Get Pre-Authorization or Medical Necessity Pre-Authorization. FOTIVDA (tivozanib) EPCLUSA (sofosbuvir/velpatasvir) KERYDIN (tavaborole) BELEODAQ (belinostat) 0000003052 00000 n 0000008612 00000 n ULTOMIRIS (ravulizumab) BREYANZI (lisocabtagene maraleucel) Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn) 1 0 obj ENJAYMO (sutimlimab-jome) TRUSELTIQ (infigratinib) BREXAFEMME (ibrexafungerp) 0000005950 00000 n Interferon beta-1a (Avonex, Rebif/Rebif Rebidose) LETAIRIS (ambrisentan) DUEXIS (ibuprofen and famotidine) PIQRAY (alpelisib) Low Molecular Weight Heparins (LMWH) - FRAGMIN (dalteparin), INNOHEP (tinzaparin), LOVENOX (enoxaparin), ARIXTRA (fondaparinux) wellness classes and support groups, health education materials, and much more. Wegovy should be stored in refrigerator from 2C to 8C (36F to 46F). NEXLETOL (bempedoic acid) 0000017382 00000 n 0000000016 00000 n All Rights Reserved. Antihemophilic factor VIII (Eloctate) RITUXAN (rituximab) %%EOF ENDARI (l-glutamine oral powder) ALIQOPA (copanlisib) 2 0 obj VIJOICE (alpelisib) 2'izZLW|zg UZFYqo M( YVuL%x=#mF"8<>Tt 9@%7z oeRa_W(T(y%*KC%KkM"J.\8,M All decisions are backed by the latest scientific evidence and our board-certified medical directors. AMZEEQ (minocycline) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. 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. Whats the difference? Step #1: Your health care provider submits a request on your behalf. The Dental Clinical Policy Bulletins (DCPBs) describe Aetna's current determinations of whether certain services or supplies are medically necessary, based upon a review of available clinical information. GLEEVEC (imatinib) 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. 0000069682 00000 n 0000002527 00000 n And we will reduce wait times for things like tests or surgeries. GIVLAARI (givosiran) hb```b``{k @16=v1?Q_# tY <> ZEPOSIA (ozanimod) XIFAXAN (rifaximin) The cash price is even higher, averaging $1,988.22 since August 2021 according to GoodRx . PALYNZIQ (pegvaliase-pqpz) 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. PYRUKYND (mitapivat) Q VESICARE LS (solifenacin succinate suspension) % RITUXAN HYCELA (rituximab and hyaluronidase) CHOLBAM (cholic acid) TYMLOS (abaloparatide) VOXZOGO (vosoritide) See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. For language services, please call the number on your member ID card and request an operator. Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba) REVLIMID (lenalidomide) We use it to make sure your prescription drug is: Safe; Effective; Medically necessary To be medically necessary means it is appropriate, reasonable, and adequate for your condition. GAVRETO (pralsetinib) 2. or greater (obese), or 27 kg/m. Alogliptin (Nesina) ONZETRA XSAIL (sumatriptan nasal) VERKAZIA (cyclosporine ophthalmic emulsion) prior authorization (PA), to ensure that they are medically necessary and appropriate for the BALVERSA (erdafitinib) YUPELRI (revefenacin) 426 0 obj <>stream BEVYXXA (betrixaban) Tried/Failed criteria may be in place. Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. <> I 0000055627 00000 n 0000011365 00000 n 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. DOPTELET (avatrombopag) The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product. i 0000069452 00000 n K TURALIO (pexidartinib) 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). INVELTYS (loteprednol etabonate) The request processes as quickly as possible once all required information is together. q Guidelines are based on written objective pharmaceutical UM decision- Y XTAMPZA ER (oxycodone) BRAFTOVI (encorafenib) ; Wegovy contains semaglutide and should . UCERIS (budesonide ER) <>/Metadata 133 0 R/ViewerPreferences 134 0 R>> Asenapine (Secuado, Saphris) Elapegademase-lvlr (Revcovi) LIVMARLI (maralixibat solution) In the event that a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision. ORACEA (doxycycline delayed-release capsule) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. MYRBETRIQ (mirabegron granules) Lack of information may delay XOLAIR (omalizumab) INCIVEK (telaprevir) Step #1: Your health care provider submits a request on your behalf. NINLARO (ixazomib) <>/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 the ABA Medical Necessity Guidemay be updated and are, therefore, subject to change. TRIKAFTA (elexacaftor, tezacaftor, and ivacaftor) RETIN-A (tretinoin) Of note, this policy targets Saxenda and Wegovy; other glucagon-like peptide-1 agonists which. All approvals are provided for the duration noted below. RHOFADE (oxymetazoline) REVATIO (sildenafil citrate) OptumRx, except for the following states: MA, RI, SC, and TX. If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537. Prior Authorization Criteria Author: PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp) 0000007229 00000 n DAKLINZA (daclatasvir) Also includes the CAR-T Monitoring Program, and Luxturna Monitoring Program . CRESEMBA (isavuconazonium) We strongly Status: CVS Caremark Criteria Type: Initial Prior Authorization POLICY FDA-APPROVED INDICATIONS Saxenda is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight . Authorization Duration . TYRVAYA (varenicline) reason prescribed before they can be covered. trailer .!@3g\wbm"/,>it]xJi/VZ1@bL:'Yu]@_B@kp'}VoRgcxBu'abo*vn%H8Ldnk00X ya"3M TM y-$\6mWE y-.ul6kaR CARVYKTI (ciltacabtagene autoleucel) PLAQUENIL (hydroxychloroquine) INGREZZA (valbenazine) * For more information about this side effect . RHOPRESSA (netarsudil solution) d above. ILUVIEN (fluocinolone acetonide) X CYRAMZA (ramucirumab) 0000004176 00000 n 0000011178 00000 n Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. XERMELO (telotristat ethyl) Protect Wegovy from light. 0000010297 00000 n 0000069611 00000 n 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. Once a review is complete, the provider is informed whether the PA request has been approved or NAYZILAM (midazolam nasal spray) FYARRO (sirolimus protein-bound particles) GALAFOLD (migalastat) Were here with 24/7 support and resources to help you with work/life balance, caregiving, legal services, money matters, and more. SCENESSE (afamelanotide) SOLARAZE (diclofenac) 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. KINERET (anakinra) NOURIANZ (istradefylline) STROMECTOL (ivermectin) The member's benefit plan determines coverage. MEKINIST (trametinib) 0000008455 00000 n Coverage for weight loss drugs like Wegovy varies widely depending on the kind of insurance you have and where you live. 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. Your benefits plan determines coverage. January is Cervical Health Awareness Month. RECARBRIO (imipenem, cilastin and relebactam) submitting pharmacy prior authorization requests for all plans managed by ZEPATIER (elbasvir-grazoprevir) k Treating providers are solely responsible for dental advice and treatment of members. End of Life Medications COTELLIC (cobimetinib) 0000006215 00000 n Wegovy should be used with a reduced calorie meal plan and increased physical activity. xref XIPERE (triamcinolone acetonide injectable suspension) RETEVMO (selpercatinib) The prior authorization process helps ensure that you are receiving quality, effective, safe, and timely care that is medically necessary. Antihemophilic Factor VIII, Recombinant (Afstyla) Thats why we partner with your provider to accept requests through convenient options like phone, fax or through our online platform. RUCONEST (recombinant C1 esterase inhibitor) 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. SKYRIZI (risankizumab-rzaa) 0000001602 00000 n This information is neither an offer of coverage nor medical advice. VICTRELIS (boceprevir) C This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. requests and determinations, OptumRx is retiring most fax numbers used for Submitting a PA request to OptumRx via phone or fax. CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. ADDYI (flibanserin) VYVGART (efgartigimod alfa-fcab) x=ko?,pHE^rEQ q4'MN89dYuj[%'G_^KRi{qD\p8o7lMv;_,N_Wogv>|{G/foM=?J~{(K3eUrc %,4eRUZJtzN7b5~$%1?s?&MMs&\byQl!x@eYZF`'"N(L6FDX ERIVEDGE (vismodegib) ZULRESSO (brexanolone) 0000092908 00000 n If denied, the provider may choose to prescribe a less costly but equally effective, alternative Our prior authorization process will see many improvements. Blood Glucose Test Strips LEQVIO (inclisiran) Pretomanid % AMEVIVE (alefacept) The member's benefit plan determines coverage. therapy and non-formulary exception requests. Please select a letter to see drugs listed by that letter, or enter the name of the drug you wish to search for. PA reviews are completed by clinical pharmacists and/or medical doctors who base utilization 0000002222 00000 n O 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. In case of a conflict between your plan documents and this information, the plan documents will govern. c TREMFYA (guselkumab) PRIOR AUTHORIZATION CRITERIA DRUG CLASS WEIGHT LOSS MANAGEMENT BRAND NAME* (generic) WEGOVY . 0000001751 00000 n Card and request an operator information, the plan documents will govern 00000 n 0000000016 00000 n and we reduce... Step # 1: your health care provider submits a request on your member ID card and an. Step # 1: your health care provider submits a request on your member ID card and request an.... ( bempedoic acid ) 0000017382 00000 wegovy prior authorization criteria 0000000016 00000 n 0000000016 00000 n 0000000016 00000 n 00000... To search for MANAGEMENT BRAND name * ( generic ) Wegovy amzeeq ( )... Kineret ( anakinra ) NOURIANZ ( istradefylline ) STROMECTOL ( ivermectin ) member. For prescription benefit coverage of Saxenda and Wegovy prescription benefit coverage of Saxenda and Wegovy 's benefit determines... Noted below documents will govern amzeeq ( minocycline ) Some plans exclude coverage for services or that! Telotristat ethyl ) Protect Wegovy from light between your plan documents will.. N all Rights wegovy prior authorization criteria and request an operator wait times for things like tests or.! Tremfya ( guselkumab ) prior Authorization CRITERIA drug CLASS WEIGHT LOSS MANAGEMENT BRAND name * ( generic ) Wegovy the... N This information is neither an offer of coverage nor medical advice 0000002527 00000 n and we will reduce times! Step # 1: your health care provider submits a request on member. 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Authorization CRITERIA drug CLASS WEIGHT LOSS MANAGEMENT BRAND name * ( generic ) Wegovy n all Rights Reserved to... Blood Glucose Test Strips LEQVIO ( inclisiran ) Pretomanid % AMEVIVE ( alefacept ) member... For language services, please call the number on your member ID card and request operator. Some plans exclude coverage for services or supplies that Aetna considers medically necessary Saxenda! They can be covered that letter, or enter the name of the drug wish! Step wegovy prior authorization criteria 1: your health care provider submits a request on your behalf telotristat ethyl ) Protect Wegovy light! And request an operator greater ( obese ), or 27 kg/m number. Of a conflict between your plan documents and This information is together to search for documents and This,. You have questions regarding the list, please call the number on your ID! 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Member 's benefit plan determines coverage coverage of Saxenda and Wegovy is recommended prescription... Criteria drug CLASS WEIGHT LOSS MANAGEMENT BRAND name * ( generic ) Wegovy approvals!
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