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. VIJOICE (alpelisib) XOSPATA (gilteritinib) CHOLBAM (cholic acid) This means that based on evidence-based guidelines, our clinical experts agree with your health care providers recommendation for your treatment. JEMPERLI (dostarlimab-gxly) RECORLEV (levoketoconazole) RETEVMO (selpercatinib) CIMZIA (certolizumab pegol) FABRAZYME (agalsidase beta) The request processes as quickly as possible once all required information is together. 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) 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. LEUKINE (sargramostim) a State mandates may apply. L REVATIO (sildenafil citrate) endstream endobj 425 0 obj <>/Filter/FlateDecode/Index[21 368]/Length 35/Size 389/Type/XRef/W[1 1 1]>>stream 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 SYMDEKO (tezacaftor-ivacaftor) OFEV (nintedanib) PENNSAID (diclofenac) X 0000008227 00000 n Click on "Claims," "CPT/HCPCS Coding Tool," "Clinical Policy Code Search. End of Life Medications OXLUMO (lumasiran) While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. MARGENZA (margetuximab-cmkb) ADHD Stimulants, Extended-Release (ER) OXERVATE (cenegermin-bkbj) 0000001076 00000 n It is . 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. Alogliptin-Metformin (Kazano) KRYSTEXXA (pegloticase) The responsibility for the content of this product is with Aetna, Inc. and no endorsement by the AMA is intended or implied. OPDUALAG (nivolumab/relatlimab) PEPAXTO (melphalan flufenamide) CYRAMZA (ramucirumab) In case of a conflict between your plan documents and this information, the plan documents will govern. Riluzole (Exservan, Rilutek, Tiglutik, generic riluzole) AIMOVIG (erenumab-aooe) CPT is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physicians. CPT is a registered trademark of the American Medical Association. 0000003227 00000 n Hyaluronic Acid derivatives (Synvisc, Hyalgan, Orthovisc, Euflexxa, Supartz) a TECFIDERA (dimethyl fumarate) RINVOQ (upadacitinib) 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. PCSK9-Inhibitors (Repatha, Praluent) The prior authorization process helps ensure that you are receiving quality, effective, safe, and timely care that is medically necessary. 0000004176 00000 n m stream KORSUVA (difelikefalin) ULTOMIRIS (ravulizumab) OTEZLA (apremilast) 0000009958 00000 n Any use of CPT outside of Aetna Clinical Policy Bulletins (CPBs) should refer to the most current Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. % 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 . ORILISSA (elagolix) q[#rveQ:7cntFHb)?&\FmBmF[l~7NizfdUc\q (^"_>{s^kIi&=s oqQ^Ne[* h$h~^h2:YYWO8"Si5c@9tUh1)4 Pharmacy General Exception Forms Wegovy should be used with a reduced calorie meal plan and increased physical activity. OCREVUS (ocrelizumab) TRACLEER (bosentan) hb```b``mf`c`[ @Q{9 P@`mOU.Iad2J1&@ZX\2 6ttt `D> `g`QJ@ gg`apc7t3N``X tgD?>H7X570}``^ 0C7|^ '2000 G> BELEODAQ (belinostat) The responsibility for the content of Aetna Clinical Policy Bulletins (CPBs) is with Aetna and no endorsement by the AMA is intended or should be implied. Once a review is complete, the provider is informed whether the PA request has been approved or iMo::>91}h9 KESIMPTA (ofatumumab) XTAMPZA ER (oxycodone) PROBUPHINE (buprenorphine implant for subdermal administration) As an OptumRx provider, you know that certain medications require approval, or XADAGO (safinamide) Y EPIDIOLEX (cannabidiol) G uG4A4O9WbAtfwZj6_[X3 @[gL(vJ2U'=-"g~=G2^VZOgae8JG 2|@sGb 7ow@u"@|)7YRx$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. of the following: (a) Patient is 18 years of age for Wegovy (b) Patient is 12 years of age for Saxenda (3) Failure to lose > 5% of body weight through at least 6 months of lifestyle modification alone (e.g., dietary or caloric restriction, exercise, behavioral support, community . 0000005021 00000 n 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. If providers are unable to submit electronically, we offer the following options: Call 1-800-711-4555 to submit a verbal PA request 0000039610 00000 n ENBREL (etanercept) Navitus believes that effective and efficient communication is the key to ensuring a strong working relationship with our prescribers. TECENTRIQ (atezolizumab) 2>7_0ns]+hVaP{}A ILARIS (canakinumab) . ARALEN (chloroquine phosphate) 0000003046 00000 n Wegovy, a new prescription medication for chronic weight management, launched with a price tag of around $1,627 a month before insurance. 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. VEMLIDY (tenofovir alafenamide) 0000062995 00000 n XURIDEN (uridine triacetate) If you can't submit a request via telephone, please use our general request form or one of the state specific forms below . PROAIR DIGIHALER (albuterol) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. 0000070343 00000 n LUMOXITI (moxetumomab pasudotox-tdfk) %PDF-1.7 ONFI (clobazam) INREBIC (fedratinib) NAPRELAN (naproxen) If denied, the provider may choose to prescribe a less costly but equally effective, alternative ZOKINVY (lonafarnib) 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). VIZIMPRO (dacomitinib) Interferon beta-1b (Betaseron, Extavia) Discontinue WEGOVY if the patient cannot tolerate the 2.4 mg dose. 0 0000001794 00000 n The Dental Clinical Policy Bulletins (DCPBs) describe Aetna's current determinations of whether certain services or supplies are medically necessary, based upon a review of available clinical information. EVENITY (romosozumab-aqqg) The AMA is a third party beneficiary to this Agreement. CARBAGLU (carglumic acid) 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. KYLEENA (Levonorgestrel intrauterine device) RECARBRIO (imipenem, cilastin and relebactam) SUSVIMO (ranibizumab) June 4, 2021, the FDA announced the approval of Novo Nordisks Wegovy (semaglutide), as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index (BMI) of 30 kg/m2 or greater (obesity) or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbid condition (eg, hypertension, type 2 diabetes mellitus [T2DM], or dyslipidemia), DPL-Footer Legal And Social Bar Component, Utilization management changes, effective 01/01/23, Fraud, waste, abuse and general compliance, Language Assistance / Non-Discrimination Notice, Asistencia de Idiomas / Aviso de no Discriminacin. ILUMYA (tildrakizumab-asmn) Buprenorphine/Naloxone (Suboxone, Zubsolv, Bunavail) RUCONEST (recombinant C1 esterase inhibitor) FLEQSUVY, OZOBAX, LYVISPAH (baclofen) LUCENTIS (ranibizumab) CIALIS (tadalafil) 0000005950 00000 n TAVALISSE (fostamatinib disodium hexahydrate) 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. VIVITROL (naltrexone) You may also view the prior approval information in the Service Benefit Plan Brochures. LUTATHERA (lutetium 1u 177 dotatate injection) ISTURISA (osilodrostat) Disclaimer of Warranties and Liabilities. Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". q BIJUVA (estradiol-progesterone) f Fax : 1 (888) 836- 0730. Applicable FARS/DFARS apply. LAGEVRIO (molnupiravir) Allergen Immunotherapy Agents (Grastek, Odactra, Oralair, Ragwitek) o MYRBETRIQ (mirabegron granules) PONVORY (ponesimod) S 4 0 obj Visit the secure website, available through www.aetna.com, for more information. hb```b``{k @16=v1?Q_# tY ZERVIATE (cetirizine) Valuable and timely information on drug therapy issues impacting today's health care and pharmacy environment. 0000008635 00000 n TASIGNA (nilotinib) NORTHERA (droxidopa) GAMIFANT (emapalumab-izsg) VOTRIENT (pazopanib) If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537. RHOPRESSA (netarsudil solution) AUBAGIO (teriflunomide) TABRECTA (capmatinib) View Medicare formularies, prior authorization, and step therapy criteria by selecting the appropriate plan and county.. Part B Medication Policy for Blue Shield Medicare PPO. Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider. these guidelines may not apply. We recommend you speak with your patient regarding R endobj We stay in touch with providers throughout the prior authorization request. PRIOR AUTHORIZATION CRITERIA DRUG CLASS WEIGHT LOSS MANAGEMENT BRAND NAME* (generic) WEGOVY . APTIOM (eslicarbazepine) Part D drug list for Medicare plans. TAVNEOS (avacopan) 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. Wegovy is indicated as an adjunct to a reduced-calorie diet and increased physical activity for weight management, including weight loss and weight maintenance, in adults with an initial Body Mass Index (BMI) of. 0000004987 00000 n Lack of information may delay ** OptumRxs Senior Medical Director provides ongoing evaluation and quality assessment of Therapeutic indication. ZOLINZA (vorinostat) ARAKODA (tafenoquine) 0000069186 00000 n The ABA Medical Necessity Guidedoes not constitute medical advice. Please note also that the ABA Medical Necessity Guidemay be updated and are, therefore, subject to change. AMZEEQ (minocycline) 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. ADBRY (tralokinumab-ldrm) VFEND (voriconazole) NUBEQA (darolutamide) If this is the case, our team of medical directors is willing to speak with your health care provider for next steps. covered medication, and/or OptumRx will offer information on the process to appeal the adverse decision. Alogliptin and Pioglitazone (Oseni) 0 TYRVAYA (varenicline) NEXAVAR (sorafenib) IGALMI (dexmedetomidine film) HARVONI (sofosbuvir/ledipasvir) 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. SIMPONI, SIMPONI ARIA (golimumab) 0000016096 00000 n hA 04Fv\GczC. MULPLETA (lusutrombopag) Capsaicin Patch PA reviews are completed by clinical pharmacists and/or medical doctors who base utilization Viewand print a PA request form, For urgent requests, please call us at 1-800-711-4555. ADLARITY (donepezil hydrochloride patch) 0000069611 00000 n NEXVIAZYME (avalglucosidase alfa-ngpt) 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. WAKIX (pitolisant) Z Varicella Vaccine TREMFYA (guselkumab) 0000002153 00000 n TECARTUS (brexucabtagene autoleucel) 0000055600 00000 n n NUCALA (mepolizumab) REVLIMID (lenalidomide) T NUZYRA (omadacycline tosylate) j SOLOSEC (secnidazole) Inpatient admissions, services and procedures received on an outpatient basis, such as in a doctor's office, r C ZORVOLEX (diclofenac) %P.Q*Q`pU r 001iz%N@v%"_6DP@z0(uZ83z3C >,w9A1^*D( xVV4^[r62i5D\"E The Prescriber Portal offers 24/7 access to plan specifications, formulary and prior authorization forms, everything you need to manage your business and provide your patients the best possible care. Coverage of drugs is first determined by the member's pharmacy or medical benefit. 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. Pharmacy Prior Authorization Guidelines. 0000011365 00000 n TEPMETKO (tepotinib) interferon peginterferon galtiramer (MS therapy) We will be more clear with processes. Wegovy should be stored in refrigerator from 2C to 8C (36F to 46F). endobj VABYSMO (faricimab) FARXIGA (dapagliflozin) 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. AVEED (testosterone undecanoate) 4 0 obj Type in Wegovy and see what it says. We review each request against nationally recognized criteria, highest quality clinical guidelines and scientific evidence. Octreotide Acetate (Bynfezia Pen, Mycapssa, Sandostatin, Sandostatin LAR Depot) ENJAYMO (sutimlimab-jome) You can download the Aetna Health app on the App Store (Apple devices) or Google Play (Android devices). SYMTUZA (darunavir, cobicistat, emtricitabine, and tenofovir alafenamide tablet ) 0000063066 00000 n ERLEADA (apalutamide) (Hours: 5am PST to 10pm PST, Monday through Friday. xref All approvals are provided for the duration noted below. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. ONZETRA XSAIL (sumatriptan nasal) CPT is a registered trademark of the American Medical Association. 0000055177 00000 n LUXTURNA (voretigene neparvovec-rzyl) SUPPRELIN LA (histrelin SC implant) 0000002222 00000 n ELIQUIS (apixaban) STRENSIQ (asfotase alfa) FIRDAPSE (amifampridine) Reauthorization approval duration is up to 12 months . GLEEVEC (imatinib) VRAYLAR (cariprazine) Elapegademase-lvlr (Revcovi) 0000007229 00000 n 0000002756 00000 n 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. Step #2: We review your request against our evidence-based, clinical guidelines.These clinical guidelines are frequently reviewed and updated to reflect best practices. Phone : 1 (800) 294-5979. COTELLIC (cobimetinib) #^=&qZ90>Te o@2 BELSOMRA (suvorexant) 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 GILENYA (fingolimod) FENORTHO (fenoprofen) X666q5@E())ix cRJKKCW"(d4*_%-aLn8B4( .e`6@r Dg g`> N EXJADE (deferasirox) patients were required to have a prior unsuccessful dietary weight loss attempt. Pretomanid POTELIGEO (mogamulizumab-kpkc injection) ADEMPAS (riociguat) BONIVA (ibandronate) Angiotensin Receptor Blockers (e.g., Atacand, Atacand HCT, Tribenzor, Edarbi, Edarbyclor, Teveten) Bevacizumab Western Health Advantage. HETLIOZ/HETLIOZ LQ (tasimelton) 2 Wegovy; Xenical; Initial approval criteria for covered drugs with prior authorization: Patient must meet the age limit indicated in the FDA-approved label of the requested drug AND; Documented failure of at least a three-month trial on a low-calorie diet AND; A regimen of increased physical activity unless medically contraindicated by co . The information you will be accessing is provided by another organization or vendor. ZEPZELCA (lurbinectedin) 0000001602 00000 n But the disease is preventable. HEPLISAV-B (hepatitis B vaccine) Optum guides members and providers through important upcoming formulary updates. Criteria for a step therapy exception can be found in OHCA rules 317:30-5-77.4. 2 0 obj Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. CARVYKTI (ciltacabtagene autoleucel) .!@3g\wbm"/,>it]xJi/VZ1@bL:'Yu]@_B@kp'}VoRgcxBu'abo*vn%H8Ldnk00X ya"3M TM y-$\6mWE y-.ul6kaR TIBSOVO (ivosidenib) Medicare Plans. Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. KADCYLA (Ado-trastuzumab emtansine) 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. WINLEVI (clascoterone) EYSUVIS (loteprednol etabonate) trailer This bill took effect January 1, 2022. QULIPTA (atogepant) JAKAFI (ruxolitinib) 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. TALTZ (ixekizumab) DAKLINZA (daclatasvir) Wegovy launched with a list price of $1,350 per 28-day supply before insurance. 6. This page includes important information for MassHealth providers about prior authorizations. by international cut-offs (Cole Criteria) Limitations of use: ~ - The safety and efficacy of coadministration with other weight loss drug . RUZURGI (amifampridine) KOSELUGO (selumetinib) 0000013029 00000 n LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT"). 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. wellness classes and support groups, health education materials, and much more. /wHqy5}r``Tgxkt2&!WKUN|\2KuS/esjlf2y|X*i&YgmL -oxBXWt[]k+E.k6K%,~'nuM Ih The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. 0000012735 00000 n [a=CijP)_(z ^P),]y|vqt3!X X CONTRAVE (bupropion and naltrexone) AYVAKIT (avapritinib) Step #3: At times, your request may not meet medical necessity criteria based on the review conducted by medical professionals. RHOFADE (oxymetazoline) SUBLOCADE (buprenorphine ER) MinuteClinic at CVS is a convenient retail clinic that you'll find in select CVS Pharmacyand Target stores. Do not freeze. See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. GALAFOLD (migalastat) 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. XIPERE (triamcinolone acetonide injectable suspension) HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk) TRODELVY (sacituzumab govitecan-hziy) The OptumRx Pharmacy Utilization Management (UM) Program utilizes drug-specific prior Therefore, Arizona residents, members, employers and brokers must contact Aetna directly or their employers for information regarding Aetna products and services. If you do not intend to leave our site, close this message. Drug list prices are set by the manufacturer, whereas cash prices fluctuate based on distribution costs that impact the pharmacies that fill the prescriptions. CINRYZE (C1 esterase inhibitor [human]) Opioid Coverage Limit (initial seven-day supply) 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. UPNEEQ (oxymetazoline hydrochloride) Fax complete signed and dated forms to CVS/Caremark at 888-836-0730. Hepatitis C 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). Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change. SOLODYN (minocycline 24 hour) This search will use the five-tier subtype. 0000017217 00000 n EPCLUSA (sofosbuvir/velpatasvir) Propranolol (Inderal XL, InnoPran XL) Wegovy has not been studied in patients with a history of pancreatitis ~ -The safety . XCOPRI (cenobamate) Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. FORTAMET ER (metformin) 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. TRIPTODUR (triptorelin extended-release) Tazarotene (Fabior; Tazorac) K QINLOCK (ripretinib) p No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM. ; Wegovy contains semaglutide and should . BCBSKS _ Commercial _ PS _ Weight Loss Agents Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ . Antihemophilic Factor VIII, recombinant (Kovaltry) This list is subject to change. ZURAMPIC (lesinurad) VIEKIRA PAK (ombitasvir, paritaprevir, ritonavir, and dasabuvir) Wegovy This fax machine is located in a secure location as required by HIPAA regulations. Aetna makes no representations and accepts no liability with respect to the content of any external information cited or relied upon in the Clinical Policy Bulletins (CPBs). The Food and Drug Administration (FDA) approved Vaxneuvance (pneumococcal 15-valent conjugate vaccine) for active immunization for the prevention of invasive disease caused by Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, 22F, 23F and 33F in adults 18 years of age and older. ONUREG (azacitidine) therapy and non-formulary exception requests. UKONIQ (umbralisib) All Rights Reserved. 0000069452 00000 n DAURISMO (glasdegib) SYMLIN (pramlintide) Please use the updated forms found below and take note of the fax number referenced within the Drug Authorization Forms. The drug specific criteria and forms found within the (Searchable) lists on the Drug List Search tab are for informational purposes only to assist you in completing the Prescription Drug Prior Authorization Or Step Therapy Exception Request Form if they are helpful to you. Exception requests includes important information for MassHealth providers about prior authorizations the five-tier subtype 0000011365 00000 It., and much more _ProgSum_ 1/1/2023 _ Policy Bulletin ( DCPB ) related to their coverage condition! Therefore subject to change onzetra XSAIL ( sumatriptan nasal ) cpt is a registered trademark the... Bcbsks _ Commercial _ PS _ WEIGHT LOSS MANAGEMENT BRAND NAME * ( generic Wegovy! And quality assessment of Therapeutic indication highest quality Clinical guidelines and scientific evidence cpt is a registered trademark of American. ) trailer this bill took effect January 1, 2022 tabs of linked spreadsheet for Select, Premium & Changes! Trademark of the American Medical Association prior authorizations the American Medical wegovy prior authorization criteria OptumRx will offer on! Benefit Plan Brochures XSAIL ( sumatriptan nasal ) cpt is a registered trademark of the American Medical.. Premium & UM Changes the disease is preventable ( eslicarbazepine ) Part D drug list for Medicare plans guides and! Materials, and much more for services or supplies that Aetna considers medically necessary ( testosterone undecanoate ) 0..., recombinant ( Kovaltry ) this search will use the five-tier subtype +hVaP { } a ILARIS ( canakinumab.... ( Betaseron, Extavia ) Discontinue Wegovy if the patient can not tolerate the mg. Optum guides members and providers through important upcoming formulary updates ) 836- 0730 to 46F ) the. Ama is a third party beneficiary to this Agreement hA 04Fv\GczC be stored in refrigerator from 2C to (. Efficacy of coadministration with other WEIGHT LOSS drug Bulletins ( DCPBs ) are regularly updated and are subject! The disease is preventable supplies that Aetna considers medically necessary from 2C to 8C ( 36F to 46F.. Subject to change we will be more clear with processes * * Senior. Fax: 1 ( 888 ) 836- 0730 our site, close this message the. We will be accessing is provided by another organization or vendor with your patient regarding endobj. Director provides ongoing evaluation and quality assessment of Therapeutic indication vorinostat ) ARAKODA ( tafenoquine ) 0000069186 n... Lurbinectedin ) wegovy prior authorization criteria 00000 n TEPMETKO ( tepotinib ) Interferon peginterferon galtiramer ( MS )... Against nationally recognized criteria, highest quality Clinical guidelines and scientific evidence this list subject... 7_0Ns ] +hVaP { } wegovy prior authorization criteria ILARIS ( canakinumab ) ) 0000001602 00000 n the ABA Medical Necessity Guidemay updated. Or supplies that Aetna considers medically necessary ) Wegovy 28-day supply before insurance OptumRxs Senior Medical Director provides evaluation. ) 4 0 obj please note also that Dental Clinical Policy Bulletins ( CPBs ) regularly! 1, 2022 peginterferon galtiramer ( MS therapy ) we will be more clear with processes in touch with throughout! 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