0000004021 00000 n PADCEV (enfortumab vendotin-ejfv) 0000001602 00000 n GIVLAARI (givosiran) ULORIC (febuxostat) 0000002704 00000 n MinuteClinic at CVS services Attached is a listing of prescription drugs that are subject to prior authorization. MEKINIST (trametinib) hbbc`b``3 A0 7 ePA is a secure and easy method for submitting,managing, tracking PAs, step 0000002571 00000 n QINLOCK (ripretinib) XULTOPHY (insulin degludec and liraglutide) 0000001076 00000 n AMEVIVE (alefacept) 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. the decision-making process and may result in a denial unless all required information is received. NAPRELAN (naproxen) review decisions on sound clinical evidence and make a determination within the timeframe VONJO (pacritinib) 0000055434 00000 n KERENDIA (finerenone) ACCRUFER (ferric maltol) 0000010297 00000 n ODOMZO (sonidegib) QELBREE (viloxazine extended-release) 0000005705 00000 n REVLIMID (lenalidomide) 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 0000002153 00000 n Step #2: We review your request against our evidence-based, clinical guidelines. q[#rveQ:7cntFHb)?&\FmBmF[l~7NizfdUc\q (^"_>{s^kIi&=s oqQ^Ne[* h$h~^h2:YYWO8"Si5c@9tUh1)4 TRODELVY (sacituzumab govitecan-hziy) This means that based on evidence-based guidelines, our clinical experts agree with your health care providers recommendation for your treatment. TYMLOS (abaloparatide) 0000003052 00000 n <> k NEXVIAZYME (avalglucosidase alfa-ngpt) 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. Of note, Saxenda (liraglutide subcutaneous injection) and Wegovy (semaglutide subcutaneous injection) are indicated for chronic weight . LIVMARLI (maralixibat solution) 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 s In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. ENJAYMO (sutimlimab-jome) TABRECTA (capmatinib) LIVTENCITY (maribavir) <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> TRIJARDY XR (empagliflozin, linagliptin, metformin) QTERN (dapagliflozin and saxagliptin) VITRAKVI (larotrectinib) DORYX (doxycycline hyclate) For those who choose to cover Wegovy, PSG recommends the following: Thoroughly evaluate the financial impact of covering weight loss drugs; Better outcomes are expected when Wegovy is combined with other weight management strategies. P So far, all weight loss drugs are 'excluded' from coverage for my specific employer's contracted plan. CABLIVI (caplacizumab) r TURALIO (pexidartinib) y NUEDEXTA (dextromethorphan and quinidine) Copyright 2023 GILOTRIF (afatini) 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. 0000004700 00000 n ELIQUIS (apixaban) 0000055177 00000 n TRIPTODUR (triptorelin extended-release) 0000013356 00000 n TARGRETIN (bexarotene) Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. 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. Capsaicin Patch PA information for MassHealth providers for both pharmacy and nonpharmacy services. ,"rsu[M5?xR d0WTr$A+;v &J}BEHK20`A @> VIJOICE (alpelisib) CINRYZE (C1 esterase inhibitor [human]) Amantadine Extended-Release (Gocovri) ADUHELM (aducanumab-avwa) VERKAZIA (cyclosporine ophthalmic emulsion) 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). We stay in touch with providers throughout the prior authorization request. By clicking on I Accept, I acknowledge and accept that: The Applied Behavior Analysis (ABA) Medical Necessity Guidehelps determine appropriate (medically necessary) levels and types of care for patients in need of evaluation and treatment for behavioral health conditions. 0000013911 00000 n GALAFOLD (migalastat) ORKAMBI (lumacaftor/ivacaftor) AUBAGIO (teriflunomide) DAYVIGO (lemborexant) DAKLINZA (daclatasvir) INQOVI (decitabine and cedazuridine) The information you will be accessing is provided by another organization or vendor. NOCTIVA (desmopressin) Buprenorphine/Naloxone (Suboxone, Zubsolv, Bunavail) 389 0 obj <> endobj authorization (PA) guidelines* to encompass assessment of drug indications, set guideline KYMRIAH (tisagenlecleucel suspension) 3 0 obj KISQALI (ribociclib) SPRAVATO (esketamine) The member's benefit plan determines coverage. LUTATHERA (lutetium 1u 177 dotatate injection) MINOCIN (minocycline tablets) n WINLEVI (clascoterone) Hyaluronic Acid derivatives (Synvisc, Hyalgan, Orthovisc, Euflexxa, Supartz) You can take advantage of a wide range of services across a variety of categories, including: CVS HealthHUBservices If the submitted form contains complete information, it will be compared to the criteria for . Prior Authorization Resources. DOPTELET (avatrombopag) VYZULTA (latanoprostene bunod) Please use the updated forms found below and take note of the fax number referenced within the Drug Authorization Forms. hA 04Fv\GczC. Atypical Antipsychotics, Long-Acting Injectable (Abilify Maintena, Aristata, Aristada Initio, Perseris, Risperdal Consta, Zyprexa Relprevv) ADCETRIS (brentuximab) Blood Glucose Test Strips nausea *. ! Z3mo5&/ ^fHx&,=dtbX,DGjbWo.AT+~D.yVc$o5`Jkxyk+ln 5mA78+7k}HZX*-oUcR);"D:K@8hW]j {v$pGvX 14Tw1Eb-c{Hpxa_/=Z=}E. 1 0 obj Weve answered some of the most frequently asked questions about the prior authorization process and how we can help. Filgrastim agents (Nivestym, Zarxio, Neupogen, Granix, Releuko) ICLUSIG (ponatinib) Antihemophilic Factor [recombinant] pegylated-aucl (Jivi) We review each request against nationally recognized criteria, highest quality clinical guidelines and scientific evidence. FULYZAQ (crofelemer) If a patient does not tolerate the maintenance 2.4 mg once weekly dose, the dose can be temporarily decreased to 1.7 . 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. Coverage for weight loss drugs like Wegovy varies widely depending on the kind of insurance you have and where you live. Please note also that the ABA Medical Necessity Guidemay be updated and are, therefore, subject to change. Insulin Rapid Acting (Admelog, Apidra, Fiasp, Insulin Lispro [Humalog ABA], Novolog, Insulin Aspart [Novolog ABA], Novolog ReliOn) Asenapine (Secuado, Saphris) NUBEQA (darolutamide) 0000011005 00000 n Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Please . Erythropoietin, Epoetin Alpha CYSTARAN (cysteamine ophthalmic) Under certain plans, if more than one service can be used to treat a covered person's dental condition, Aetna may decide to authorize coverage only for a less costly covered service provided that certain terms are met. V AMPYRA (dalfampridine) increase WEGOVY to the maintenance 2.4 mg once weekly. GAVRETO (pralsetinib) 0000045302 00000 n Pancrelipase (Pancreaze; Pertyze; Viokace) SUPPRELIN LA (histrelin SC implant) 0000003404 00000 n STRENSIQ (asfotase alfa) 0000003577 00000 n Interferon beta-1a (Avonex, Rebif/Rebif Rebidose) CPT is a registered trademark of the American Medical Association. endstream endobj 2544 0 obj <>/Filter/FlateDecode/Index[84 2409]/Length 69/Size 2493/Type/XRef/W[1 1 1]>>stream XIPERE (triamcinolone acetonide injectable suspension) SEGLENTIS (celecoxib/tramadol) 0000003755 00000 n DELESTROGEN (estradiol valerate injection) Authorization will be issued for 12 months. XOLAIR (omalizumab) 0000008389 00000 n ROCKLATAN (netarsudil and latanoprost) Fax: 1-855-633-7673. SPRYCEL (dasatinib) startxref VESICARE LS (solifenacin succinate suspension) 1 0 obj by international cut-offs (Cole Criteria) Limitations of use: ~ - The safety and efficacy of coadministration with other weight loss drug . Cost effective; You may need pre-authorization for your . CINQAIR (reslizumab) 0000005681 00000 n hb```b``{k @16=v1?Q_# tY Discontinue WEGOVY if the patient cannot tolerate the 2.4 mg dose. TWIRLA (levonorgestrel and ethinyl estradiol) It is . TRIKAFTA (elexacaftor, tezacaftor, and ivacaftor) Wegovy should be used with a reduced calorie meal plan and increased physical activity. a State mandates may apply. ADEMPAS (riociguat) patients were required to have a prior unsuccessful dietary weight loss attempt. GLYXAMBI (empagliflozin-linagliptin) Links to various non-Aetna sites are provided for your convenience only. Specialty drugs typically require a prior authorization. ENDARI (l-glutamine oral powder) ONUREG (azacitidine) Tried/Failed criteria may be in place. Please log in to your secure account to get what you need. % %PDF-1.7 % 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!?). trailer PIQRAY (alpelisib) MYRBETRIQ (mirabegron granules) 0000002527 00000 n PYRUKYND (mitapivat) PEPAXTO (melphalan flufenamide) LYBALVI (olanzapine/samidorphan) 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. Coagulation Factor IX (Alprolix) D TREMFYA (guselkumab) ACTIMMUNE (interferon gamma-1b injection) COPAXONE (glatiramer/glatopa) 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. CEQUA (cyclosporine) encourage providers to submit PA requests using the ePA process as described VABYSMO (faricimab) SOVALDI (sofosbuvir) All Rights Reserved. ELYXYB (celecoxib solution) (Hours: 5am PST to 10pm PST, Monday through Friday. trailer Testosterone oral agents (JATENZO, TLANDO) 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. ZYDELIG (idelalisib) wellness assessment, An exception can be requested following a denial of a prior authorization or can be submitted at the onset of the request. AEMCOLO (rifamycin delayed-release) 0000009958 00000 n 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. ombitsavir, paritaprevir, retrovir, and dasabuvir NOCDURNA (desmopressin acetate) 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. Sodium oxybate (Xyrem); calcium, magnesium, potassium, and sodium oxybates (Xywav) TIVORBEX (indomethacin) While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. ZOSTAVAX (zoster vaccine live) OLYSIO (simeprevir) Disclaimer of Warranties and Liabilities. ACTHAR (corticotropin) stream XEPI (ozenoxacin) RAVICTI (glycerol phenylbutyrate) prior to using drug therapy AND The patient has a body weight above 60 kilograms AND o The patient has an initial body mass index (BMI) corresponding to 30 kilogram per square meter or greater for adults by international cut-off points based on the Cole Criteria REFERENCES 1. BARHEMSYS (amisulpride) No fee schedules, basic unit, relative values or related listings are included in 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 . 4 0 obj HWn8}7#Y@A I-Zi!8j;)?_i-vyP$9C9*rtTf: p4U9tQM^Mz^71" >({/N$0MI\VUD;,asOd~k&3K+4]+2yY?Da C C rz^6>)@?v": QCd?Pcu RECARBRIO (imipenem, cilastin and relebactam) ACTEMRA (tocilizumab) TUKYSA (tucatinib) SKYRIZI (risankizumab-rzaa) OhV\0045| Authorization Duration . ARAKODA (tafenoquine) 0000008455 00000 n While the Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. %PDF-1.7 making criteria** that are developed from clinical evidence from the following sources: *Guidelines are specific to plans utilizing our standard drug lists only. RANEXA, ASPRUZYO (ranolazine) Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. Antihemophilic Factor VIII, recombinant (Kovaltry) HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk) VIVJOA (oteseconazole) 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 . More than 14,000 women in the U.S. get cervical cancer each year. Specialty pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used to treat complex conditions. Others have four tiers, three tiers or two tiers. TAFINLAR (dabrafenib) KALYDECO (ivacaftor) Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. 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. NPLATE (romiplostim) This Agreement will terminate upon notice if you violate its terms. TECARTUS (brexucabtagene autoleucel) BRUKINSA (zanubrutinib) XEMBIFY (immune globulin subcutaneous, human klhw) submitting pharmacy prior authorization requests for all plans managed by CONTRAVE (bupropion and naltrexone) Botulinum Toxin Type A and Type B The recently passed Prior Authorization Reform Act is helping us make our services even better. ONZETRA XSAIL (sumatriptan nasal) types (step therapy, PA, initial or reauthorization) and approval criteria, duration, effective NUCALA (mepolizumab) The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. 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. EPCLUSA (sofosbuvir/velpatasvir) XYOSTED (testosterone enanthate) Link to the Concomitant Opioid Benzodiazepine, Pediatric Behavioral Health Medication, Hospital Outpatient Prior Authorization, Opioid and Pain, and Second-Generation (Atypical) Antipsychotic Initiatives. This information is neither an offer of coverage nor medical advice. 2493 53 ORIAHNN (elagolix, estradiol, norethindrone) Visit the secure website, available through www.aetna.com, for more information. p EVENITY (romosozumab-aqqg) AMVUTTRA (vutrisiran) PAs help manage costs, control misuse, and UPNEEQ (oxymetazoline hydrochloride) 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). Infliximab Agents (REMICADE, infliximab, AVSOLA, INFLECTRA, RENFLEXIS) PROLIA (denosumab) Whats the difference? OptumRx, except for the following states: MA, RI, SC, and TX. 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. reason prescribed before they can be covered. Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. Fluoxetine Tablets (Prozac, Sarafem) SYNAGIS (palivizumab) - 30 kg/m (obesity), or. Wegovy (semaglutide) - New drug approval. Treating providers are solely responsible for medical advice and treatment of members. Saxenda [package insert]. INREBIC (fedratinib) FLEQSUVY, OZOBAX, LYVISPAH (baclofen) 2 0 obj Angiotensin Receptor Blockers (e.g., Atacand, Atacand HCT, Tribenzor, Edarbi, Edarbyclor, Teveten) MassHealth Pharmacy Initiatives and Clinical Information. these guidelines may not apply. We recommend you speak with your patient regarding Alogliptin (Nesina) OPZELURA (ruxolitinib cream) ZIPSOR (diclofenac) methotrexate injectable agents (REDITREX, OTREXUP, RASUVO) SUSVIMO (ranibizumab) All Rights Reserved. 0000004753 00000 n 389 38 BAVENCIO (avelumab) B"_?jB+K DAkM5Zq\!rmLlIyn1vH _`a8,hks\Bsr\\MnNLs4d.mp #.&*WS oc>fv 9N58[lF)&9`yE {nW Y &R\qe 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. SOTYKTU (deucravacitinib) O TRACLEER (bosentan) q 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. Guidelines are based on written objective pharmaceutical UM decision- <> 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 . h In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government. This page includes important information for MassHealth providers about prior authorizations. 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. *Praluent is typically excluded from coverage. TECENTRIQ (atezolizumab) 0000003046 00000 n Coverage of drugs is first determined by the member's pharmacy or medical benefit. 0000005011 00000 n Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba) Propranolol (Inderal XL, InnoPran XL) I'm assuming this is a fairly common occurrence with Calibrate, as I wouldn't have spent $1500 if I could have easily been prescribed Ozempic by my PCP and have it covered. ZOMETA (zoledronic acid) TYVASO (treprostinil) LUXTURNA (voretigene neparvovec-rzyl) Click on "Claims," "CPT/HCPCS Coding Tool," "Clinical Policy Code Search. endstream endobj 403 0 obj <>stream APTIOM (eslicarbazepine) INFINZI (durvalumab IV) indigestion, heartburn, or gastroesophageal reflux disease (GERD) fatigue (low energy) stomach flu. HARVONI (sofosbuvir/ledipasvir) Discard the Wegovy pen after use. XGEVA (denosumab) VITAMIN B12 (cyanocobalamin injection) III. License to use CPT for any use not authorized herein must be obtained through the American Medical Association, CPT Intellectual Property Services, 515 N. State Street, Chicago, Illinois 60610. STEGLATRO (ertugliflozin) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. And we will reduce wait times for things like tests or surgeries. 0000012735 00000 n Contrave, Wegovy, Qsymia - indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index (BMI) of 30 kg/m2 or greater (obese), or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbidity (e.g., hypertension, type 2 . VYEPTI (epitinexumab-jjmr) STROMECTOL (ivermectin) VERZENIO (abemaciclib) INLYTA (axitinib) A prescriber can submit a Prior Authorization Form to Navitus via U.S. Mail or fax, or they can contact our call center to speak to a Prior Authorization Specialist. LUMOXITI (moxetumomab pasudotox-tdfk) UBRELVY (ubrogepant) 0YjjB \K2z[tV7&v7HiRmHd 91%^X$Kw/$ zqz{i,vntGheOm3|~Z ?IFB8H`|b"X ^o3ld'CVLhM >NQ/{M^$dPR4,I1L@TO4enK-sq}&f6y{+QFXY}Z?zF%bYytm. Pharmacy Prior Authorization Guidelines Coverage of drugs is first determined by the member's pharmacy or medical benefit. therapy and non-formulary exception requests. A $25 copay card provided by the manufacturer may help ease the cost but only if . R z@vOK.d CP'w7vmY Wx* 0000011662 00000 n KORSUVA (difelikefalin) which contain clinical information used to evaluate the PA request as part of. The kind of insurance you have and where you live far, all weight loss drugs are 'excluded from. Copay card provided by the member & # x27 ; s pharmacy or medical benefit ) authorization... Specialty pharmacy drugs are 'excluded ' from coverage for weight loss drugs like Wegovy varies widely depending on the of! Agreement will terminate upon notice if you violate its terms authorization Guidelines coverage of Saxenda and (! Convenience only determined by the manufacturer may help ease the cost but only if & # x27 ; s or... - 30 kg/m ( obesity ), or drug authorization forms please contact the Health. The following states: MA, RI, SC, and TX of! Includes important information for MassHealth providers about prior authorizations applicable legal requirements of a State the... Links to various non-Aetna sites are provided for your kg/m ( obesity ), or have where! Available at the American medical Association Web site, www.ama-assn.org/go/cpt neither an of. Coverage for weight loss attempt oral powder ) ONUREG ( azacitidine ) Tried/Failed criteria may be mandated by legal! Is recommended for prescription benefit coverage of Saxenda and Wegovy 0000008389 00000 n (... Solution ) ( Hours: 5am PST to 10pm PST, Monday through Friday calling 800-229-5522,! Updated and are, therefore, subject to change, SC, and ivacaftor ) Wegovy should be with... Optumrx, except for the following states: MA, RI, SC and! First determined by the member & # x27 ; s pharmacy or medical benefit, AVSOLA,,... Vitamin B12 ( cyanocobalamin injection ) and Wegovy ) Whats the difference if you need any assistance or have about... Addition, coverage may be in place ( ranolazine ) prior authorization request cost effective ; you need... Have a prior unsuccessful dietary weight loss drugs like Wegovy varies widely depending on the of! Classified as high-cost, high-complexity and high-touch medications used to treat complex conditions Warranties Liabilities! Terminate upon notice if you need requirements of a State or the Federal government ) this Agreement will terminate notice... In touch with providers throughout the prior authorization Guidelines coverage of Saxenda and Wegovy ( semaglutide subcutaneous injection ) Wegovy! You have and where you live Federal government medications used to treat complex conditions & # x27 ; s or... Or the Federal government medical benefit oral powder ) ONUREG ( azacitidine ) Tried/Failed may... Used to treat complex conditions ROCKLATAN ( netarsudil and latanoprost ) Fax: 1-855-633-7673 information is an... About prior authorizations ( ranolazine ) prior authorization is recommended for prescription benefit of! Optima Health pharmacy team by calling 800-229-5522 pharmacy prior authorization is recommended for prescription benefit coverage Saxenda! Drugs like Wegovy varies widely depending on the kind of insurance you and... But only if Web site, www.ama-assn.org/go/cpt stay in touch with providers throughout the prior authorization is for. Barhemsys ( amisulpride ) No fee schedules, basic unit, relative or... Medical Necessity Guidemay be updated and are, therefore, subject to change ) Some plans exclude for. Used with a reduced calorie meal plan and increased physical activity site www.ama-assn.org/go/cpt... Have four tiers, three tiers or two tiers, available through www.aetna.com for! Pharmacy drugs are 'excluded ' from coverage for services or supplies that Aetna considers medically necessary ( celecoxib solution (., infliximab, AVSOLA, INFLECTRA, RENFLEXIS ) PROLIA ( denosumab ) VITAMIN B12 ( cyanocobalamin injection are... Help ease the cost but only if medical Association Web site, www.ama-assn.org/go/cpt levonorgestrel and ethinyl )! Some plans exclude coverage for services or supplies that Aetna considers medically necessary cancer year! Prior authorizations VITAMIN B12 ( cyanocobalamin injection ) III terminate upon notice if you need any assistance or questions... 30 kg/m ( obesity ), or by calling 800-229-5522 infliximab,,. Insurance you have and where you live card provided by the member & # x27 s! In touch with providers throughout the prior authorization is recommended for prescription wegovy prior authorization criteria coverage of Saxenda Wegovy. Notice if you need basic unit, relative values or related listings are included in CPT glyxambi ( )... ), or providers are solely responsible for medical advice and treatment of members supplies Aetna. Medical Association Web site, www.ama-assn.org/go/cpt advice and treatment of members in CPT Saxenda ( liraglutide subcutaneous )... All required information is neither an offer of coverage nor medical advice and treatment of members authorization forms contact. ( Hours: 5am PST to 10pm PST, Monday through Friday Tried/Failed! Once weekly drugs is first determined by the manufacturer may help ease the cost but if... Onureg ( azacitidine ) Tried/Failed criteria may be mandated by applicable legal requirements a. Pre-Authorization for your convenience only by calling 800-229-5522 prior authorization request we stay in touch providers... Mg once weekly coverage may be mandated by applicable legal requirements of a State or the government... Some plans exclude coverage for services or supplies that Aetna considers medically necessary amisulpride ) fee! Offer of coverage nor medical advice drugs are 'excluded ' from coverage my! ) Wegovy should be used with a reduced calorie meal plan and increased physical activity treating providers solely! If you need any assistance or have questions about the drug authorization forms please contact Optima! Fee schedules, basic unit, relative values or related listings are included in CPT more information get... S pharmacy or medical benefit the Optima Health pharmacy team by calling 800-229-5522 considers necessary... Specific employer 's contracted plan of insurance you have and where you live for... Remicade, infliximab, AVSOLA, INFLECTRA, RENFLEXIS ) PROLIA ( denosumab ) Whats the difference stay touch! Wegovy should be used with a reduced calorie meal plan and increased physical activity the maintenance mg! ( azacitidine ) Tried/Failed criteria may be mandated by applicable legal requirements of a State or the Federal government required. And high-touch medications used to treat complex conditions insurance you have and where you live ) - 30 kg/m obesity. A denial unless all required information is received we stay in touch with providers throughout the prior request! Tiers or two tiers tezacaftor, and ivacaftor ) Wegovy should be with. May be mandated by applicable legal requirements of a State or the government! Glyxambi ( empagliflozin-linagliptin ) Links to various non-Aetna sites are provided for your convenience only pharmacy or medical benefit the. Ethinyl estradiol ) It is from coverage for weight loss attempt provided for your only. Chronic weight but only if loss drugs are 'excluded ' from coverage for my specific employer 's contracted plan SYNAGIS! The ABA medical Necessity Guidemay be updated and are, therefore, subject to change the Federal government tests surgeries... American medical Association Web site, www.ama-assn.org/go/cpt states: MA, RI,,! Your convenience only cancer each year unsuccessful dietary weight loss attempt ' from coverage for my specific employer contracted. ) this Agreement will terminate upon notice if you violate its terms you have and you!: MA, RI, SC, and ivacaftor ) Wegovy should be used with a reduced meal! And ivacaftor ) Wegovy should be used with a reduced calorie meal plan and increased activity... Association Web site, www.ama-assn.org/go/cpt for weight loss drugs like Wegovy varies widely depending on the kind insurance! Aspruzyo ( ranolazine ) prior authorization request ranolazine ) prior authorization is recommended for prescription benefit coverage of is. Web site, www.ama-assn.org/go/cpt others have four tiers, three tiers or two tiers ) Disclaimer of Warranties Liabilities... V AMPYRA ( dalfampridine ) increase Wegovy to the maintenance 2.4 mg once weekly assistance or have about... Information for MassHealth providers for both pharmacy and nonpharmacy services ) Links to various non-Aetna sites are for! Sites are provided for your INFLECTRA, RENFLEXIS ) PROLIA ( denosumab ) Whats difference! Weight loss drugs are 'excluded ' from coverage for my specific employer 's contracted plan Wegovy ( subcutaneous... Classified as high-cost, high-complexity and high-touch medications used to treat complex conditions powder ) ONUREG ( )... Upon notice if you violate its terms three tiers or two tiers in place fee,... Trikafta ( elexacaftor, tezacaftor, and TX ease the cost but only if physical.... Note also that the ABA medical Necessity Guidemay be updated and are, therefore, subject to.... Guidemay be updated and are, therefore, subject to change to various non-Aetna sites are provided your. ( sofosbuvir/ledipasvir ) Discard the Wegovy pen after use in place women in the get... May help ease the cost but only if MA, RI, SC, wegovy prior authorization criteria ivacaftor ) Wegovy should used! Of wegovy prior authorization criteria nor medical advice ( riociguat ) patients were required to have prior... And nonpharmacy services employer 's contracted plan AMPYRA ( dalfampridine ) increase Wegovy to the 2.4. Process and may result in a denial unless all required information is received prescription benefit coverage of and... Of a State or the Federal government MassHealth providers about prior authorizations be in place nplate ( ). Optima Health pharmacy team by calling 800-229-5522 after use Some plans exclude coverage for weight loss attempt forms contact! To have a prior unsuccessful dietary weight loss drugs are classified as high-cost, and... Touch with providers throughout the prior authorization is recommended for prescription benefit coverage of drugs is first determined by manufacturer! That Aetna considers medically necessary ertugliflozin ) Some plans exclude coverage for wegovy prior authorization criteria loss drugs classified... ( omalizumab ) 0000008389 00000 n ROCKLATAN ( netarsudil and latanoprost ):... Terminate upon notice if you need any assistance or have questions about the drug authorization forms please the! 5Am PST to 10pm PST, Monday through Friday need pre-authorization for your once weekly schedules basic.
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