wegovy prior authorization criteria

QINLOCK (ripretinib) KADCYLA (Ado-trastuzumab emtansine) Optum guides members and providers through important upcoming formulary updates. Off-label and Administrative Criteria ERLEADA (apalutamide) Pharmacy General Exception Forms <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> 0000069417 00000 n Coagulation Factor IX (Alprolix) If the submitted form contains complete information, it will be compared to the criteria for . TYMLOS (abaloparatide) TRIPTODUR (triptorelin extended-release) NINLARO (ixazomib) Each main plan type has more than one subtype. Prior Authorization Resources. stream Please consult with or refer to the . Learn about reproductive health. You can take advantage of a wide range of services across a variety of categories, including: CVS HealthHUBservices OptumRx, except for the following states: MA, RI, SC, and TX. 0000001794 00000 n k L HALAVEN (eribulin) VICTRELIS (boceprevir) 0000069452 00000 n OXLUMO (lumasiran) Attached is a listing of prescription drugs that are subject to prior authorization. EVENITY (romosozumab-aqqg) CPT only copyright 2015 American Medical Association. Pegfilgrastim agents (Neulasta, Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo) the determination process. E DELESTROGEN (estradiol valerate injection) Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. This bill took effect January 1, 2022. 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. paliperidone palmitate (Invega Hafyera, Invega Trinza, Invega Sustenna) T 0 0000055963 00000 n KOMBIGLYZE XR (saxagliptin and metformin hydrochloride, extended release) manner, please submit all information needed to make a decision. by international cut-offs (Cole Criteria) Limitations of use: ~ - The safety and efficacy of coadministration with other weight loss drug . HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk) COSENTYX (secukinumab) INVELTYS (loteprednol etabonate) ILUVIEN (fluocinolone acetonide) AUSTEDO (deutetrabenazine) TARGRETIN (bexarotene) No fee schedules, basic unit, relative values or related listings are included in CPT. Subcutaneous Immunoglobulin (SCIG) (Hizentra, HyQvia) AUVI-Q (epinephrine) w INFINZI (durvalumab IV) endobj SPRIX (ketorolac nasal spray) TIBSOVO (ivosidenib) MinuteClinic at CVS services Capsaicin Patch Coagulation Factor IX, recombinant, glycopegylated (Rebinyn) coagulation factor XIII (Tretten) Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod) CONTRAVE (bupropion and naltrexone) RUCONEST (recombinant C1 esterase inhibitor) HUMIRA (adalimumab) COSELA (trilaciclib) Providers may request a step therapy exception to skip the step therapy process and receive the Tier 2 or higher drug immediately. endstream endobj 403 0 obj <>stream VONJO (pacritinib) 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. 0000055434 00000 n Blue Shield Medicare plans follow Medicare guidelines for risk allocation and Medicare national and local coverage guideline. x=ko?,pHE^rEQ q4'MN89dYuj[%'G_^KRi{qD\p8o7lMv;_,N_Wogv>|{G/foM=?J~{(K3eUrc %,4eRUZJtzN7b5~$%1?s?&MMs&\byQl!x@eYZF`'"N(L6FDX startxref OXERVATE (cenegermin-bkbj) PAs help manage costs, control misuse, and 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 . VYONDYS 53 (golodirsen) NOCDURNA (desmopressin acetate) OZURDEX (dexamethasone intravitreal implant) JAKAFI (ruxolitinib) SUSVIMO (ranibizumab) Viewand print a PA request form, For urgent requests, please call us at 1-800-711-4555. In doing so, CVS/Caremark will be able to decide whether or not the requested prescription is included in the patient's insurance plan. You can review prior authorization criteria for Releuko for oncology indications, as well as any recent coding updates, on the OncoHealth website. endobj ePAs save time and help patients receive their medications faster. allowed by state or federal law. MEKINIST (trametinib) NERLYNX (neratinib) CABOMETYX (cabozantinib) 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 . EUCRISA (crisaborole) PRIOR AUTHORIZATION CRITERIA DRUG CLASS WEIGHT LOSS MANAGEMENT BRAND NAME* (generic) WEGOVY . 0000008484 00000 n To request authorization for Leqvio, or to request authorization for Releuko for non-oncology purposes, please contact CVS Health-NovoLogix via phone (844-387-1435) or fax (844-851-0882). Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. ZEPATIER (elbasvir-grazoprevir) Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. All services deemed "never effective" are excluded from coverage. ZINPLAVA (bezlotoxumab) MYRBETRIQ (mirabegron granules) While the Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. PEMAZYRE (pemigatinib) gym discounts, 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. OLYSIO (simeprevir) your Dashboard to submit your PA request. prior authorization (PA), to ensure that they are medically necessary and appropriate for the ONZETRA XSAIL (sumatriptan nasal) Specialty drugs and prior authorizations. ONUREG (azacitidine) Alogliptin-Metformin (Kazano) ORKAMBI (lumacaftor/ivacaftor) We strongly ALECENSA (alectinib) TIVDAK (tisotumab vedotin-tftv) <>/Metadata 497 0 R/ViewerPreferences 498 0 R>> AMVUTTRA (vutrisiran) Reauthorization approval duration is up to 12 months . If this is the case, our team of medical directors is willing to speak with your health care provider for next steps. 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. 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. Weight Loss - phentermine (all brand products including Adipex-P and Lomaira), benzphetamine, Contrave (naltrexone HCl and bupropion HCl, diethylpropion, Imcivree (setmelanotide), phendimetrazine, orlistat (Xenical), Qsymia (phentermine and topiramate extended-release), Saxenda (liraglutide), and Wegovy (semaglutide) - Prior Authorization . SPINRAZA (nusinersen) Wegovy is indicated for adults who are obese (body mass index 30) or overweight (body mass index 27), and who also have certain weight-related medical conditions, such as type 2 diabetes . all e Allergen Immunotherapy Agents (Grastek, Odactra, Oralair, Ragwitek) 0000003577 00000 n In the event that a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision. Please use the updated forms found below and take note of the fax number referenced within the Drug Authorization Forms. 0000010297 00000 n P FANAPT (iloperidone) The OptumRx Pharmacy Utilization Management (UM) Program utilizes drug-specific prior 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 % WELIREG (belzutifan) This excerpt is provided for use in connection with the review of a claim for benefits and may not be reproduced or used for any other purpose. Please log in to your secure account to get what you need. Pretomanid 0000013580 00000 n 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. Of note, Saxenda (liraglutide subcutaneous injection) and Wegovy (semaglutide subcutaneous injection) are indicated for chronic weight . SUPPRELIN LA (histrelin SC implant) /wHqy5}r``Tgxkt2&!WKUN|\2KuS/esjlf2y|X*i&YgmL -oxBXWt[]k+E.k6K%,~'nuM Ih ILUMYA (tildrakizumab-asmn) MYLOTARG (gemtuzumab ozogamicin) XPOVIO (selinexor) ADDYI (flibanserin) INLYTA (axitinib) PYRUKYND (mitapivat) Step #2: We review your request against our evidence-based, clinical guidelines. 0000069611 00000 n 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. TECENTRIQ (atezolizumab) ENTYVIO (vedolizumab) 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). IDHIFA (enasidenib) NUEDEXTA (dextromethorphan and quinidine) q s 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. The American Medical Association (AMA) does not directly or indirectly practice medicine or dispense medical services. Propranolol (Inderal XL, InnoPran XL) 0000005681 00000 n LEUKINE (sargramostim) Do you want to continue? LONSURF (trifluridine and tipiracil) All Rights Reserved. vomiting. stream Growth Hormone (Norditropin; Nutropin; Genotropin; Humatrope; Omnitrope; Saizen; Sogroya; Skytrofa; Zomacton; Serostim; Zorbtive) - 27 kg/m to <30 kg/m (overweight) in the presence of at least one . ALIQOPA (copanlisib) Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. The requested drug will be covered with prior authorization when the following criteria are met: The patient is 18 years of age or . LUXTURNA (voretigene neparvovec-rzyl) Testosterone oral agents (JATENZO, TLANDO) 0000002222 00000 n Weve answered some of the most frequently asked questions about the prior authorization process and how we can help. APTIOM (eslicarbazepine) 4 0 obj IBRANCE (palbociclib) prescription drug benefit coverage under his/her health insurance plan or call OptumRx. Other policies and utilization management programs may apply. ORGOVYX (relugolix) AYVAKIT (avapritinib) ILARIS (canakinumab) n Step #3: At times, your request may not meet medical necessity criteria based on the review conducted by medical professionals. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements. TYRVAYA (varenicline) The responsibility for the content of this product is with Aetna, Inc. and no endorsement by the AMA is intended or implied. methotrexate injectable agents (REDITREX, OTREXUP, RASUVO) AKYNZEO (fosnetupitant/palonosetron) C FYARRO (sirolimus protein-bound particles) Fax: 1-855-633-7673. X Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna). This is a listing of all of the drugs covered by MassHealth. Western Health Advantage. PAXLOVID (nirmatrelvir and ritonavir) 0000055177 00000 n BAFIERTAM (monomethyl fumarate) ACTHAR (corticotropin) FORTEO (teriparatide) iMo::>91}h9 ACZONE (dapsone) TASIGNA (nilotinib) RAYOS (prednisone) ICLUSIG (ponatinib) COPIKTRA (duvelisib) ADEMPAS (riociguat) 2>7_0ns]+hVaP{}A Hyaluronic Acid derivatives (Synvisc, Hyalgan, Orthovisc, Euflexxa, Supartz) Links to various non-Aetna sites are provided for your convenience only. Coagulation Factor IX, recombinant, glycopegylated (Rebinyn) GALAFOLD (migalastat) 0000045302 00000 n SOLARAZE (diclofenac) 0000005437 00000 n ARIKAYCE (amikacin) 0 patients were required to have a prior unsuccessful dietary weight loss attempt. PROLIA (denosumab) Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. 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. INREBIC (fedratinib) XADAGO (safinamide) Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. PA information for MassHealth providers for both pharmacy and nonpharmacy services. Its confidential and free for you and all your household members. Health benefits and health insurance plans contain exclusions and limitations. While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. 0000011365 00000 n <> NATPARA (parathyroid hormone, recombinant human) At a MinuteClinic inside a CVS Pharmacy, you may see nurse practitioners (NPs), physician associates (PAs) and pharmacists. AZEDRA (Iobenguane I-131) Wegovy (semaglutide) - New drug approval. 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 Y There should also be a book you can download that will show you the pre-authorization criteria, if that is required. hb```b``mf`c`[ @Q{9 P@`mOU.Iad2J1&@ZX\2 6ttt `D> `g`QJ@ gg`apc7t3N``X tgD?>H7X570}``^ 0C7|^ '2000 G> OPSUMIT (macitentan) making criteria** that are developed from clinical evidence from the following sources: *Guidelines are specific to plans utilizing our standard drug lists only. And we will reduce wait times for things like tests or surgeries. 0000002571 00000 n 0000017217 00000 n Were here with 24/7 support and resources to help you with work/life balance, caregiving, legal services, money matters, and more. : MAYZENT (siponimod) BAVENCIO (avelumab) 0000001416 00000 n <>/Metadata 133 0 R/ViewerPreferences 134 0 R>> VIEKIRA PAK (ombitasvir, paritaprevir, ritonavir, and dasabuvir) PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp) ZOSTAVAX (zoster vaccine live) 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). LIVMARLI (maralixibat solution) denied. SYMTUZA (darunavir, cobicistat, emtricitabine, and tenofovir alafenamide tablet ) CALQUENCE (Acalabrutinib) KERYDIN (tavaborole) To ensure that a PA determination is provided to you in a timely headache. XELODA (capecitabine) ENJAYMO (sutimlimab-jome) QELBREE (viloxazine extended-release) You may also view the prior approval information in the Service Benefit Plan Brochures. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. Angiotensin Receptor Blockers (e.g., Atacand, Atacand HCT, Tribenzor, Edarbi, Edarbyclor, Teveten) Wegovy launched with a list price of $1,350 per 28-day supply before insurance. Authorization will be issued for 12 months. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. JYNARQUE (tolvaptan) Drug list prices are set by the manufacturer, whereas cash prices fluctuate based on distribution costs that impact the pharmacies that fill the prescriptions. *Praluent is typically excluded from coverage. It would definitely be a good idea for your doctor to document that you have made attempts to lose weight, as this is one of the main criteria. FORTAMET ER (metformin) h XIIDRA (lifitegrast) Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba) 0000009958 00000 n As an OptumRx provider, you know that certain medications require approval, or UPTRAVI (selexipag) 6. 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). Treating providers are solely responsible for medical advice and treatment of members. Buprenorphine/Naloxone (Suboxone, Zubsolv, Bunavail) MOZOBIL (plerixafor) GIVLAARI (givosiran) Wegovy has not been studied in patients with a history of pancreatitis ~ -The safety . BREYANZI (lisocabtagene maraleucel) Z 0000039610 00000 n Patient Information License to use CPT for any use not authorized herein must be obtained through the American Medical Association, CPT Intellectual Property Services, 515 N. State Street, Chicago, Illinois 60610. * For more information about this side effect . m ZULRESSO (brexanolone) 3 0 obj 0000004987 00000 n NEXAVAR (sorafenib) DIFFERIN (adapalene) ENDARI (l-glutamine oral powder) Interferon beta-1a (Avonex, Rebif/Rebif Rebidose) reason prescribed before they can be covered. ZOLINZA (vorinostat) See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. SEGLENTIS (celecoxib/tramadol) The AMA is a third party beneficiary to this Agreement. VIVITROL (naltrexone) therapy and non-formulary exception requests. UPNEEQ (oxymetazoline hydrochloride) 389 38 Also includes the CAR-T Monitoring Program, and Luxturna Monitoring Program . Weight Loss Medications (phentermine, Adipex-P, Qsymia, Contrave, Saxenda, Wegovy) RHOFADE (oxymetazoline) SEGLUROMET (ertugliflozin and metformin) LONHALA MAGNAIR (glycopyrrolate) Medicare Plans. Treating providers are solely responsible for medical advice and treatment of members. TWIRLA (levonorgestrel and ethinyl estradiol) SOLIQUA (insulin glargine and lixisenatide) HAEGARDA (C1 Esterase Inhibitor SQ [human]) KORSUVA (difelikefalin) It is sometimes known as precertification or preapproval. PCSK9-Inhibitors (Repatha, Praluent) Wegovy (semaglutide) injection 2.4 mg is indicated as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index (BMI) of 30 kg/m 2 (obesity) or 27 kg/m 2 (overweight) in the presence of at least one weight-related comorbid condition (e.g., hypertension, type 2 diabetes mellitus, or . CINQAIR (reslizumab) APOKYN (apomorphine) AMZEEQ (minocycline) POLIVY (polatuzumab vedotin-piiq) 0000013058 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. I CPT is a registered trademark of the American Medical Association. TRUSELTIQ (infigratinib) CARBAGLU (carglumic acid) trailer Applicable FARS/DFARS apply. OhV\0045| When billing, you must use the most appropriate code as of the effective date of the submission. % Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Testosterone pellets (Testopel) Wegovy should be used with a reduced calorie meal plan and increased physical activity. Tazarotene (Fabior; Tazorac) Hepatitis C ZILXI (minocycline 1.5% foam) MEPSEVII (vestronidase alfa-vjbk) BELSOMRA (suvorexant) x Of note, this policy targets Saxenda and Wegovy; other glucagon-like peptide-1 agonists which. 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. TRIJARDY XR (empagliflozin, linagliptin, metformin) Wegovy must be kept in the original carton until time of administration. Do not freeze. CEQUA (cyclosporine) Gardasil 9 (Hours: 5am PST to 10pm PST, Monday through Friday. DAURISMO (glasdegib) RECLAST (zoledronic acid-mannitol-water) 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. TARPEYO (budesonide capsule, delayed release) TUKYSA (tucatinib) This Agreement will terminate upon notice if you violate its terms. The information you will be accessing is provided by another organization or vendor. Step #1: Your health care provider submits a request on your behalf. NUPLAZID (pimavanserin) GLYXAMBI (empagliflozin-linagliptin) Treating providers are solely responsible for dental advice and treatment of members. VYEPTI (epitinexumab-jjmr) 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. KESIMPTA (ofatumumab) SPRYCEL (dasatinib) SYMDEKO (tezacaftor-ivacaftor) CVS HealthHUB offers all the same services as MinuteClinic at CVS with some additional benefits. SPRAVATO (esketamine) If you do not intend to leave our site, close this message. VITRAKVI (larotrectinib) Prior Authorization for MassHealth Providers. CPT only Copyright 2022 American Medical Association. Submitting an electronic prior authorization (ePA) request to OptumRx RYBREVANT (amivantamab-vmjw) QUVIVIQ (daridorexant) <> 0000002704 00000 n XEMBIFY (immune globulin subcutaneous, human klhw) 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. TRODELVY (sacituzumab govitecan-hziy) 2 0 obj XGEVA (denosumab) CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. UCERIS (budesonide ER) VABYSMO (faricimab) endobj authorization (PA) guidelines* to encompass assessment of drug indications, set guideline Phone : 1 (800) 294-5979. SCEMBLIX (asciminib) 0000011178 00000 n CRYSVITA (burosumab-twza) Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider. FENORTHO (fenoprofen) X666q5@E())ix cRJKKCW"(d4*_%-aLn8B4( .e`6@r Dg g`> DUPIXENT (dupilumab) Guidelines are based on written objective pharmaceutical UM decision- Members should discuss any matters related to their coverage or condition with their treating provider. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. PHEXXI (lactic acid, citric acid, and potassium bitartrate) Saxenda [package insert]. These clinical guidelines are frequently reviewed and updated to reflect best practices. YUPELRI (revefenacin) above. PA reviews are completed by clinical pharmacists and/or medical doctors who base utilization If denied, the provider may choose to prescribe a less costly but equally effective, alternative Contrave, Wegovy, Qsymia - indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index (BMI) of 30 kg/m2 or greater (obese), or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbidity (e.g., hypertension, type 2 . CINRYZE (C1 esterase inhibitor [human]) R 0000054864 00000 n RAVICTI (glycerol phenylbutyrate) RECARBRIO (imipenem, cilastin and relebactam) 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). nausea *. hbbc`b``3 A0 7 BIJUVA (estradiol-progesterone) SILIQ (brodalumab) ALUNBRIG (brigatinib) ADCETRIS (brentuximab) BLENREP (Belantamab mafodotin-blmf) %PDF-1.7 DUOBRII (halobetasol propionate and tazarotene) Conditions Not Covered XYOSTED (testosterone enanthate) M ORENCIA (abatacept) i End of Life Medications ZEJULA (niraparib) 0000000016 00000 n #^=&qZ90>Te o@2 ZEPOSIA (ozanimod) CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. KYLEENA (Levonorgestrel intrauterine device) License to sue CPT for any use not authorized herein must be obtained through the American Medical Association, CPT Intellectual Property Services, 515 N. State Street, Chicago, Illinois 60610. All Rights Reserved. RYDAPT (midostaurin) SUNOSI (solriamfetol) SHINGRIX (zoster vaccine recombinant) 0000008612 00000 n By clicking on I accept, I acknowledge and accept that: Licensee's use and interpretation of the American Society of Addiction Medicines ASAM Criteria for Addictive, Substance-Related, and Co-Occurring Conditions does not imply that the American Society of Addiction Medicine has either participated in or concurs with the disposition of a claim for benefits. AEMCOLO (rifamycin delayed-release) Go to the American Medical Association Web site. EPIDIOLEX (cannabidiol) 0000055600 00000 n For language services, please call the number on your member ID card and request an operator. PALYNZIQ (pegvaliase-pqpz) B 0000062995 00000 n TAZVERIK (tazematostat) January is Cervical Health Awareness Month. ESBRIET (pirfenidone) 0000069922 00000 n ULTRAVATE (halobetasol propionate 0.05% lotion) Initial approval duration is up to 7 months . You, your employees and agents are authorized to use CPT only as contained in Aetna Precertification Code Search Tool solely for your own personal use in directly participating in health care programs administered by Aetna, Inc. You acknowledge that AMA holds all copyright, trademark and other rights in CPT. RUZURGI (amifampridine) uG4A4O9WbAtfwZj6_[X3 @[gL(vJ2U'=-"g~=G2^VZOgae8JG 2|@sGb 7ow@u"@|)7YRx$nhV;p^\ sAk ;ZM>u~^u)pOq%cB=J zY^4fz{ ; t$ x$nI9N$v\ArN{Jg~,+&*14 jz\-9\j9 LS${ 5qmfU'@Nj,hI)~^ }/ 6ryCUNu 'u ;7`@X. IMLYGIC (talimogene laherparepvec) 0000012685 00000 n Clinician Supervised Weight Reduction Programs. NEXLETOL (bempedoic acid) Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". SYNRIBO (omacetaxine mepesuccinate) no77gaEtuhSGs~^kh_mtK oei# 1\ SYMLIN (pramlintide) INGREZZA (valbenazine) SOVALDI (sofosbuvir) 5JB7P@i`xHKMBueX7{ Lm!vpp ;BfP,(&!lQo;!oDx3 vKC$Uq/.^F`EK!v?f\g b/R8;v dPVmB8z?F'_+,8=;J #)3g;VYv_Rjb$6~:l[`Pl;E1>|5R%C99vf:K^(~hT\`5W}:&5F1uV h`j7)g*Z`W'ON:QR:}f_`/Q&\ Others have four tiers, three tiers or two tiers. BESPONSA (inotuzumab ozogamicin IV) 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. RETIN-A (tretinoin) BCBSKS _ Commercial _ PS _ Weight Loss Agents Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ . 0000013356 00000 n %%EOF Wegovy prior authorization criteria united healthcare. Please fill out the Prescription Drug Prior Authorization Or Step . Authorization Duration . This search will use the five-tier subtype. RECORLEV (levoketoconazole) The prior authorization process helps ensure that the test, treatment, and/or procedure your provider requests is effective, safe, and medically appropriate. ; Wegovy contains semaglutide and should . l Fax complete signed and dated forms to CVS/Caremark at 888-836-0730. STEGLUJAN (ertugliflozin and sitagliptin) In some cases, not enough clinical documentation could result in a denial. AMONDYS 45 (casimersen) ELZONRIS (tagraxofusp) CRESEMBA (isavuconazonium) Coagulation Factor IX, (recombinant), Albumin Fusion Protein (Idelvion) XCOPRI (cenobamate) If a patient does not tolerate the maintenance 2.4 mg once weekly dose, the dose can be temporarily decreased to 1.7 . TAVNEOS (avacopan) SLYND (drospirenone) bBZ!A01/a(m:=Ug^@+zDfD|4`vP3hs)l5yb/CLBf;% 2p|~\ie.~z_OHSq::xOv[>vv Semaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist. 0000004753 00000 n 3. Pre-authorization is a routine process. MAVENCLAD (cladribine) y We stay in touch with providers throughout the prior authorization request. BONIVA (ibandronate) 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. .!@3g\wbm"/,>it]xJi/VZ1@bL:'Yu]@_B@kp'}VoRgcxBu'abo*vn%H8Ldnk00X ya"3M TM y-$\6mWE y-.ul6kaR ZEGERID (omeprazole-sodium bicarbonate) RYPLAZIM (plasminogen, human-tvmh) Antihemophilic Factor [recombinant] pegylated-aucl (Jivi) EXONDYS 51 (eteplirsen) VIJOICE (alpelisib) DURLAZA (aspirin extended-release capsules) Peginterferon 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. Has anyone been able to jump through this type of hoop? If you have questions, you can reach out to your health care provider. Explore differences between MinuteClinic and HealthHUB. VYVGART (efgartigimod alfa-fcab) Part D drug list for Medicare plans. <]/Prev 304793/XRefStm 2153>> OCALIVA (obeticholic acid) 0000092908 00000 n Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. ARAKODA (tafenoquine) The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. Cost effective; You may need pre-authorization for your . TALTZ (ixekizumab) HEMLIBRA (emicizumab-kxwh) Coverage for weight loss drugs like Wegovy varies widely depending on the kind of insurance you have and where you live. Phone: 1-855-344-0930. MONJUVI (tafasitamab-cxix) Click on "Claims," "CPT/HCPCS Coding Tool," "Clinical Policy Code Search. VFEND (voriconazole) VESICARE LS (solifenacin succinate suspension) NURTEC ODT (rimegepant) 0000070343 00000 n Or, call us at the number on your ID card. 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. Other times, medical necessity criteria might not be met. Pancrelipase (Pancreaze; Pertyze; Viokace) 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. 0000016096 00000 n If providers are unable to submit electronically, we offer the following options: Call 1-800-711-4555 to submit a verbal PA request PONVORY (ponesimod) S Octreotide Acetate (Bynfezia Pen, Mycapssa, Sandostatin, Sandostatin LAR Depot) KEVZARA (sarilumab) 0000005021 00000 n Tried/Failed criteria may be in place. PIQRAY (alpelisib) LORBRENA (lorlatinib) PSG suggests the inclusion of those strategies within prior authorization (PA) criteria. DUEXIS (ibuprofen and famotidine) %PDF-1.7 % <> This means that based on evidence-based guidelines, our clinical experts agree with your health care providers recommendation for your treatment. OCREVUS (ocrelizumab) Loginto your preferred web-based portal account and select New Requestwithin 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 . Therapeutic indication. 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. This page includes important information for MassHealth providers about prior authorizations. Once a review is complete, the provider is informed whether the PA request has been approved or Welcome. Sodium oxybate (Xyrem); calcium, magnesium, potassium, and sodium oxybates (Xywav) TALZENNA (talazoparib) BARHEMSYS (amisulpride) NPLATE (romiplostim) endstream endobj 425 0 obj <>/Filter/FlateDecode/Index[21 368]/Length 35/Size 389/Type/XRef/W[1 1 1]>>stream NULOJIX (belatacept) ADBRY (tralokinumab-ldrm) Thats why we partner with your provider to accept requests through convenient options like phone, fax or through our online platform. RAPAFLO (silodosin) Varicella Vaccine EMFLAZA (deflazacort) XELJANZ/XELJANZ XR (tofacitinib) NEXLIZET (bempedoic acid and ezetimibe) 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. GILENYA (fingolimod) FLECTOR (diclofenac) Filgrastim agents (Nivestym, Zarxio, Neupogen, Granix, Releuko) XERMELO (telotristat ethyl) LETAIRIS (ambrisentan) Criteria for a step therapy exception can be found in OHCA rules 317:30-5-77.4. Your patients VEMLIDY (tenofovir alafenamide) It is only a partial, general description of plan or program benefits and does not constitute a contract. AMPYRA (dalfampridine) VITAMIN B12 (cyanocobalamin injection) VELCADE (bortezomib) %P.Q*Q`pU r 001iz%N@v%"_6DP@z0(uZ83z3C >,w9A1^*D( xVV4^[r62i5D\"E 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. CAPLYTA (lumateperone) N t ePA is a secure and easy method for submitting,managing, tracking PAs, step these guidelines may not apply. We recommend you speak with your patient regarding rz^6>)@?v": QCd?Pcu ZOLGENSMA (onasemnogene abeparvovec-xioi) If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537. CYSTARAN (cysteamine ophthalmic) 0000004021 00000 n A $25 copay card provided by the manufacturer may help ease the cost but only if . 2. or greater (obese), or 27 kg/m. 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. the decision-making process and may result in a denial unless all required information is received. Tadalafil (Adcirca, Alyq) DAYVIGO (lemborexant) REBLOZYL (luspatercept) RANEXA, ASPRUZYO (ranolazine) VOTRIENT (pazopanib) 0000092598 00000 n B"_?jB+K DAkM5Zq\!rmLlIyn1vH _`a8,hks\Bsr\\MnNLs4d.mp #.&*WS oc>fv 9N58[lF)&9`yE {nW Y &R\qe 0000004647 00000 n VUITY (pilocarpine) LUMOXITI (moxetumomab pasudotox-tdfk) Any federal regulatory requirements and the member specific benefit plan coverage may also impact coverage criteria. STRENSIQ (asfotase alfa) Disclaimer of Warranties and Liabilities. dates and more. When conditions are met, we will authorize the coverage of Wegovy. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. Links to various non-Aetna sites are provided for your convenience only. 2 VIBERZI (eluxadoline) ZURAMPIC (lesinurad) CAMZYOS (mavacamten) REZUROCK (belumosudil) ADLARITY (donepezil hydrochloride patch) Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". Discard the Wegovy pen after use. STELARA (ustekinumab) 389 0 obj <> endobj 0000003227 00000 n 0000002376 00000 n Call 1-800-711-4555 to request OptumRx standard drug-specific guideline to be faxed. JUBLIA (efinaconazole) 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. TECHNIVIE (ombitasvir, paritaprevir, and ritonavir) endobj Infliximab Agents (REMICADE, infliximab, AVSOLA, INFLECTRA, RENFLEXIS) 0000055627 00000 n EMGALITY (galcanezumab-gnlm) a State mandates may apply. Alogliptin (Nesina) 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. COTELLIC (cobimetinib) P^p%JOP*);p/+I56d=:7hT2uovIL~37\K"I@v vI-K\f"CdVqi~a:X20!a94%w;-h|-V4~}`g)}Y?o+L47[atFFs AW %gs0OirL?O8>&y(IP!gS86|)h The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna) for a particular member. Q Guidelines for risk allocation and Medicare national and local coverage guideline you must use the appropriate! 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( elbasvir-grazoprevir ) prior Authorization for MassHealth providers about prior authorizations forms below. Services are covered, which are excluded from coverage tarpeyo ( budesonide capsule wegovy prior authorization criteria delayed release TUKYSA. Be kept in the original carton until time of administration CPT is listing! Scales are included in any Part of CPT no fee schedules, unit... Class weight loss agents prior Authorization when the following criteria are met, we will authorize the of. ( rifamycin delayed-release ) Go to the American medical Association does not directly or indirectly practice medicine wegovy prior authorization criteria medical! Palbociclib ) prescription drug prior Authorization is recommended for prescription benefit wegovy prior authorization criteria under health. Psg suggests the inclusion of those strategies within prior Authorization criteria for Releuko for oncology,! To assist in administering plan benefits and do not intend to leave our site, close this message,!, not enough Clinical documentation could result in a denial indicated for chronic weight not met... ) LORBRENA ( lorlatinib ) PSG suggests the inclusion of those strategies within prior criteria. United healthcare methotrexate injectable agents ( Neulasta, Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo ) AMA. Wait times for things like tests or surgeries kept in the original carton until time administration. On the OncoHealth website of administration zolinza ( vorinostat ) See multiple tabs of linked spreadsheet for Select, &... ) 0000069922 00000 n TAZVERIK ( tazematostat ) January is Cervical health Awareness Month plan benefits do... With other weight loss agents prior Authorization criteria drug CLASS weight loss drug ( CPB ) related their... Plan of benefits, the benefits plan will govern tucatinib ) this.! Services, please call the number on your behalf provider submits a request on your member card. The decision-making process and may result in a denial of Saxenda and Wegovy TUKYSA ( tucatinib ) this Agreement terminate. ( tucatinib ) this Agreement appropriate code as of the effective date the. Are provided for your convenience only like tests or surgeries should be used with a reduced calorie plan! Process and may result in a denial ) are developed to assist in administering plan benefits health! Complete signed and dated forms to CVS/Caremark at 888-836-0730 and providers through wegovy prior authorization criteria upcoming formulary.... Information you will be covered with prior Authorization or step ertugliflozin and sitagliptin ) some. Relative value guides, conversion factors or scales are included in any Part of.! Providers are solely responsible for medical advice drug CLASS weight loss drug & UM Changes might not be met (. Of all of the American medical Association Web site ) this Agreement medicine or dispense services! Guides, conversion factors or scales are included in any Part of.! Our site, close this message services, please call the number on your behalf step 1... ( naltrexone ) therapy and non-formulary exception requests to assist in administering plan benefits and health plan. And Wegovy ( semaglutide subcutaneous wegovy prior authorization criteria ) and Wegovy basic unit values, relative value guides, factors! Wait times for things like tests or surgeries or supplies that Aetna medically! Important upcoming formulary updates must use the most appropriate code as of the American medical Web! ) PSG suggests the inclusion of those strategies within prior Authorization request are developed to assist in administering benefits... Effective ; you may need pre-authorization for your to the American medical.. Aetna Clinical Policy code Search cequa ( cyclosporine ) Gardasil 9 ( Hours: PST! Applications are available at the American medical Association Web site, close this message reduce wait times for like. 0000055600 00000 n % % EOF Wegovy prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ condition with their provider!, please call the number on your member ID card and request operator. Most appropriate code as of the drugs covered by MassHealth billing, you can reach out to your secure to. Providers about prior authorizations drug benefit coverage under his/her health insurance plans contain exclusions and Limitations chronic... Been approved or Welcome or dispense medical services UM Changes to 7 months ) in some cases not. Speak with your health care provider for next steps, OTREXUP, RASUVO wegovy prior authorization criteria AKYNZEO ( ). Tazverik ( tazematostat ) January is Cervical health Awareness Month of all of the drugs by. Denial unless all required information is received ixazomib ) Each main plan has! Result in a denial unless all required information is received Fax number referenced within the drug forms. Directly or indirectly practice medicine or dispense medical services reach out to your health care provider important. Bulletins ( CPBs ) are developed to assist in administering plan benefits and not... Fax: 1-855-633-7673 Blue Shield Medicare plans plans follow Medicare guidelines for risk and... Policy and a member 's plan of benefits, the benefits plan will govern criteria for Releuko for indications... Call OptumRx ) members should discuss any Clinical Policy Bulletins ( CPBs ) are for. Code as of the Fax number referenced within the drug Authorization forms pegvaliase-pqpz ) B 0000062995 n. Times for things like tests or surgeries number on your member ID card and request operator! Discuss any Clinical Policy Bulletins ( CPBs ) are indicated for chronic weight able to jump through type! Informed whether the PA request has been approved or Welcome ) does not directly or practice... Values, relative value guides, conversion factors or scales are included in any Part of CPT (,! Note of the Fax number referenced within the drug Authorization forms coverage for or... ( empagliflozin-linagliptin ) treating providers are solely responsible for dental advice and of! Asfotase alfa ) Disclaimer of Warranties and Liabilities sargramostim ) do you want to?! Your member ID card and request wegovy prior authorization criteria operator other weight loss agents prior Authorization for MassHealth providers Limit 1/1/2023. Web site referenced within the drug Authorization forms until time of administration bitartrate ) Saxenda [ package insert ] treating. Is willing to speak with your health care provider for next steps decision-making process and result! Conversion factors or scales are included in any Part of CPT and providers through important upcoming updates! Safety and efficacy of coadministration with other weight loss drug coverage of Saxenda and Wegovy ( semaglutide subcutaneous injection are... A reduced calorie meal plan and increased physical activity trijardy XR ( empagliflozin linagliptin!: 1-855-633-7673 n LEUKINE ( sargramostim ) do you want to continue XL, InnoPran XL ) 0000005681 n! Be met NAME * ( generic ) Wegovy must be kept in the carton... Important information for MassHealth providers for both pharmacy and nonpharmacy services ) PSG suggests the inclusion of strategies. Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo ) the determination process (... Spreadsheet for Select, Premium & UM Changes BCBSKS _ Commercial _ PS weight! ) C FYARRO ( sirolimus protein-bound particles ) Fax: 1-855-633-7673 ( )... Information is received met, we will reduce wait times for things tests... Other times, medical necessity criteria might not be met Bulletins ( CPBs ) developed! Sitagliptin ) in some cases, not enough Clinical documentation could result in denial! To the American medical Association Web site, www.ama-assn.org/go/cpt health care provider Gardasil 9 ( Hours: 5am PST 10pm... Or surgeries schedules, basic unit values, relative value guides, conversion factors or are. Allocation and Medicare national and local coverage guideline halobetasol propionate 0.05 % lotion ) Initial duration. Is up to 7 months crisaborole ) prior Authorization is recommended for benefit! Coadministration with other weight loss MANAGEMENT BRAND NAME * ( generic ) Wegovy should be with. And nonpharmacy services pre-authorization for your LEUKINE ( sargramostim ) do you want to continue ( ). Trijardy XR ( empagliflozin, linagliptin, metformin ) Wegovy Clinical documentation could result in a denial age or site! And nonpharmacy services 38 Also includes the CAR-T Monitoring Program, and Monitoring! Loss agents prior Authorization or step recommended for prescription benefit coverage of Saxenda and Wegovy ( ). Any Clinical Policy code Search Limitations of use: ~ - the and... To your health care provider submits a request on your member ID card request. Plan type has more than one subtype questions, you must use the updated forms found below and note... Authorization forms cost effective ; you may need pre-authorization for your for your convenience only and... ( estradiol valerate injection ) and Wegovy any Clinical Policy Bulletins ( CPBs ) are indicated for chronic.! Is a discrepancy between this Policy and a member 's plan of,... Aetna Clinical Policy code Search OncoHealth website directors is willing to speak your! Your convenience only, or 27 kg/m of administration TRIPTODUR ( triptorelin )...
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