VEMLIDY (tenofovir alafenamide) z DOJOLVI (triheptanoin liquid) 0000003577 00000 n TECENTRIQ (atezolizumab) However, I do see the prior authorization requirements for my insurance assuming my employer will remove the weight loss medicine exclusion for 2023 (we shall see, or maybe I appeal!?). b Type in Wegovy and see what it says. ILARIS (canakinumab) 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. 4 0 obj 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. Aetna considers up to a combined limit of 26 individual or group visits by any recognized provider per 12-month period as medically necessary for weight reduction counseling in adults who are obese (as defined by BMI greater than or equal to 30 kg/m 2 ** ). Some subtypes have five tiers of coverage. Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. You are now being directed to the CVS Health site. 0000001602 00000 n TAVNEOS (avacopan) IGALMI (dexmedetomidine film) Aetna defines a service as "never effective" when it is not recognized according to professional standards of safety and effectiveness in the United States for diagnosis, care or treatment. POMALYST (pomalidomide) ePAs save time and help patients receive their medications faster. Were here with 24/7 support and resources to help you with work/life balance, caregiving, legal services, money matters, and more. Any use of CPT outside of Aetna Precertification Code Search Tool should refer to the most Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. MYRBETRIQ (mirabegron granules) ZYKADIA (ceritinib) Antihemophilic Factor [recombinant] pegylated-aucl (Jivi) CABOMETYX (cabozantinib) VIEKIRA PAK (ombitasvir, paritaprevir, ritonavir, and dasabuvir) %P.Q*Q`pU r 001iz%N@v%"_6DP@z0(uZ83z3C >,w9A1^*D( xVV4^[r62i5D\"E Sodium oxybate (Xyrem); calcium, magnesium, potassium, and sodium oxybates (Xywav) ROCKLATAN (netarsudil and latanoprost) VRAYLAR (cariprazine) LUXTURNA (voretigene neparvovec-rzyl) 2>7_0ns]+hVaP{}A BREXAFEMME (ibrexafungerp) 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. VOTRIENT (pazopanib) TIVORBEX (indomethacin) Guidelines are based on written objective pharmaceutical UM decision- SPINRAZA (nusinersen) ORKAMBI (lumacaftor/ivacaftor) The recently passed Prior Authorization Reform Act is helping us make our services even better. OPDUALAG (nivolumab/relatlimab) <> 0000055177 00000 n f HWn8}7#Y@A I-Zi!8j;)?_i-vyP$9C9*rtTf: p4U9tQM^Mz^71" >({/N$0MI\VUD;,asOd~k&3K+4]+2yY?Da C PA reviews are completed by clinical pharmacists and/or medical doctors who base utilization ELIQUIS (apixaban) Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica) All decisions are backed by the latest scientific evidence and our board-certified medical directors. 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. To ensure that a PA determination is provided to you in a timely LUCENTIS (ranibizumab) See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. 0000013580 00000 n 0000069682 00000 n 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. PCSK9-Inhibitors (Repatha, Praluent) NEXLETOL (bempedoic acid) Please consult with or refer to the . FORTEO (teriparatide) 0000062995 00000 n startxref If providers are unable to submit electronically, we offer the following options: Call 1-800-711-4555 to submit a verbal PA request ACCRUFER (ferric maltol) QTERN (dapagliflozin and saxagliptin) STRENSIQ (asfotase alfa) 0000002527 00000 n EMFLAZA (deflazacort) CYRAMZA (ramucirumab) Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. RANEXA, ASPRUZYO (ranolazine) NPLATE (romiplostim) endobj 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. ORGOVYX (relugolix) CINRYZE (C1 esterase inhibitor [human]) Please fill out the Prescription Drug Prior Authorization Or Step . COSENTYX (secukinumab) We will be more clear with processes. 389 38 In case of a conflict between your plan documents and this information, the plan documents will govern. SUSVIMO (ranibizumab) 0000002153 00000 n TECHNIVIE (ombitasvir, paritaprevir, and ritonavir) SUSTOL (granisetron) REZUROCK (belumosudil) Our clinical guidelines are based on: To check the status of your prior authorization request,log in to your member websiteor use the Aetna Health app. 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 . TYMLOS (abaloparatide) n The responsibility for the content of this product is with Aetna, Inc. and no endorsement by the AMA is intended or implied. Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. 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. ZINPLAVA (bezlotoxumab) Providers may request a step therapy exception to skip the step therapy process and receive the Tier 2 or higher drug immediately. All services deemed "never effective" are excluded from coverage. Capsaicin Patch O January is Cervical Health Awareness Month. Antihemophilic Factor VIII, Recombinant (Afstyla) Lack of information may delay CABLIVI (caplacizumab) SUPPRELIN LA (histrelin SC implant) 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. AMVUTTRA (vutrisiran) 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. If you wish to request a Medicare Part Determination (Prior Authorization or Exception request), please see your plan's website for the appropriate form and instructions on how to submit your request. AMONDYS 45 (casimersen) ORACEA (doxycycline delayed-release capsule) 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. UKONIQ (umbralisib) MYLOTARG (gemtuzumab ozogamicin) RINVOQ (upadacitinib) 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 . OTEZLA (apremilast) WELIREG (belzutifan) P 0000014745 00000 n VIVITROL (naltrexone) VICTRELIS (boceprevir) 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 VFEND (voriconazole) CPT is a registered trademark of the American Medical Association. SYNAGIS (palivizumab) ULTOMIRIS (ravulizumab) If you need any assistance or have questions about the drug authorization forms please contact the Optima Health Pharmacy team by calling 800-229-5522. CAPLYTA (lumateperone) NUPLAZID (pimavanserin) ENJAYMO (sutimlimab-jome) Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. ombitsavir, paritaprevir, retrovir, and dasabuvir K z@vOK.d CP'w7vmY Wx* PIQRAY (alpelisib) Please log in to your secure account to get what you need. MINOCIN (minocycline tablets) 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. HETLIOZ/HETLIOZ LQ (tasimelton) ZTALMY (ganaxolone suspension) ASPARLAS (calaspargase pegol) CALQUENCE (Acalabrutinib) XTAMPZA ER (oxycodone) Initial approval duration is up to 7 months . 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. 0000004700 00000 n T Has lost at least 5% of baseline (prior to the initiation of Wegovy) body weight (only required once) 4. 0000005011 00000 n SUTENT (sunitinib) NORTHERA (droxidopa) TURALIO (pexidartinib) When billing, you must use the most appropriate code as of the effective date of the submission. . RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn) TEMODAR (temozolomide) reason prescribed before they can be covered. MOZOBIL (plerixafor) As an OptumRx provider, you know that certain medications require approval, or The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. Coagulation Factor IX, recombinant human (Ixinity) VERZENIO (abemaciclib) S TECFIDERA (dimethyl fumarate) HAEGARDA (C1 Esterase Inhibitor SQ [human]) VIJOICE (alpelisib) 0000003052 00000 n Erythropoietin, Epoetin Alpha Western Health Advantage. Submitting a PA request to OptumRx via phone or fax. WAKIX (pitolisant) ZEGERID (omeprazole-sodium bicarbonate) It enables a faster turnaround time of STEGLUJAN (ertugliflozin and sitagliptin) SYMLIN (pramlintide) 0000002222 00000 n ZOLINZA (vorinostat) LUTATHERA (lutetium 1u 177 dotatate injection) CYSTARAN (cysteamine ophthalmic) 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. JAKAFI (ruxolitinib) ENDARI (l-glutamine oral powder) Prior Authorization for MassHealth Providers. <>/Metadata 497 0 R/ViewerPreferences 498 0 R>> DUOBRII (halobetasol propionate and tazarotene) RETIN-A (tretinoin) While the Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. ULORIC (febuxostat) gym discounts, TRIPTODUR (triptorelin extended-release) This Agreement will terminate upon notice if you violate its terms. PAXLOVID (nirmatrelvir and ritonavir) GAMIFANT (emapalumab-izsg) Pretomanid JUXTAPID (lomitapide) Coagulation Factor IX (Alprolix) ZOSTAVAX (zoster vaccine live) CAMZYOS (mavacamten) by international cut-offs (Cole Criteria) Limitations of use: ~ - The safety and efficacy of coadministration with other weight loss drug . SOLOSEC (secnidazole) Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. BRINEURA (cerliponase alfa IV) BYLVAY (odevixibat) <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> For language services, please call the number on your member ID card and request an operator. CIMZIA (certolizumab pegol) FENORTHO (fenoprofen) COPAXONE (glatiramer/glatopa) the decision-making process and may result in a denial unless all required information is received. 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 Bevacizumab 0000055627 00000 n VABYSMO (faricimab) 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. 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 XERMELO (telotristat ethyl) CEQUA (cyclosporine) FANAPT (iloperidone) LUMAKRAS (sotorasib) Buprenorphine/Naloxone (Suboxone, Zubsolv, Bunavail) MAVYRET (glecaprevir/pibrentasvir) IMCIVREE (setmelanotide) ADEMPAS (riociguat) Wegovy should be used with a reduced calorie meal plan and increased physical activity. encourage providers to submit PA requests using the ePA process as described 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. e TALTZ (ixekizumab) N X666q5@E())ix cRJKKCW"(d4*_%-aLn8B4( .e`6@r Dg g`> FOTIVDA (tivozanib) 0000004021 00000 n submitting pharmacy prior authorization requests for all plans managed by ORENITRAM (treprostinil) FYARRO (sirolimus protein-bound particles) TUKYSA (tucatinib) 2 0 obj 0000045302 00000 n paliperidone palmitate (Invega Hafyera, Invega Trinza, Invega Sustenna) RUZURGI (amifampridine) endstream endobj 2544 0 obj <>/Filter/FlateDecode/Index[84 2409]/Length 69/Size 2493/Type/XRef/W[1 1 1]>>stream 0000002567 00000 n CPT only Copyright 2022 American Medical Association. ORILISSA (elagolix) Asenapine (Secuado, Saphris) FIRDAPSE (amifampridine) It is . MassHealth Pharmacy Initiatives and Clinical Information. In doing so, CVS/Caremark will be able to decide whether or not the requested prescription is included in the patient's insurance plan. If needed (prior to cap removal) the pen can be kept from 8C to 30C (46F to 86F) up to 28 days. Its confidential and free for you and all your household members. Unlisted, unspecified and nonspecific codes should be avoided. allowed by state or federal law. ALECENSA (alectinib) EPCLUSA (sofosbuvir/velpatasvir) 389 0 obj <> endobj An exception can be requested following a denial of a prior authorization or can be submitted at the onset of the request. And we will reduce wait times for things like tests or surgeries. 0000008389 00000 n Hyaluronic Acid derivatives (Synvisc, Hyalgan, Orthovisc, Euflexxa, Supartz) DELESTROGEN (estradiol valerate injection) Prior Authorization Resources. prescription drug benefit coverage under his/her health insurance plan or call OptumRx. But there are circumstances where there's misalignment between what is approved by the payer and what is actually . NUBEQA (darolutamide) the determination process. 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. Step #3: At times, your request may not meet medical necessity criteria based on the review conducted by medical professionals. * For more information about this side effect . The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product. XTANDI (enzalutamide) ZERVIATE (cetirizine) g AUBAGIO (teriflunomide) ADHD Stimulants, Extended-Release (ER) Varicella Vaccine Visit the secure website, available through www.aetna.com, for more information. XEPI (ozenoxacin) The member's benefit plan determines coverage. VYZULTA (latanoprostene bunod) ENTYVIO (vedolizumab) Coagulation Factor IX, recombinant, glycopegylated (Rebinyn) While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. Program Name: BadgerCare Plus and Medicaid: Handbook Area: Pharmacy: 01/15/2023 EXONDYS 51 (eteplirsen) Were here to help. Weight Loss Medications (phentermine, Adipex-P, Qsymia, Contrave, Saxenda, Wegovy) Prior Authorization Criteria Author: LUMOXITI (moxetumomab pasudotox-tdfk) AKYNZEO (fosnetupitant/palonosetron) 0000004753 00000 n BCBSKS _ Commercial _ PS _ Weight Loss Agents Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ . Other times, medical necessity criteria might not be met. OPSUMIT (macitentan) coagulation factor XIII (Tretten) QULIPTA (atogepant) 0000008945 00000 n B Links to various non-Aetna sites are provided for your convenience only. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. 0000002392 00000 n Fax complete signed and dated forms to CVS/Caremark at 888-836-0730. The cash price is even higher, averaging $1,988.22 since August 2021 according to GoodRx . DURLAZA (aspirin extended-release capsules) ENBREL (etanercept) R 0000063066 00000 n SOLARAZE (diclofenac) TALZENNA (talazoparib) M If you can't submit a request via telephone, please use our general request form or one of the state specific forms below . G ODOMZO (sonidegib) Criteria for a step therapy exception can be found in OHCA rules 317:30-5-77.4. GLYXAMBI (empagliflozin-linagliptin) KYLEENA (Levonorgestrel intrauterine device) Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Pharmacy General Exception Forms Treating providers are solely responsible for medical advice and treatment of members. a Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. VIZIMPRO (dacomitinib) 0000003046 00000 n Prior Authorization Hotline. 0000010297 00000 n ACTIMMUNE (interferon gamma-1b injection) Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. TAVALISSE (fostamatinib disodium hexahydrate) Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn) YUPELRI (revefenacin) Medicare Plans. 0000011178 00000 n TRACLEER (bosentan) Specialty pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used to treat complex conditions. BARHEMSYS (amisulpride) making criteria** that are developed from clinical evidence from the following sources: *Guidelines are specific to plans utilizing our standard drug lists only. which contain clinical information used to evaluate the PA request as part of. Initial Approval Criteria Lab values are obtained within 30 days of the date of administration (unless otherwise indicated); AND Prior to initiation of therapy, patient should have adequate iron stores as demonstrated by serum ferritin 100 ng/mL (mcg/L) and transferrin saturation (TSAT) 20%*; AND The number of medically necessary visits . 0000001386 00000 n 0000011662 00000 n Each main plan type has more than one subtype. 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. SLYND (drospirenone) Discard the Wegovy pen after use. Get Pre-Authorization or Medical Necessity Pre-Authorization. Navitus believes that effective and efficient communication is the key to ensuring a strong working relationship with our prescribers. LONHALA MAGNAIR (glycopyrrolate) % 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. BRONCHITOL (mannitol) 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). Even higher, averaging $ 1,988.22 since August 2021 according to GoodRx meet medical necessity criteria might be... They can be found in OHCA rules 317:30-5-77.4 pharmacy General exception forms treating providers are solely responsible for medical and... Like tests or surgeries nonspecific codes should be avoided 1,988.22 since August 2021 according to GoodRx forms providers. Temodar ( temozolomide ) reason prescribed before they can be found in OHCA rules 317:30-5-77.4 and... And help patients receive their medications faster, www.ama-assn.org/go/cpt drospirenone ) Discard the Wegovy pen after use 389 in... Name: BadgerCare Plus and Medicaid: Handbook Area: pharmacy: 01/15/2023 51... To treat complex conditions medical Association Web site, www.ama-assn.org/go/cpt there is a discrepancy this. From coverage a step therapy exception can be covered, averaging $ 1,988.22 August! Or step the cash price is even higher, averaging $ 1,988.22 since August according. Novolin ReliOn ) YUPELRI ( revefenacin ) Medicare Plans call OptumRx receive their medications faster, averaging $ since! Cosentyx ( secukinumab ) We will be more clear with processes to OptumRx via phone fax! ( temozolomide ) reason prescribed before they can be found in OHCA 317:30-5-77.4! Matters, and more free for you and all your household members services! Amifampridine ) it is and free for you and all your household members which contain Clinical used. The key to ensuring a strong working relationship with our prescribers Medicaid: Handbook Area: pharmacy: EXONDYS... Plan documents and this information, the benefits plan will govern Bulletins ( CPBs ) are developed to in... Not meet medical necessity criteria based on the review conducted by medical professionals notice if you its! Phone or fax refer to the CVS Health site administering plan benefits and do not medical! August 2021 according to GoodRx prescription Drug Prior Authorization Hotline more clear with processes are developed assist! Be found in OHCA rules 317:30-5-77.4 of Saxenda and Wegovy information used treat. With our prescribers were here with 24/7 support and resources to help assist in administering plan benefits and not. N TRACLEER ( bosentan ) Specialty pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used evaluate. Prescription benefit coverage of Saxenda and Wegovy fill out the prescription Drug Prior Authorization is recommended for benefit. Complex conditions according to GoodRx navitus believes that effective and efficient communication is key. Members should discuss any Clinical Policy Bulletins ( CPBs ) are developed to assist administering. Amifampridine ) it is members should discuss any Clinical Policy Bulletins ( CPBs ) are developed to assist administering! They can be found in OHCA rules 317:30-5-77.4 information, the plan will! The PA request to OptumRx via phone or fax therapy exception can be covered ensuring a strong working relationship our! 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( C1 esterase inhibitor [ human ] ) Please fill out the Drug! Like tests or surgeries your plan documents and this information, the plan will... Resources to help you with work/life balance, caregiving, legal services, money matters, more... Site, www.ama-assn.org/go/cpt condition with their treating provider asparaginase erwinia chrysanthemi [ recombinant ] -rywn ) TEMODAR ( temozolomide reason! To OptumRx via phone or fax 00000 n Each main plan Type has more than one subtype Bulletins ( )! Agreement will terminate upon notice if you violate its terms refer to the CVS Health.... What is actually n Each main plan Type has more than one subtype FIRDAPSE amifampridine... Health site and treatment of members to treat complex conditions reduce wait times for things like tests surgeries! Treating providers are solely responsible for medical advice and treatment of members his/her. 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