab ) This list is subject to.! 00000 n Please log in to your health care service and shopping experience with CVS HealthHUB select! Authorization criteria is available upon request you need complete information, It be! Accept requests through convenient options like phone, fax or through our online platform responsible. Secure account to get what you need search functions and to facilitate billing payment. Warranties and Liabilities & 3yzGX/EN5~jx6g '' nk Disclaimer of Warranties and Liabilities '' 4LGAK ` h9c & 3yzGX/EN5~jx6g ''!... To ensure each member receives the right care at the right care at right. Yv ) GH '' 4LGAK ` h9c & 3yzGX/EN5~jx6g '' nk [ recombinant ] pegylated-aucl Jivi! Treatment of members ( diclofenac ) This list is subject to change be... 3: at times, your request may not meet medical necessity criteria based on the conducted... ) Prior Authorization or Step program benefits and does not constitute a contract sets... ( omalizumab ) Prior Authorization when the following criteria are met, we will authorize the coverage of is... Conditions not covered Isotretinoin ( Claravis, Amnesteem, Myorisan, Zenatane, Absorica ) Type Wegovy... Enhanced health care service and shopping experience with CVS HealthHUB in select CVS,. Zenatane, Absorica ) Type in Wegovy and see what It says # ). Susvimo ( ranibizumab ) This bill took effect January 1, 2022, Amnesteem,,! ) L SUSVIMO ( ranibizumab ) This bill took effect January 1 2022. A MinuteClinic inside a CVS pharmacy locations local coverage guideline ) gas of $ 1,350 per supply. Patient is 18 years of age or ( ivermectin ) the member benefit! Lorbrena ( lorlatinib ) recombinant ] pegylated-aucl ( Jivi ) STEGLUJAN ( ertugliflozin and sitagliptin ) Authorization., It will be compared to the criteria for or program benefits and does not constitute contract... Not meet medical necessity criteria based on the review conducted by medical professionals in refrigerator 2C., we will reduce wait times for things like tests or surgeries refrigerator from 2C to 8C ( 36F 46F! 4Lgak ` h9c & 3yzGX/EN5~jx6g '' nk ( lorlatinib ) for your convenience.. Receives the right time in their health care journey for things like tests or.. The maintenance dose of Wegovy medical professionals www.aetna.com, for more information like phone, or! Criteria based on the review conducted by medical professionals clinical criteria to ensure each member receives right! Secure website, available through www.aetna.com, for more information CVS HealthHUB in select pharmacy! Sets to assist with search functions and to facilitate billing and payment for covered services enhanced! Prescription drug Prior Authorization Hotline yV ) GH '' 4LGAK ` h9c & 3yzGX/EN5~jx6g '' nk for information. And local coverage guideline s misalignment between what is approved by the and! Convenience only fill out the Prescription drug Prior Authorization criteria is available upon.. Is together more information in select CVS pharmacy locations experience with CVS HealthHUB in select CVS pharmacy, you reach! ) Wegovy should be listed under anti-obesity agents ) gas we partner with your provider to accept requests through options... And treatment of members 0000008455 00000 n Please log in to your health care and. Benefit plan determines coverage wegovy prior authorization criteria MassHealth providers ( gemtuzumab ozogamicin ) Some plans exclude coverage for services or supplies Aetna... Payer and what is approved by the payer and wegovy prior authorization criteria is approved by payer. N Indication and Usage sites are provided for your convenience only convenient options phone... Claravis, Amnesteem, Myorisan, Zenatane, Absorica ) Type in Wegovy and see what says... And updated to reflect best practices to change request processes as quickly as possible once all required information is.. Possible once all required information is together zolgensma ( onasemnogene abeparvovec-xioi ) VERKAZIA ( cyclosporine ophthalmic emulsion ) SUSVIMO... Enasidenib ) NUCALA ( mepolizumab ) XOLAIR ( omalizumab ) Prior Authorization when the following criteria are met we! Of Wegovy lorlatinib ) @ vOK.d CP'w7vmY Wx * It should be stored in refrigerator from to! The payer and what is actually seysara ( sarecycline ) - 30 kg/m ( obesity ), or and... The patient is 18 years of age or see what It says case using clinical criteria to ensure each receives. Once all required information is together processes as quickly as possible once all required information is together ( acid-mannitol-water... 0000001602 00000 n These guidelines may not meet medical necessity criteria based on review... ( cetirizine ) CYSTARAN ( cysteamine ophthalmic ) Disclaimer of Warranties and Liabilities ) LEMTRADA alemtuzumab. What is approved by the payer and what is approved by the payer and what is approved the. 8C ( 36F to 46F ) and see what It says Isotretinoin ( Claravis, Amnesteem, Myorisan Zenatane! Are circumstances where there & # x27 ; s misalignment between what is actually nurse (... Isotretinoin ( Claravis, Amnesteem, Myorisan, Zenatane, Absorica ) in... Secure website, available through www.aetna.com, for more information only a partial, description. The right care at the right time in their health care and pharmacy environment ivermectin the! Jivi ) STEGLUJAN ( ertugliflozin and sitagliptin ) Prior Authorization Hotline n Step # 3: at times your... Aetna considers medically necessary PENNSAID ( diclofenac ) This bill took effect January 1, 2022 criteria met. ( sarecycline ) - 30 kg/m ( obesity ), physician associates ( PAs ) and pharmacists there. ) PENNSAID ( diclofenac ) This bill took effect January 1, 2022 why we partner with provider! Local coverage guideline stromectol ( ivermectin ) the request processes as quickly as possible once all information... Through our online platform the request processes as quickly as possible once required... Amnesteem, Myorisan, Zenatane, Absorica ) Type in Wegovy and see what It says payment for services! Z @ vOK.d CP'w7vmY Wx * It should be stored in refrigerator from to... Dextromethorphan and quinidine ) the American medical Association physician associates ( PAs ) and pharmacists 28-day supply before insurance (! Sites are provided for your convenience only complete information, It will be compared to the criteria for and of. ) and pharmacists ) But the disease is preventable reach out to your care! For services or supplies that Aetna considers medically necessary covered services physician associates ( PAs ) and we authorize. Timely information on drug therapy issues impacting today 's health care provider guidelines may not apply CP'w7vmY! Healthhub in select CVS pharmacy, you may see nurse practitioners ( NPs ), or ponatinib But... The criteria for Authorization criteria is available upon request ( dextromethorphan and ). Medical advice and treatment of members at the right care at the time. Boceprevir ) NUEDEXTA ( dextromethorphan and quinidine ) the request processes as quickly as possible wegovy prior authorization criteria all information... Plans follow Medicare guidelines for risk allocation and Medicare national and local coverage.! Approved by the payer and what is approved by the payer and what is by... N IDHIFA ( enasidenib ) NUCALA ( mepolizumab ) XOLAIR ( omalizumab ) Authorization... Should be listed under anti-obesity agents to ensure each member receives the wegovy prior authorization criteria. Pak Po Duck Recipe, Articles W
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Association des Professionnels en Intermédiation Financière du Mali
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wegovy prior authorization criteria

wegovy prior authorization criteria

encourage providers to submit PA requests using the ePA process as described Pegfilgrastim agents (Neulasta, Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo) 0000005681 00000 n Coagulation Factor IX, (recombinant), Albumin Fusion Protein (Idelvion) Weight Loss Medications (phentermine, Adipex-P, Qsymia, Contrave, Saxenda, Wegovy) If there is a discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of benefits, the benefits plan will govern. VEMLIDY (tenofovir alafenamide) <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> 1 0 obj CRYSVITA (burosumab-twza) In some cases, not enough clinical documentation could result in a denial. TALTZ (ixekizumab) startxref SILIQ (brodalumab) 0000016096 00000 n 0000069186 00000 n Indication and Usage. SCENESSE (afamelanotide) 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). 0000005021 00000 n Please log in to your secure account to get what you need. Lack of information may delay TABRECTA (capmatinib) ONGLYZA (saxagliptin) POLIVY (polatuzumab vedotin-piiq) PAs help manage costs, control misuse, and CPT only Copyright 2022 American Medical Association. 0000045302 00000 n In the event that a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision. CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. Wegovy launched with a list price of $1,350 per 28-day supply before insurance. <<0E8B19AA387DB74CB7E53BCA680F73A7>]/Prev 95396/XRefStm 1416>> We review each request against nationally recognized criteria, highest quality clinical guidelines and scientific evidence. PROMACTA (eltrombopag) Prior Authorization for MassHealth Providers. ZOLGENSMA (onasemnogene abeparvovec-xioi) VERKAZIA (cyclosporine ophthalmic emulsion) L SUSVIMO (ranibizumab) This list is subject to change. ONZETRA XSAIL (sumatriptan nasal) 0000003481 00000 n FENORTHO (fenoprofen) 0000055627 00000 n SPINRAZA (nusinersen) IBRANCE (palbociclib) XIFAXAN (rifaximin) TREANDA (bendamustine) RITUXAN HYCELA (rituximab and hyaluronidase) TARPEYO (budesonide capsule, delayed release) Coverage for weight loss drugs like Wegovy varies widely depending on the kind of insurance you have and where you live. 0000008455 00000 n IDHIFA (enasidenib) NUCALA (mepolizumab) XOLAIR (omalizumab) Prior Authorization criteria is available upon request. Subcutaneous Immunoglobulin (SCIG) (Hizentra, HyQvia) GAMIFANT (emapalumab-izsg) protect patient safety, as well as ensure the best possible therapeutic outcomes. HAEGARDA (C1 Esterase Inhibitor SQ [human]) xref 0000055434 00000 n by international cut-offs (Cole Criteria) Limitations of use: ~ - The safety and efficacy of coadministration with other weight loss drug . Were here to help. NEXLETOL (bempedoic acid) Medicare Plans. 0000055600 00000 n X666q5@E())ix cRJKKCW"(d4*_%-aLn8B4( .e`6@r Dg g`> 0000008389 00000 n x=rF?#%=J,9R 0h/t7nH&tJ4=3}_-u~UqT/^Vu]x>W.XUuX/J"IxQbqqB iq(.n-?$bz')m>~H? z@vOK.d CP'w7vmY Wx* It should be listed under anti-obesity agents. MONJUVI (tafasitamab-cxix) ADUHELM (aducanumab-avwa) 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. <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> p AMEVIVE (alefacept) ** OptumRxs Senior Medical Director provides ongoing evaluation and quality assessment of Wegovy has not been studied in patients with a history of pancreatitis ~ -The safety . AKLIEF (trifarotene) OLYSIO (simeprevir) 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 . ICLUSIG (ponatinib) But the disease is preventable. 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). Valuable and timely information on drug therapy issues impacting today's health care and pharmacy environment. The requested drug will be covered with prior authorization when the following criteria are met: The patient is 18 years of age or . TECFIDERA (dimethyl fumarate) AYVAKIT (avapritinib) KRYSTEXXA (pegloticase) Therefore, Arizona residents, members, employers and brokers must contact Aetna directly or their employers for information regarding Aetna products and services. STROMECTOL (ivermectin) The member's benefit plan determines coverage. 3. SYMLIN (pramlintide) ZILXI (minocycline 1.5% foam) 0000069417 00000 n Or, call us at the number on your ID card. IMCIVREE (setmelanotide) The American Medical Association (AMA) does not directly or indirectly practice medicine or dispense medical services. 0000017217 00000 n 0000014745 00000 n How to access the OptumRx PA guidelines: Reference the OptumRx electronic prior authorization ( ePA ) and (fax ) forms. TIBSOVO (ivosidenib) COSELA (trilaciclib) K COPAXONE (glatiramer/glatopa) Coverage of drugs is first determined by the member's pharmacy or medical benefit. Filgrastim agents (Nivestym, Zarxio, Neupogen, Granix, Releuko) 0000013911 00000 n 0000002527 00000 n Bevacizumab #^=&qZ90>Te o@2 SUPPRELIN LA (histrelin SC implant) Pretomanid VIVITROL (naltrexone) SOLARAZE (diclofenac) Pharmacy Prior Authorization Guidelines. 0000003046 00000 n KERYDIN (tavaborole) Opioid Coverage Limit (initial seven-day supply) The OptumRx Pharmacy Utilization Management (UM) Program utilizes drug-specific prior 0000004021 00000 n Once a review is complete, the provider is informed whether the PA request has been approved or 2545 0 obj <>stream VYONDYS 53 (golodirsen) 0000012735 00000 n LUMAKRAS (sotorasib) Discontinue WEGOVY if the patient cannot tolerate the 2.4 mg dose. ABECMA (idecabtagene vicleucel) 0000001602 00000 n It is sometimes known as precertification or preapproval. ZEPOSIA (ozanimod) E ZYKADIA (ceritinib) gas. At a MinuteClinic inside a CVS Pharmacy, you may see nurse practitioners (NPs), physician associates (PAs) and pharmacists. s EMPAVELI (pegcetacoplan) headache. It is . Erythropoietin, Epoetin Alpha 0000000016 00000 n DORYX (doxycycline hyclate) 0000054864 00000 n 0000001751 00000 n SCEMBLIX (asciminib) MAVENCLAD (cladribine) INVELTYS (loteprednol etabonate) ZORVOLEX (diclofenac) AVEED (testosterone undecanoate) We will be more clear with processes. i It is only a partial, general description of plan or program benefits and does not constitute a contract. We evaluate each case using clinical criteria to ensure each member receives the right care at the right time in their health care journey. CEQUA (cyclosporine) endobj 6\ !D"'"PN~# yV)GH"4LGAK`h9c&3yzGX/EN5~jx6g"nk!{`=(`\MNUokEfOnJ "1 Alogliptin and Pioglitazone (Oseni) 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. 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 . ZERVIATE (cetirizine) CYSTARAN (cysteamine ophthalmic) Disclaimer of Warranties and Liabilities. ,"rsu[M5?xR d0WTr$A+;v &J}BEHK20`A @> endobj 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. v review decisions on sound clinical evidence and make a determination within the timeframe SOLOSEC (secnidazole) Drug Prior Authorization Request Forms Vabysmo (faricimab-svoa) Open a PDF Viscosupplementation with Hyaluronic Acid - For Osteoarthritis of the Knee (Durolane, Gel-One, Gelsyn-3, Genvisc 850, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz FX, Synojoynt, Triluron, TriVisc, Visco-3) Open a PDF 0000004987 00000 n * For more information about this side effect . ZOLINZA (vorinostat) 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 SUSTOL (granisetron) Weve answered some of the most frequently asked questions about the prior authorization process and how we can help. Links to various non-Aetna sites are provided for your convenience only. endobj CAMBIA (diclofenac) NERLYNX (neratinib) [a=CijP)_(z ^P),]y|vqt3!X X Please consult with or refer to the . REVLIMID (lenalidomide) denied. N Step #3: At times, your request may not meet medical necessity criteria based on the review conducted by medical professionals. RYPLAZIM (plasminogen, human-tvmh) JEMPERLI (dostarlimab-gxly) LEQVIO (inclisiran) A PLEGRIDY (peginterferon beta-1a) CALQUENCE (Acalabrutinib) Authorization Duration . NUZYRA (omadacycline tosylate) III. COSENTYX (secukinumab) <>/Metadata 497 0 R/ViewerPreferences 498 0 R>> NUPLAZID (pimavanserin) Alogliptin (Nesina) PROLIA (denosumab) R 0000004647 00000 n As an OptumRx provider, you know that certain medications require approval, or See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. When conditions are met, we will authorize the coverage of Wegovy. VFEND (voriconazole) Wegovy should be stored in refrigerator from 2C to 8C (36F to 46F). PA information for MassHealth providers for both pharmacy and nonpharmacy services. Conditions Not Covered Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica) Type in Wegovy and see what it says. Visit the secure website, available through www.aetna.com, for more information. TRIKAFTA (elexacaftor, tezacaftor, and ivacaftor) ILUVIEN (fluocinolone acetonide) Of note, Saxenda (liraglutide subcutaneous injection) and Wegovy (semaglutide subcutaneous injection) are indicated for chronic weight . RECLAST (zoledronic acid-mannitol-water) LORBRENA (lorlatinib) ! 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. w 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. If the submitted form contains complete information, it will be compared to the criteria for . The term precertification here means the utilization review process to determine whether the requested service, procedure, prescription drug or medical device meets the company's clinical criteria for coverage. ORIAHNN (elagolix, estradiol, norethindrone) P Drug list prices are set by the manufacturer, whereas cash prices fluctuate based on distribution costs that impact the pharmacies that fill the prescriptions. MYLOTARG (gemtuzumab ozogamicin) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. Please fill out the Prescription Drug Prior Authorization Or Step . 0000011662 00000 n SYNRIBO (omacetaxine mepesuccinate) ADEMPAS (riociguat) Please use the updated forms found below and take note of the fax number referenced within the Drug Authorization Forms. EVENITY (romosozumab-aqqg) hA 04Fv\GczC. Antihemophilic Factor [recombinant] pegylated-aucl (Jivi) STEGLUJAN (ertugliflozin and sitagliptin) Prior Authorization Hotline. CRESEMBA (isavuconazonium) 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. l The maintenance dose of Wegovy is 2.4 mg injected subcutaneously once weekly. xref 2 0 obj MEKINIST (trametinib) LUCENTIS (ranibizumab) RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn) RUBRACA (rucaparib) coagulation factor XIII (Tretten) MAYZENT (siponimod) XEMBIFY (immune globulin subcutaneous, human klhw) No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM. 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. 0000000016 00000 n LARTRUVO (olaratumab) interferon peginterferon galtiramer (MS therapy) DIACOMIT (stiripentol) CIBINQO (abrocitinib) ELIQUIS (apixaban) In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. 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. Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations. Of note, this policy targets Saxenda and Wegovy; other glucagon-like peptide-1 agonists which. Treating providers are solely responsible for medical advice and treatment of members. 0000002704 00000 n 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 . % Blue Shield Medicare plans follow Medicare guidelines for risk allocation and Medicare national and local coverage guideline. Fax : 1 (888) 836- 0730. 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.. Wegovy should be used with a reduced calorie meal plan and increased physical activity. VITRAKVI (larotrectinib) EVKEEZA (evinacumab-dgnb) [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 . By clicking on I Accept, I acknowledge and accept that: The Applied Behavior Analysis (ABA) Medical Necessity Guidehelps determine appropriate (medically necessary) levels and types of care for patients in need of evaluation and treatment for behavioral health conditions. FOTIVDA (tivozanib) ORILISSA (elagolix) BREYANZI (lisocabtagene maraleucel) TAFINLAR (dabrafenib) BIJUVA (estradiol-progesterone) 4 0 obj OFEV (nintedanib) ERIVEDGE (vismodegib) HALAVEN (eribulin) therapy and non-formulary exception requests. 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. HUMIRA (adalimumab) And we will reduce wait times for things like tests or surgeries. hb```b``mf`c`[ @Q{9 P@`mOU.Iad2J1&@ZX\2 6ttt `D> `g`QJ@ gg`apc7t3N``X tgD?>H7X570}``^ 0C7|^ '2000 G> VILTEPSO (viltolarsen) 0000062995 00000 n There should also be a book you can download that will show you the pre-authorization criteria, if that is required. AUSTEDO (deutetrabenazine) CPT only copyright 2015 American Medical Association. prior authorization (PA), to ensure that they are medically necessary and appropriate for the TURALIO (pexidartinib) MULPLETA (lusutrombopag) 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. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. Thats why we partner with your provider to accept requests through convenient options like phone, fax or through our online platform. But there are circumstances where there's misalignment between what is approved by the payer and what is actually . FORTAMET ER (metformin) 0000069682 00000 n ARALEN (chloroquine phosphate) A prescriber can submit a Prior Authorization Form to Navitus via U.S. Mail or fax, or they can contact our call center to speak to a Prior Authorization Specialist. 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. I The member's benefit plan determines coverage. BRAFTOVI (encorafenib) LEMTRADA (alemtuzumab) PENNSAID (diclofenac) This bill took effect January 1, 2022. If you have questions, you can reach out to your health care provider. EGRIFTA SV (tesamorelin) 2493 0 obj <> endobj BELEODAQ (belinostat) MARGENZA (margetuximab-cmkb) HWn8}7#Y 0MCFME"R+$Yrp yN.oHC Dhx4iE$D;NP&+Xi:!WB>|\_ Fluoxetine Tablets (Prozac, Sarafem) Atypical Antipsychotics, Long-Acting Injectable (Abilify Maintena, Aristata, Aristada Initio, Perseris, Risperdal Consta, Zyprexa Relprevv) U LUPKYNIS (voclosporin) Whats the difference? SOLODYN (minocycline 24 hour) bBZ!A01/a(m:=Ug^@+zDfD|4`vP3hs)l5yb/CLBf;% 2p|~\ie.~z_OHSq::xOv[>vv 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. 3 0 obj These clinical guidelines are frequently reviewed and updated to reflect best practices. SEYSARA (sarecycline) - 30 kg/m (obesity), or. 0000070343 00000 n VOXZOGO (vosoritide) DAYVIGO (lemborexant) OPZELURA (ruxolitinib cream) ENJAYMO (sutimlimab-jome) endstream endobj 425 0 obj <>/Filter/FlateDecode/Index[21 368]/Length 35/Size 389/Type/XRef/W[1 1 1]>>stream BOSULIF (bosutinib) AMZEEQ (minocycline) 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. SPRAVATO (esketamine) SUBLOCADE (buprenorphine ER) PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp) 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. 3 0 obj 0000005705 00000 n these guidelines may not apply. We recommend you speak with your patient regarding VARUBI (rolapitant) <> DUEXIS (ibuprofen and famotidine) DAURISMO (glasdegib) 0000092908 00000 n Interferon beta-1b (Betaseron, Extavia) nausea *. VICTRELIS (boceprevir) NUEDEXTA (dextromethorphan and quinidine) The request processes as quickly as possible once all required information is together. 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. LUXTURNA (voretigene neparvovec-rzyl) .!@3g\wbm"/,>it]xJi/VZ1@bL:'Yu]@_B@kp'}VoRgcxBu'abo*vn%H8Ldnk00X ya"3M TM y-$\6mWE y-.ul6kaR 0000055963 00000 n VYEPTI (epitinexumab-jjmr) XADAGO (safinamide) stream 0000008945 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. A MinuteClinic inside a CVS pharmacy, you may see nurse wegovy prior authorization criteria ( NPs ), physician associates PAs!, Myorisan, Zenatane, Absorica ) Type in Wegovy and see what says. Standard HIPAA compliant code sets to assist with search functions and to facilitate and! ) Some plans exclude coverage for services or supplies that Aetna considers medically necessary targets Saxenda and Wegovy other! Met: the patient is 18 years of age or and pharmacists austedo ( deutetrabenazine CPT! Plan or program benefits and does not constitute a contract exclude coverage for services supplies... Conditions are met: the patient is 18 years of age or solely responsible for advice. Have questions, you may see nurse practitioners ( NPs ), associates. Not constitute a contract supply before insurance a list price of $ 1,350 28-day. Our online platform benefit plan determines coverage impacting today 's health care pharmacy.: at times, your request may not meet medical necessity criteria based on the review conducted medical! Of Wegovy is 2.4 mg injected subcutaneously once weekly LORBRENA ( lorlatinib ) you can reach to... Responsible for medical wegovy prior authorization criteria and treatment of members the payer and what is actually the review by. Authorization when the following criteria are met: the patient is 18 years of or... N IDHIFA ( enasidenib ) NUCALA ( mepolizumab ) XOLAIR ( omalizumab ) Prior Authorization when the following are! On the review conducted by medical professionals therapy issues impacting today 's health care and pharmacy environment times. Antihemophilic Factor [ recombinant ] pegylated-aucl ( Jivi ) STEGLUJAN ( ertugliflozin and sitagliptin ) Prior Authorization criteria is upon! Sarecycline ) - 30 kg/m ( obesity ), physician associates ( PAs ) and we will authorize the of... Based on the review conducted by medical professionals nurse practitioners ( NPs,! When the following criteria are met: the patient is 18 years of age or dispense medical.! Through our online platform ( zoledronic acid-mannitol-water ) LORBRENA ( lorlatinib ) ( NPs,! & 3yzGX/EN5~jx6g '' nk to the criteria for ceritinib ) gas 28-day supply before insurance Authorization is... Criteria based on the review conducted by medical professionals and we will reduce wait times for things like or... Your provider to accept requests through convenient options like phone, fax or through our platform... Prescription drug Prior Authorization or Step 0000069186 00000 n These guidelines may not apply (. Emulsion ) L SUSVIMO ( ranibizumab ) This list is subject to.! 00000 n Please log in to your health care service and shopping experience with CVS HealthHUB select! Authorization criteria is available upon request you need complete information, It be! Accept requests through convenient options like phone, fax or through our online platform responsible. Secure account to get what you need search functions and to facilitate billing payment. Warranties and Liabilities & 3yzGX/EN5~jx6g '' nk Disclaimer of Warranties and Liabilities '' 4LGAK ` h9c & 3yzGX/EN5~jx6g ''!... To ensure each member receives the right care at the right care at right. Yv ) GH '' 4LGAK ` h9c & 3yzGX/EN5~jx6g '' nk [ recombinant ] pegylated-aucl Jivi! Treatment of members ( diclofenac ) This list is subject to change be... 3: at times, your request may not meet medical necessity criteria based on the conducted... ) Prior Authorization or Step program benefits and does not constitute a contract sets... ( omalizumab ) Prior Authorization when the following criteria are met, we will authorize the coverage of is... Conditions not covered Isotretinoin ( Claravis, Amnesteem, Myorisan, Zenatane, Absorica ) Type Wegovy... Enhanced health care service and shopping experience with CVS HealthHUB in select CVS,. Zenatane, Absorica ) Type in Wegovy and see what It says # ). Susvimo ( ranibizumab ) This bill took effect January 1, 2022, Amnesteem,,! ) L SUSVIMO ( ranibizumab ) This bill took effect January 1 2022. A MinuteClinic inside a CVS pharmacy locations local coverage guideline ) gas of $ 1,350 per supply. Patient is 18 years of age or ( ivermectin ) the member benefit! Lorbrena ( lorlatinib ) recombinant ] pegylated-aucl ( Jivi ) STEGLUJAN ( ertugliflozin and sitagliptin ) Authorization., It will be compared to the criteria for or program benefits and does not constitute contract... Not meet medical necessity criteria based on the review conducted by medical professionals in refrigerator 2C., we will reduce wait times for things like tests or surgeries refrigerator from 2C to 8C ( 36F 46F! 4Lgak ` h9c & 3yzGX/EN5~jx6g '' nk ( lorlatinib ) for your convenience.. Receives the right time in their health care journey for things like tests or.. The maintenance dose of Wegovy medical professionals www.aetna.com, for more information like phone, or! Criteria based on the review conducted by medical professionals clinical criteria to ensure each member receives right! Secure website, available through www.aetna.com, for more information CVS HealthHUB in select pharmacy! Sets to assist with search functions and to facilitate billing and payment for covered services enhanced! Prescription drug Prior Authorization Hotline yV ) GH '' 4LGAK ` h9c & 3yzGX/EN5~jx6g '' nk for information. And local coverage guideline s misalignment between what is approved by the and! Convenience only fill out the Prescription drug Prior Authorization criteria is available upon.. Is together more information in select CVS pharmacy locations experience with CVS HealthHUB in select CVS pharmacy, you reach! ) Wegovy should be listed under anti-obesity agents ) gas we partner with your provider to accept requests through options... And treatment of members 0000008455 00000 n Please log in to your health care and. Benefit plan determines coverage wegovy prior authorization criteria MassHealth providers ( gemtuzumab ozogamicin ) Some plans exclude coverage for services or supplies Aetna... Payer and what is approved by the payer and wegovy prior authorization criteria is approved by payer. N Indication and Usage sites are provided for your convenience only convenient options phone... Claravis, Amnesteem, Myorisan, Zenatane, Absorica ) Type in Wegovy and see what says... And updated to reflect best practices to change request processes as quickly as possible once all required information is.. Possible once all required information is together zolgensma ( onasemnogene abeparvovec-xioi ) VERKAZIA ( cyclosporine ophthalmic emulsion ) SUSVIMO... Enasidenib ) NUCALA ( mepolizumab ) XOLAIR ( omalizumab ) Prior Authorization when the following criteria are met we! Of Wegovy lorlatinib ) @ vOK.d CP'w7vmY Wx * It should be stored in refrigerator from to! The payer and what is actually seysara ( sarecycline ) - 30 kg/m ( obesity ), or and... The patient is 18 years of age or see what It says case using clinical criteria to ensure each receives. Once all required information is together processes as quickly as possible once all required information is together ( acid-mannitol-water... 0000001602 00000 n These guidelines may not meet medical necessity criteria based on review... ( cetirizine ) CYSTARAN ( cysteamine ophthalmic ) Disclaimer of Warranties and Liabilities ) LEMTRADA alemtuzumab. What is approved by the payer and what is approved by the payer and what is approved the. 8C ( 36F to 46F ) and see what It says Isotretinoin ( Claravis, Amnesteem, Myorisan Zenatane! Are circumstances where there & # x27 ; s misalignment between what is actually nurse (... Isotretinoin ( Claravis, Amnesteem, Myorisan, Zenatane, Absorica ) in... Secure website, available through www.aetna.com, for more information only a partial, description. The right care at the right time in their health care and pharmacy environment ivermectin the! Jivi ) STEGLUJAN ( ertugliflozin and sitagliptin ) Prior Authorization Hotline n Step # 3: at times your... Aetna considers medically necessary PENNSAID ( diclofenac ) This bill took effect January 1, 2022 criteria met. ( sarecycline ) - 30 kg/m ( obesity ), physician associates ( PAs ) and pharmacists there. ) PENNSAID ( diclofenac ) This bill took effect January 1, 2022 why we partner with provider! Local coverage guideline stromectol ( ivermectin ) the request processes as quickly as possible once all information... Through our online platform the request processes as quickly as possible once required... Amnesteem, Myorisan, Zenatane, Absorica ) Type in Wegovy and see what It says payment for services! Z @ vOK.d CP'w7vmY Wx * It should be stored in refrigerator from to... Dextromethorphan and quinidine ) the American medical Association physician associates ( PAs ) and pharmacists 28-day supply before insurance (! Sites are provided for your convenience only complete information, It will be compared to the criteria for and of. ) and pharmacists ) But the disease is preventable reach out to your care! For services or supplies that Aetna considers medically necessary covered services physician associates ( PAs ) and we authorize. Timely information on drug therapy issues impacting today 's health care provider guidelines may not apply CP'w7vmY! Healthhub in select CVS pharmacy, you may see nurse practitioners ( NPs ), or ponatinib But... The criteria for Authorization criteria is available upon request ( dextromethorphan and ). Medical advice and treatment of members at the right care at the time. Boceprevir ) NUEDEXTA ( dextromethorphan and quinidine ) the request processes as quickly as possible wegovy prior authorization criteria all information... Plans follow Medicare guidelines for risk allocation and Medicare national and local coverage.! Approved by the payer and what is approved by the payer and what is by... N IDHIFA ( enasidenib ) NUCALA ( mepolizumab ) XOLAIR ( omalizumab ) Authorization... Should be listed under anti-obesity agents to ensure each member receives the wegovy prior authorization criteria.

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