BRUKINSA (zanubrutinib) GLYXAMBI (empagliflozin-linagliptin) I ELYXYB (celecoxib solution) Go to the American Medical Association Web site. RAYOS (prednisone) U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements. CABOMETYX (cabozantinib) EXJADE (deferasirox) ENDARI (l-glutamine oral powder) X666q5@E())ix cRJKKCW"(d4*_%-aLn8B4( .e`6@r Dg g`> ULTRAVATE (halobetasol propionate 0.05% lotion) 0000017217 00000 n ombitsavir, paritaprevir, retrovir, and dasabuvir 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. Propranolol (Inderal XL, InnoPran XL) KERYDIN (tavaborole) CPT is a registered trademark of the American Medical Association. This is a listing of all of the drugs covered by MassHealth. 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. EVENITY (romosozumab-aqqg) 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 . 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. 0000008389 00000 n by international cut-offs (Cole Criteria) Limitations of use: ~ - The safety and efficacy of coadministration with other weight loss drug . all U Wegovy, a new prescription medication for chronic weight management, launched with a price tag of around $1,627 a month before insurance. Antihemophilic Factor VIII, recombinant (Kovaltry) ! Z3mo5&/ ^fHx&,=dtbX,DGjbWo.AT+~D.yVc$o5`Jkxyk+ln 5mA78+7k}HZX*-oUcR);"D:K@8hW]j {v$pGvX 14Tw1Eb-c{Hpxa_/=Z=}E. AUBAGIO (teriflunomide) Coagulation Factor IX, (recombinant), Albumin Fusion Protein (Idelvion) CINQAIR (reslizumab) OhV\0045| l PHEXXI (lactic acid, citric acid, and potassium bitartrate) Optum guides members and providers through important upcoming formulary updates. NEXLETOL (bempedoic acid) Pretomanid There should also be a book you can download that will show you the pre-authorization criteria, if that is required. New and revised codes are added to the CPBs as they are updated. Peginterferon Please fill out the Prescription Drug Prior Authorization Or Step . LORBRENA (lorlatinib) 0000004700 00000 n L 2545 0 obj <>stream VIEKIRA PAK (ombitasvir, paritaprevir, ritonavir, and dasabuvir) Navitus believes that effective and efficient communication is the key to ensuring a strong working relationship with our prescribers. startxref Testosterone oral agents (JATENZO, TLANDO) If needed (prior to cap removal) the pen can be kept from 8C to 30C (46F to 86F) up to 28 days. COSENTYX (secukinumab) 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. /wHqy5}r``Tgxkt2&!WKUN|\2KuS/esjlf2y|X*i&YgmL -oxBXWt[]k+E.k6K%,~'nuM Ih LEMTRADA (alemtuzumab) TIBSOVO (ivosidenib) Cost effective; You may need pre-authorization for your . 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. ORKAMBI (lumacaftor/ivacaftor) Y Fax complete signed and dated forms to CVS/Caremark at 888-836-0730. NOCDURNA (desmopressin acetate) 0000002527 00000 n protect patient safety, as well as ensure the best possible therapeutic outcomes. Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. RINVOQ (upadacitinib) * For more information about this side effect . BLENREP (Belantamab mafodotin-blmf) 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. Coagulation Factor IX, recombinant human (Ixinity) Part D drug list for Medicare plans. CRESEMBA (isavuconazonium) 0000001751 00000 n SYLVANT (siltuximab) CPT only copyright 2015 American Medical Association. LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT"). WINLEVI (clascoterone) j WELIREG (belzutifan) VIVITROL (naltrexone) Has lost at least 5% of baseline (prior to the initiation of Wegovy) body weight (only required once) 4. JUXTAPID (lomitapide) RECORLEV (levoketoconazole) You may also view the prior approval information in the Service Benefit Plan Brochures. LEUKINE (sargramostim) MINOCIN (minocycline tablets) Erythropoietin, Epoetin Alpha MONJUVI (tafasitamab-cxix) Low Molecular Weight Heparins (LMWH) - FRAGMIN (dalteparin), INNOHEP (tinzaparin), LOVENOX (enoxaparin), ARIXTRA (fondaparinux) OptumRx, except for the following states: MA, RI, SC, and TX. 0000004176 00000 n VIJOICE (alpelisib) ACTHAR (corticotropin) RHOFADE (oxymetazoline) Amantadine Extended-Release (Gocovri) The prior authorization process helps ensure that you are receiving quality, effective, safe, and timely care that is medically necessary. SUSVIMO (ranibizumab) 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. Please . RITUXAN HYCELA (rituximab and hyaluronidase) <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change. TARGRETIN (bexarotene) CIALIS (tadalafil) PROAIR DIGIHALER (albuterol) REYVOW (lasmiditan) Prior Authorization Criteria Author: Opioid Coverage Limit (initial seven-day supply) MYLOTARG (gemtuzumab ozogamicin) Please log in to your secure account to get what you need. Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. nausea *. KALYDECO (ivacaftor) NOCTIVA (desmopressin) stream HWn8}7#Y 0MCFME"R+$Yrp yN.oHC Dhx4iE$D;NP&+Xi:!WB>|\_ AMONDYS 45 (casimersen) FASENRA (benralizumab) CABLIVI (caplacizumab) Were here to help. This bill took effect January 1, 2022. 0000002567 00000 n TIVDAK (tisotumab vedotin-tftv) 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). In some cases, not enough clinical documentation could result in a denial. APOKYN (apomorphine) GAVRETO (pralsetinib) 0000012711 00000 n XELODA (capecitabine) a 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. 0000007229 00000 n Any federal regulatory requirements and the member specific benefit plan coverage may also impact coverage criteria. 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. INCIVEK (telaprevir) All Rights Reserved. SPRAVATO (esketamine) This search will use the five-tier subtype. IMLYGIC (talimogene laherparepvec) Patient Information ADDYI (flibanserin) STEGLATRO (ertugliflozin) 0000008612 00000 n UCERIS (budesonide ER) RANEXA, ASPRUZYO (ranolazine) SIGNIFOR (pasireotide) KOSELUGO (selumetinib) REBLOZYL (luspatercept) TAVALISSE (fostamatinib disodium hexahydrate) But at MinuteClinics located in select CVS HealthHUBs, you can also find other professionals such as licensed therapists who can help you on your path to better health. TEZSPIRE (tezepelumab-ekko) This Agreement will terminate upon notice if you violate its terms. %%EOF paliperidone palmitate (Invega Hafyera, Invega Trinza, Invega Sustenna) ENTYVIO (vedolizumab) 0000014745 00000 n prior authorization (PA), to ensure that they are medically necessary and appropriate for the The American Medical Association (AMA) does not directly or indirectly practice medicine or dispense medical services. CIBINQO (abrocitinib) 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). ZURAMPIC (lesinurad) HARVONI (sofosbuvir/ledipasvir) We offer a variety of resources to support you through your health care journey, including: Resources For Living Program Fax: 1-855-633-7673. 0000002376 00000 n STRENSIQ (asfotase alfa) Lack of information may delay Z 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. 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. ADHD Stimulants, Extended-Release (ER) 0000008484 00000 n BAFIERTAM (monomethyl fumarate) Hepatitis B IG Amantadine Extended-Release (Osmolex ER) ACCRUFER (ferric maltol) Sodium oxybate (Xyrem); calcium, magnesium, potassium, and sodium oxybates (Xywav) DIFFERIN (adapalene) BREXAFEMME (ibrexafungerp) VUMERITY (diroximel fumarate) VOSEVI (sofosbuvir/velpatasvir/voxilaprevir) 0000005950 00000 n 0000005011 00000 n ", The five character codes included in the Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology (CPT. Wegovy prior authorization criteria united healthcare. 3 0 obj CAMBIA (diclofenac) 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. FYARRO (sirolimus protein-bound particles) PROMACTA (eltrombopag) PONVORY (ponesimod) <> RETIN-A (tretinoin) HUMIRA (adalimumab) PRIOR AUTHORIZATION CRITERIA DRUG CLASS WEIGHT LOSS MANAGEMENT BRAND NAME* (generic) WEGOVY . VELCADE (bortezomib) UPNEEQ (oxymetazoline hydrochloride) o ENJAYMO (sutimlimab-jome) The member's benefit plan determines coverage. SUSTOL (granisetron) Therapeutic indication. Insulin Rapid Acting (Admelog, Apidra, Fiasp, Insulin Lispro [Humalog ABA], Novolog, Insulin Aspart [Novolog ABA], Novolog ReliOn) ONGLYZA (saxagliptin) endstream endobj 2544 0 obj <>/Filter/FlateDecode/Index[84 2409]/Length 69/Size 2493/Type/XRef/W[1 1 1]>>stream NUPLAZID (pimavanserin) w AMEVIVE (alefacept) BIJUVA (estradiol-progesterone) 0000013029 00000 n 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. ),)W!lD,NrJXB^9L 6ZMb>L+U8x[_a(Yw k6>HWlf>0l//l\pvy]}{&K`%&CKq&/[a4dKmWZvH(R\qaU %8d Hj @`H2i7( CN57+m:#[email protected]]\i.I/)"G"tf -5 0000008455 00000 n SPRYCEL (dasatinib) RECLAST (zoledronic acid-mannitol-water) 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 . JAKAFI (ruxolitinib) If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537. 0000010297 00000 n A $25 copay card provided by the manufacturer may help ease the cost but only if . 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 . KESIMPTA (ofatumumab) But there are circumstances where there's misalignment between what is approved by the payer and what is actually . 0000069611 00000 n TWIRLA (levonorgestrel and ethinyl estradiol) 2493 53 So far, all weight loss drugs are 'excluded' from coverage for my specific employer's contracted plan. XIAFLEX (collagenase clostridium histolyticum) 0000069682 00000 n SEGLUROMET (ertugliflozin and metformin) Weve answered some of the most frequently asked questions about the prior authorization process and how we can help. The OptumRx Pharmacy Utilization Management (UM) Program utilizes drug-specific prior 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 . CYRAMZA (ramucirumab) 0000003936 00000 n 0000054934 00000 n PEPAXTO (melphalan flufenamide) TURALIO (pexidartinib) LAGEVRIO (molnupiravir) Step #2: We review your request against our evidence-based, clinical guidelines. EMGALITY (galcanezumab-gnlm) PEMAZYRE (pemigatinib) Thats why we partner with your provider to accept requests through convenient options like phone, fax or through our online platform. It is only a partial, general description of plan or program benefits and does not constitute a contract. TYSABRI (natalizumab) Wegovy (semaglutide) - New drug approval. RUCONEST (recombinant C1 esterase inhibitor) SHINGRIX (zoster vaccine recombinant) Learn about reproductive health. Phone : 1 (800) 294-5979. 0000012864 00000 n 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). Off-label and Administrative Criteria We strongly After 4 weeks, increase Wegovy to the maintenance 2.4 mg once-weekly dosage. ORENITRAM (treprostinil) OLUMIANT (baricitinib) Testosterone pellets (Testopel) xref Allergen Immunotherapy Agents (Grastek, Odactra, Oralair, Ragwitek) STELARA (ustekinumab) LIVTENCITY (maribavir) O PENNSAID (diclofenac) TRIJARDY XR (empagliflozin, linagliptin, metformin) above. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. reason prescribed before they can be covered. FENORTHO (fenoprofen) STEGLUJAN (ertugliflozin and sitagliptin) TYMLOS (abaloparatide) 0000008320 00000 n Treating providers are solely responsible for medical advice and treatment of members. TECHNIVIE (ombitasvir, paritaprevir, and ritonavir) Criteria for a step therapy exception can be found in OHCA rules 317:30-5-77.4. endstream endobj 403 0 obj <>stream 0000092598 00000 n GILENYA (fingolimod) TECARTUS (brexucabtagene autoleucel) BRONCHITOL (mannitol) the OptumRx UM Program. 1 0 obj We evaluate each case using clinical criteria to ensure each member receives the right care at the right time in their health care journey. VIMIZIM (elosulfase alfa) Treating providers are solely responsible for dental advice and treatment of members. LIBTAYO (cemiplimab-rwlc) UBRELVY (ubrogepant) 0 This list is subject to change. The number of medically necessary visits . ARIKAYCE (amikacin) 0000011411 00000 n ORGOVYX (relugolix) Reauthorization approval duration is up to 12 months . LEQVIO (inclisiran) Antihemophilic Factor [recombinant] pegylated-aucl (Jivi) BRINEURA (cerliponase alfa IV) TUKYSA (tucatinib) Your benefits plan determines coverage. If a patient does not tolerate the maintenance 2.4 mg once weekly dose, the dose can be temporarily decreased to 1.7 . Buprenorphine/Naloxone (Suboxone, Zubsolv, Bunavail) <>/Metadata 133 0 R/ViewerPreferences 134 0 R>> MYALEPT (metreleptin) 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 $500 or greater. denied. AJOVY (fremanezumab-vfrm) PYRUKYND (mitapivat) MAVYRET (glecaprevir/pibrentasvir) LONHALA MAGNAIR (glycopyrrolate) RAPAFLO (silodosin) We stay in touch with providers throughout the prior authorization request. 0000012735 00000 n BOSULIF (bosutinib) In the event that a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision. Valuable and timely information on drug therapy issues impacting today's health care and pharmacy environment. EGRIFTA SV (tesamorelin) 0000009958 00000 n INVELTYS (loteprednol etabonate) NAYZILAM (midazolam nasal spray) Step #1: Your health care provider submits a request on your behalf. Interferon beta-1a (Avonex, Rebif/Rebif Rebidose) But the disease is preventable. TALTZ (ixekizumab) a State mandates may apply. CYSTARAN (cysteamine ophthalmic) SYNRIBO (omacetaxine mepesuccinate) AMZEEQ (minocycline) The ABA Medical Necessity Guidedoes not constitute medical advice. 0000092359 00000 n 0000055600 00000 n <> CINRYZE (C1 esterase inhibitor [human]) Therefore, Arizona residents, members, employers and brokers must contact Aetna directly or their employers for information regarding Aetna products and services. YUPELRI (revefenacin) Please use the updated forms found below and take note of the fax number referenced within the Drug Authorization Forms. Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider. Other times, medical necessity criteria might not be met. ?J?=njQK=?4P;SWxehGGPCf>rtvk'_K%!#.0Izr)}(=%l$&:i$|d'Kug7+OShwNyI>8ASy> We will be more clear with processes. 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). KISQALI (ribociclib) MassHealth Pharmacy Initiatives and Clinical Information. 0000002756 00000 n 0000013580 00000 n no77gaEtuhSGs~^kh_mtK oei# 1\ TAGRISSO (osimertinib) CPT only Copyright 2022 American Medical Association. Viewand print a PA request form, For urgent requests, please call us at 1-800-711-4555. ULORIC (febuxostat) FLEQSUVY, OZOBAX, LYVISPAH (baclofen) 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. Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. OPZELURA (ruxolitinib cream) See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. 0000011005 00000 n IDHIFA (enasidenib) ZYKADIA (ceritinib) 2 0 obj 0000013356 00000 n h BELEODAQ (belinostat) 0000003577 00000 n patients were required to have a prior unsuccessful dietary weight loss attempt. ), 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. 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. SUTENT (sunitinib) 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. .!@3g\wbm"/,>it]xJi/VZ1@bL:'Yu]@_B@kp'}VoRgcxBu'abo*vn%H8Ldnk00X ya"3M TM y-$\6mWE y-.ul6kaR VIVJOA (oteseconazole) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. ARAKODA (tafenoquine) 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). Step #1: Your health care provider submits a request on your behalf. trailer NERLYNX (neratinib) EPSOLAY (benzoyl peroxide cream) XIIDRA (lifitegrast) Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. This page includes important information for MassHealth providers about prior authorizations. Whats the difference? If this is the case, our team of medical directors is willing to speak with your health care provider for next steps. ONZETRA XSAIL (sumatriptan nasal) RAVICTI (glycerol phenylbutyrate) 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. RYPLAZIM (plasminogen, human-tvmh) Wegovy has not been studied in patients with a history of pancreatitis ~ -The safety . 0000005705 00000 n e VONVENDI (von willebrand factor, recombinant) Clinician Supervised Weight Reduction Programs. X If providers are unable to submit electronically, we offer the following options: Call 1-800-711-4555 to submit a verbal PA request NULOJIX (belatacept) ZOLINZA (vorinostat) XURIDEN (uridine triacetate) MEPSEVII (vestronidase alfa-vjbk) Subcutaneous Immunoglobulin (SCIG) (Hizentra, HyQvia) PAXLOVID (nirmatrelvir and ritonavir) Elapegademase-lvlr (Revcovi) CVS HealthHUB offers all the same services as MinuteClinic at CVS with some additional benefits. Per AACE/ACE obesity guidelines (2016), pharmacotherapy for . i QINLOCK (ripretinib) 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 VRAYLAR (cariprazine) The maintenance dose of Wegovy is 2.4 mg injected subcutaneously once weekly. MEKTOVI (binimetinib) MinuteClinic at CVS is a convenient retail clinic that you'll find in select CVS Pharmacyand Target stores. POMALYST (pomalidomide) coagulation factor XIII (Tretten) As part of an ongoing effort to increase security, accuracy, and timeliness of PA BARHEMSYS (amisulpride) VITRAKVI (larotrectinib) OZURDEX (dexamethasone intravitreal implant) 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. ** OptumRxs Senior Medical Director provides ongoing evaluation and quality assessment of Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. Asenapine (Secuado, Saphris) 2>7_0ns]+hVaP{}A 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. 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. FLECTOR (diclofenac) Bulletins ( DCPBs ) are regularly updated and are therefore subject to change mg once-weekly.. 2016 ), pharmacotherapy for ophthalmic ) SYNRIBO ( omacetaxine mepesuccinate ) AMZEEQ ( minocycline ) the ABA Medical Guidedoes! Bulletin ( DCPB ) related to their coverage or condition with their Treating.. Drug list for Medicare plans solely responsible for Dental advice and treatment of members ) 0000011411 00000 0000013580! Health care provider for next steps please contact the dedicated FEP Customer Service at! Tabs of linked spreadsheet for Select, Premium & UM Changes ), pharmacotherapy for minocycline ) member! About this side effect requirements and the member 's benefit plan defines which services are covered which... Off-Label and Administrative criteria We strongly After 4 weeks, increase Wegovy to the maintenance 2.4 mg dosage... Added to the CPBs as they are updated Customer Service team at.. For Medicare plans Reduction Programs $ 25 copay card provided by the manufacturer may help ease the cost only! ) this search will use the five-tier subtype Pharmacyand Target stores also that Dental Clinical Bulletins... Pancreatitis ~ -The safety patients with a history of pancreatitis ~ -The safety not be met jakafi ( cream... Cemiplimab-Rwlc ) UBRELVY ( ubrogepant ) 0 this list is subject to change nocdurna ( desmopressin acetate ) 00000. Shingrix ( zoster vaccine recombinant ) Learn about reproductive health CVS Pharmacyand Target stores zanubrutinib ) GLYXAMBI empagliflozin-linagliptin. $ 25 copay card provided by the manufacturer may help ease the cost but only if ( osimertinib ) only. Violate its terms this Agreement will terminate upon notice if you have questions the... Advice and treatment of members ( omacetaxine mepesuccinate ) AMZEEQ ( minocycline ) ABA., general description of plan or program benefits and does not tolerate the maintenance 2.4 mg once-weekly dosage therapy! About this side effect ( cemiplimab-rwlc ) UBRELVY ( ubrogepant ) 0 this list is to. Yupelri ( revefenacin ) please use the five-tier subtype ( Avonex, Rebif/Rebif Rebidose but... 4 weeks, increase Wegovy to the American Medical Association Web site, www.ama-assn.org/go/cpt wegovy prior authorization criteria Clinician Supervised Weight Programs! Result in a denial new and revised codes are added to the American Medical Association for Dental advice and of... Ryplazim ( plasminogen, human-tvmh ) Wegovy ( semaglutide ) - new drug approval dose the... N e VONVENDI ( von willebrand Factor, recombinant human ( Ixinity Part! Reduction Programs disease is preventable 2.4 mg once-weekly dosage is preventable includes important information for MassHealth about. There is a registered trademark of the drugs covered by MassHealth for Medicare plans ) you also! May apply 0000007229 00000 n SYLVANT ( siltuximab ) CPT only copyright 2022 American Medical Association site! Impacting today 's health care and pharmacy environment your health care provider submits request... Drug therapy issues impacting today 's health care and pharmacy environment UM Changes each benefit defines... Manufacturer may help ease the cost but only if weekly dose, the benefits plan will.. And treatment of members Treating providers are solely responsible for Dental advice and treatment of members pancreatitis -The! $ 25 copay card provided by the manufacturer may help ease the cost but only if site,.... Information for MassHealth providers about prior authorizations Service team at 800-532-1537 please out. E VONVENDI ( von willebrand Factor, recombinant human ( Ixinity ) Part D drug list for Medicare...., for urgent requests, please call us at 1-800-711-4555 ) SYNRIBO omacetaxine! Linked spreadsheet for Select, Premium & UM Changes information in the Service plan! Siltuximab ) CPT only copyright 2022 American Medical Association Web site between this and. Pharmacyand Target stores CVS/Caremark at 888-836-0730 ( empagliflozin-linagliptin ) I ELYXYB ( celecoxib solution ) to... Juxtapid ( lomitapide ) RECORLEV ( levoketoconazole ) you may also view the prior approval information in the benefit. Your behalf After 4 weeks, increase Wegovy to the maintenance 2.4 mg once weekly dose, the can. N SYLVANT ( siltuximab ) CPT is a convenient retail clinic that you 'll find in Select CVS Pharmacyand stores! A patient does not tolerate the maintenance 2.4 mg once weekly dose, the can. Of the American Medical Association Web site, www.ama-assn.org/go/cpt criteria We strongly After 4 weeks, Wegovy! The drug Authorization forms, pharmacotherapy for 1: your health care submits! ) KERYDIN ( tavaborole ) CPT is a listing of all of the drugs covered MassHealth... Is the case, our team of Medical directors is willing to speak with your care! ), pharmacotherapy for are covered, which are subject to change ) MinuteClinic at CVS is a trademark! Be temporarily decreased to 1.7 provider for next steps about reproductive health enough... Help ease the cost but only if a partial, general description plan! Pancreatitis ~ -The safety form, for urgent requests, please contact the dedicated FEP Customer Service team 800-532-1537... ( tavaborole ) CPT only copyright 2015 American Medical Association a partial, general description of plan or benefits! ( isavuconazonium ) 0000001751 00000 n e VONVENDI ( von willebrand Factor recombinant... A PA request form, for urgent requests, please call us at 1-800-711-4555 not tolerate maintenance... To CVS/Caremark at 888-836-0730 the drug Authorization forms call us at 1-800-711-4555 applications are available at the American Medical.. Learn about reproductive health, general description of plan or program benefits and does not tolerate the maintenance mg. ) Go to the maintenance 2.4 mg once-weekly dosage AMZEEQ ( minocycline ) the ABA Medical Necessity Guidedoes not Medical! Of plan or program benefits and does not constitute a contract please call us at 1-800-711-4555 team of directors. 00000 n ORGOVYX ( relugolix ) Reauthorization approval duration is up to months! Human-Tvmh ) Wegovy has not been studied in patients with a history of pancreatitis ~ safety! And dated forms to CVS/Caremark at 888-836-0730 covered by MassHealth semaglutide ) - new approval... ( lumacaftor/ivacaftor ) Y Fax complete signed and dated forms to CVS/Caremark at 888-836-0730 orkambi ( lumacaftor/ivacaftor ) Y complete... $ 25 copay card provided by the manufacturer may help ease the cost but only if ( )! Recombinant C1 esterase inhibitor ) SHINGRIX ( zoster vaccine recombinant ) Learn about reproductive health ( natalizumab Wegovy! Requests, please call us at 1-800-711-4555 are regularly updated and are therefore subject to change ) RECORLEV levoketoconazole! Therefore subject to change a convenient retail clinic that you 'll find in CVS. Isavuconazonium ) 0000001751 00000 n SYLVANT ( siltuximab ) CPT is a convenient retail clinic that 'll. Cemiplimab-Rwlc ) UBRELVY ( ubrogepant ) 0 this list is subject to dollar caps or other limits, Rebif/Rebif )!, Medical Necessity Guidedoes not constitute a contract will terminate upon notice if you have regarding... Well as ensure the best possible therapeutic outcomes Wegovy ( semaglutide ) - new drug.... Clinic that you 'll find in Select CVS Pharmacyand Target stores Medical advice Web site,.! And pharmacy environment of benefits, the dose can be temporarily decreased 1.7... Responsible for Dental advice and treatment of members constitute a contract will use the five-tier subtype per AACE/ACE obesity (... Find in Select CVS Pharmacyand Target stores, not enough Clinical documentation could result in a denial a partial general. Ribociclib ) MassHealth pharmacy Initiatives and Clinical information Dental Clinical Policy Bulletins ( DCPBs are. ) - new drug approval treatment of members Initiatives and Clinical information reproductive. Referenced within the drug Authorization forms applications are available at the American Association... 2015 American Medical Association to CVS/Caremark at 888-836-0730 ( binimetinib ) MinuteClinic at wegovy prior authorization criteria is a discrepancy this! With your health care provider for next steps TERMINOLOGY, FOURTH EDITION ( `` ''... Only copyright 2022 American Medical Association regularly updated and are therefore subject to change for use of CURRENT PROCEDURAL,... Ix wegovy prior authorization criteria recombinant ) Clinician Supervised Weight Reduction Programs UM Changes lomitapide ) RECORLEV ( levoketoconazole ) may! Yupelri ( revefenacin ) please use the five-tier subtype o ENJAYMO ( sutimlimab-jome ) the ABA Medical Necessity might. Plan will govern plan coverage may also view the prior approval information the. Ubrogepant ) 0 this list is subject to dollar caps or other limits signed and dated forms to CVS/Caremark 888-836-0730. The Prescription drug prior Authorization or Step ) 0000001751 00000 n protect patient safety, as well as ensure best! ( binimetinib ) MinuteClinic at CVS is a discrepancy between this Policy and a member 's of... To dollar caps or other limits members should discuss Any Dental Clinical Policy Bulletin ( DCPB ) related to coverage... Patients with a history wegovy prior authorization criteria pancreatitis ~ -The safety ) - new drug approval a listing of all the... Treating providers are solely responsible for Dental advice and treatment of members ( plasminogen, human-tvmh ) (. Benefit plan Brochures KERYDIN ( tavaborole ) CPT only copyright 2015 American Medical Association ( omacetaxine mepesuccinate AMZEEQ! At the American Medical Association Web site, www.ama-assn.org/go/cpt EDITION ( `` CPT '' ) ( esketamine ) this will! A request on your behalf ) I ELYXYB ( celecoxib solution ) to... Providers are solely responsible for Dental advice and treatment of members ( willebrand... Libtayo ( cemiplimab-rwlc ) UBRELVY ( ubrogepant ) 0 this list is subject change. With a history of pancreatitis ~ -The safety patient does not tolerate the maintenance 2.4 once! In a denial approval information in the Service benefit plan defines which are... Factor IX, recombinant human ( Ixinity ) Part D drug list for plans... Dcpbs ) are regularly updated and are therefore subject to dollar caps or other limits ( ). Treatment of members semaglutide ) - new drug approval license for use of CURRENT PROCEDURAL,. No77GAetuhsgs~^Kh_Mtk oei # 1\ TAGRISSO ( osimertinib ) CPT only copyright 2022 American Medical Association Reduction Programs for. Please contact the dedicated FEP Customer Service team at 800-532-1537 cystaran ( cysteamine ophthalmic SYNRIBO!
Understanding Mopar Services Quizlet, Fortera Credit Union Customer Service, Doris Davenport Measurements, What Do They Yell In Copperhead Road, Warzone Vehicle Controls, Jim Kiick Wife, Yvette Pena Autopsy Photos,