[a=CijP)_(z ^P),]y|vqt3!X X VIVLODEX (meloxicam) q[#rveQ:7cntFHb)?&\FmBmF[l~7NizfdUc\q (^"_>{s^kIi&=s oqQ^Ne[* h$h~^h2:YYWO8"Si5c@9tUh1)4 ,"rsu[M5?xR d0WTr$A+;v &J}BEHK20`A @> Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider. VARUBI (rolapitant) 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. ! 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. IDHIFA (enasidenib) In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government. SENSIPAR (cinacalcet) VERQUVO (vericiguat) 0000003936 00000 n TRIJARDY XR (empagliflozin, linagliptin, metformin) 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. ZOLGENSMA (onasemnogene abeparvovec-xioi) Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. DIFFERIN (adapalene) Each main plan type has more than one subtype. 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. ENJAYMO (sutimlimab-jome) This Agreement will terminate upon notice if you violate its terms. ADLARITY (donepezil hydrochloride patch) gas. 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. BELEODAQ (belinostat) ADDYI (flibanserin) AMONDYS 45 (casimersen) If denied, the provider may choose to prescribe a less costly but equally effective, alternative ILUVIEN (fluocinolone acetonide) INREBIC (fedratinib) XERMELO (telotristat ethyl) ZTALMY (ganaxolone suspension) 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. TIBSOVO (ivosidenib) MARGENZA (margetuximab-cmkb) Insulin Rapid Acting (Admelog, Apidra, Fiasp, Insulin Lispro [Humalog ABA], Novolog, Insulin Aspart [Novolog ABA], Novolog ReliOn) L DUOBRII (halobetasol propionate and tazarotene) We also host webinars, outreach campaigns and educational workshops to help them navigate the process. Erythropoietin, Epoetin Alpha 0000014745 00000 n LUPKYNIS (voclosporin) 0000007229 00000 n If you do not intend to leave our site, close this message. ),)W!lD,NrJXB^9L 6ZMb>L+U8x[_a(Yw k6>HWlf>0l//l\pvy]}{&K`%&CKq&/[a4dKmWZvH(R\qaU %8d Hj @`H2i7( CN57+m:#94@.U]\i.I/)"G"tf -5 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. There should also be a book you can download that will show you the pre-authorization criteria, if that is required. NOCTIVA (desmopressin) CINRYZE (C1 esterase inhibitor [human]) 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. Whats the difference? A prior authorization is a request submitted on your behalf by your health care provider for a particular procedure, test, treatment, or prescription. VIVJOA (oteseconazole) POMALYST (pomalidomide) AMPYRA (dalfampridine) P Part D drug list for Medicare plans. Treating providers are solely responsible for medical advice and treatment of members. Please use the updated forms found below and take note of the fax number referenced within the Drug Authorization Forms. A prior approval is required for the procedures listed below for both the FEP Standard and Basic Option plan and the FEP Blue Focus plan. Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. All services deemed "never effective" are excluded from coverage. Riluzole (Exservan, Rilutek, Tiglutik, generic riluzole) Its confidential and free for you and all your household members. Cost effective; You may need pre-authorization for your . DAKLINZA (daclatasvir) You can download the Aetna Health app on the App Store (Apple devices) or Google Play (Android devices). 2545 0 obj <>stream <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> 3 0 obj TECFIDERA (dimethyl fumarate) VYONDYS 53 (golodirsen) Asenapine (Secuado, Saphris) 2 0 obj ILUMYA (tildrakizumab-asmn) Pegfilgrastim agents (Neulasta, Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo) nausea *. endstream endobj 425 0 obj <>/Filter/FlateDecode/Index[21 368]/Length 35/Size 389/Type/XRef/W[1 1 1]>>stream OPSUMIT (macitentan) headache. Medicare Plans. b O ENDARI (l-glutamine oral powder) LONHALA MAGNAIR (glycopyrrolate) <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> 0 Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. PROLIA (denosumab) WINLEVI (clascoterone) 0000000016 00000 n VESICARE LS (solifenacin succinate suspension) t TARGRETIN (bexarotene) REVLIMID (lenalidomide) UPTRAVI (selexipag) making criteria** that are developed from clinical evidence from the following sources: *Guidelines are specific to plans utilizing our standard drug lists only. 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. ACTEMRA (tocilizumab) Allergen Immunotherapy Agents (Grastek, Odactra, Oralair, Ragwitek) Please consult with or refer to the Evidence of Coverage or Certificate of Insurance document for a list of exclusions and limitations. PALYNZIQ (pegvaliase-pqpz) Wegovy launched with a list price of $1,350 per 28-day supply before insurance. Testosterone oral agents (JATENZO, TLANDO) TUKYSA (tucatinib) TALZENNA (talazoparib) Submitting a PA request to OptumRx via phone or fax. 0000092908 00000 n 0000002527 00000 n Testosterone pellets (Testopel) It should be listed under anti-obesity agents. <> ORIAHNN (elagolix, estradiol, norethindrone) 0000013058 00000 n Pharmacy General Exception Forms LORBRENA (lorlatinib) Our prior authorization process will see many improvements. No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM. A PSG suggests the inclusion of those strategies within prior authorization (PA) criteria. Weve answered some of the most frequently asked questions about the prior authorization process and how we can help. ePAs save time and help patients receive their medications faster. 0000000016 00000 n VYVGART (efgartigimod alfa-fcab) 0000011005 00000 n 0000009958 00000 n The maintenance dose of Wegovy is 2.4 mg injected subcutaneously once weekly. SIGNIFOR (pasireotide) 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 RADICAVA (edaravone) BREYANZI (lisocabtagene maraleucel) STELARA (ustekinumab) DAURISMO (glasdegib) COPIKTRA (duvelisib) - 30 kg/m (obesity), or. STEGLUJAN (ertugliflozin and sitagliptin) dates and more. Were here with 24/7 support and resources to help you with work/life balance, caregiving, legal services, money matters, and more. SUNOSI (solriamfetol) OPZELURA (ruxolitinib cream) 0000011365 00000 n 0000008227 00000 n <>/Metadata 497 0 R/ViewerPreferences 498 0 R>> S MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate) these guidelines may not apply. We recommend you speak with your patient regarding 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. LUTATHERA (lutetium 1u 177 dotatate injection) Other times, medical necessity criteria might not be met. TEPMETKO (tepotinib) ARALEN (chloroquine phosphate) ISTURISA (osilodrostat) TYSABRI (natalizumab) ALIQOPA (copanlisib) Links to various non-Aetna sites are provided for your convenience only. Hyaluronic Acid derivatives (Synvisc, Hyalgan, Orthovisc, Euflexxa, Supartz) WELIREG (belzutifan) HEMLIBRA (emicizumab-kxwh) Q ; Wegovy contains semaglutide and should . 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. Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. QUVIVIQ (daridorexant) LEUKINE (sargramostim) 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. FORTAMET ER (metformin) ZURAMPIC (lesinurad) prescription drug benefits may be covered under his/her plan-specific formulary for which 0000013356 00000 n ORACEA (doxycycline delayed-release capsule) INLYTA (axitinib) endobj Xenical (orlistat) Capsule Obesity management including weight loss and weight maintenance when used in conjunction with a reduced-calorie diet and to reduce the risk for weight regain after prior weight loss. Growth Hormone (Norditropin; Nutropin; Genotropin; Humatrope; Omnitrope; Saizen; Sogroya; Skytrofa; Zomacton; Serostim; Zorbtive) Please consult with or refer to the . BRAFTOVI (encorafenib) trailer CPT is a registered trademark of the American Medical Association. SOLOSEC (secnidazole) DELESTROGEN (estradiol valerate injection) x REZUROCK (belumosudil) therapy and non-formulary exception requests. 0000003052 00000 n Wegovy should be used with a reduced calorie meal plan and increased physical activity. FARXIGA (dapagliflozin) CIBINQO (abrocitinib) 0000001386 00000 n An exception can be requested following a denial of a prior authorization or can be submitted at the onset of the request. RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn) KALYDECO (ivacaftor) Applicable FARS/DFARS apply. vomiting. JUBLIA (efinaconazole) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. LIVTENCITY (maribavir) REBLOZYL (luspatercept) V KYLEENA (Levonorgestrel intrauterine device) PAs help manage costs, control misuse, and 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. w 0000001602 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. But there are circumstances where there's misalignment between what is approved by the payer and what is actually . But the disease is preventable. 4 0 obj BARHEMSYS (amisulpride) 0000054934 00000 n GLUMETZA ER (metformin) ONGLYZA (saxagliptin) VONJO (pacritinib) VIMIZIM (elosulfase alfa) This page includes important information for MassHealth providers about prior authorizations. ), 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, Food and Drug Administration (FDA) information, Peer-reviewed medical/pharmacy literature, including randomized clinical trials, meta-, Treatment guidelines, practice parameters, policy statements, consensus statements, Pharmaceutical, device, and/or biotech company information, Medical and pharmacy tertiary resources, including those recognized by CMS, Relevant and reputable medical and pharmacy textbooks and or websites, Reference the OptumRx electronic prior authorization. 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. PEPAXTO (melphalan flufenamide) Amantadine Extended-Release (Gocovri) We evaluate each case using clinical criteria to ensure each member receives the right care at the right time in their health care journey. ALECENSA (alectinib) Step #1: Your health care provider submits a request on your behalf. The information you will be accessing is provided by another organization or vendor. Step #2: We review your request against our evidence-based, clinical guidelines. Reauthorization approval duration is up to 12 months . VELCADE (bortezomib) 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. Elapegademase-lvlr (Revcovi) HEPLISAV-B (hepatitis B vaccine) FOTIVDA (tivozanib) 0000003577 00000 n A $25 copay card provided by the manufacturer may help ease the cost but only if . WHA members have access to a wealth of resources including a Semaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist. 0000005437 00000 n RECORLEV (levoketoconazole) If there is a discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of benefits, the benefits plan will govern. DOPTELET (avatrombopag) 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 . 0000069417 00000 n the following criteria are met for FDA Indications or Other Uses with Supportive Evidence: Prior Authorization is recommended for prescription benefit coverage of the GLP-1 agonists targeted in this policy. ARAKODA (tafenoquine) For language services, please call the number on your member ID card and request an operator. EVKEEZA (evinacumab-dgnb) Treating providers are solely responsible for medical advice and treatment of members. ELIQUIS (apixaban) TRUSELTIQ (infigratinib) AEMCOLO (rifamycin delayed-release) TASIGNA (nilotinib) EYLEA (aflibercept) TAKHZYRO (lanadelumab) Initial approval duration is up to 7 months . ARIKAYCE (amikacin) [Document the weight prior to Wegovy therapy and the weight after Wegovy therapy, including the date the weights were taken:_____] Yes No 3 Does the patient have a body mass index (BMI) greater than or equal to 30 kilogram per . At a MinuteClinic inside a CVS Pharmacy, you may see nurse practitioners (NPs), physician associates (PAs) and pharmacists. 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. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. 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). 0000013580 00000 n h Clinician Supervised Weight Reduction Programs. Fax : 1 (888) 836- 0730. UKONIQ (umbralisib) OhV\0045| GAVRETO (pralsetinib) Hepatitis C stream NINLARO (ixazomib) If you can't submit a request via telephone, please use our general request form or one of the state specific forms below . 0000002756 00000 n no77gaEtuhSGs~^kh_mtK oei# 1\ COSENTYX (secukinumab) ANNOVERA (segesterone acetate/ethinyl estradiol) 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. So far, all weight loss drugs are 'excluded' from coverage for my specific employer's contracted plan. TAGRISSO (osimertinib) SYMDEKO (tezacaftor-ivacaftor) FASENRA (benralizumab) Has anyone been able to jump through this type of hoop? In doing so, CVS/Caremark will be able to decide whether or not the requested prescription is included in the patient's insurance plan. The cash price is even higher, averaging $1,988.22 since August 2021 according to GoodRx . NPLATE (romiplostim) COSELA (trilaciclib) RETIN-A (tretinoin) SOLARAZE (diclofenac) Explore differences between MinuteClinic and HealthHUB. And we will reduce wait times for things like tests or surgeries. XIFAXAN (rifaximin) Please contact CVS/Caremark at 855-582-2022 with questions regarding the prior authorization process. 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. PONVORY (ponesimod) 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. TIVORBEX (indomethacin) LIBTAYO (cemiplimab-rwlc) These clinical guidelines are frequently reviewed and updated to reflect best practices. 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). VIBERZI (eluxadoline) 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). SUSVIMO (ranibizumab) Your benefits plan determines coverage. Antihemophilic Factor [recombinant] pegylated-aucl (Jivi) MAYZENT (siponimod) VERZENIO (abemaciclib) Saxenda [package insert]. More than 14,000 women in the U.S. get cervical cancer each year. 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. CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. 0000055600 00000 n PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp) VIVITROL (naltrexone) 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. Hepatitis B IG u Buprenorphine/Naloxone (Suboxone, Zubsolv, Bunavail) ?J?=njQK=?4P;SWxehGGPCf>rtvk'_K%!#.0Izr)}(=%l$&:i$|d'Kug7+OShwNyI>8ASy> CRYSVITA (burosumab-twza) 0000055177 00000 n hA 04Fv\GczC. Please . CYRAMZA (ramucirumab) MinuteClinic at CVS services JEMPERLI (dostarlimab-gxly) Copyright 2023 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 ** ). SUSTOL (granisetron) Discontinue WEGOVY if the patient cannot tolerate the 2.4 mg dose. 0000007133 00000 n ZOSTAVAX (zoster vaccine live) TREMFYA (guselkumab) Alogliptin (Nesina) AYVAKIT (avapritinib) Discard the Wegovy pen after use. Prior Authorization for MassHealth Providers. Fluoxetine Tablets (Prozac, Sarafem) VITRAKVI (larotrectinib) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. MOZOBIL (plerixafor) startxref d REVATIO (sildenafil citrate) The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. Wegovy prior authorization criteria united healthcare. TAFINLAR (dabrafenib) Bevacizumab XPOVIO (selinexor) CARVYKTI (ciltacabtagene autoleucel) OptumRx, except for the following states: MA, RI, SC, and TX. EXONDYS 51 (eteplirsen) ERLEADA (apalutamide) MassHealth Pharmacy Initiatives and Clinical Information. YUPELRI (revefenacin) AVEED (testosterone undecanoate) POTELIGEO (mogamulizumab-kpkc injection) manner, please submit all information needed to make a decision. 0000012864 00000 n VUMERITY (diroximel fumarate) 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). If you would like to view forms for a specific drug, visit the CVS/Caremark webpage, linked below. Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". NULIBRY (fosdenopterin) ELZONRIS (tagraxofusp) 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. Subcutaneous Immunoglobulin (SCIG) (Hizentra, HyQvia) ORILISSA (elagolix) Guidelines are based on written objective pharmaceutical UM decision- No fee schedules, basic unit, relative values or related listings are included in CPT. BEVYXXA (betrixaban) When conditions are met, we will authorize the coverage of Wegovy. SYNAGIS (palivizumab) hb```b``mf`c`[ @Q{9 P@`mOU.Iad2J1&@ZX\2 6ttt `D> `g`QJ@ gg`apc7t3N``X tgD?>H7X570}``^ 0C7|^ '2000 G> VFEND (voriconazole) 0000069452 00000 n OCREVUS (ocrelizumab) The responsibility for the content of this product is with Aetna, Inc. and no endorsement by the AMA is intended or implied. Wegovy will be used concomitantly with behavioral modification and a reduced-calorie diet . startxref CABLIVI (caplacizumab) 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. 0000062995 00000 n Antihemophilic Factor VIII, recombinant (Kovaltry) RYDAPT (midostaurin) OPDUALAG (nivolumab/relatlimab) 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. BESPONSA (inotuzumab ozogamicin IV) VYNDAQEL (tafamidis meglumine) TECHNIVIE (ombitasvir, paritaprevir, and ritonavir) SEGLUROMET (ertugliflozin and metformin) EPIDIOLEX (cannabidiol) VOXZOGO (vosoritide) VOTRIENT (pazopanib) indigestion, heartburn, or gastroesophageal reflux disease (GERD) fatigue (low energy) stomach flu.
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