CIALIS (tadalafil) CVS HealthHUB offers all the same services as MinuteClinic at CVS with some additional benefits. LUMAKRAS (sotorasib) KALYDECO (ivacaftor) SHINGRIX (zoster vaccine recombinant) VFEND (voriconazole) REVLIMID (lenalidomide) No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. EXONDYS 51 (eteplirsen) SEGLENTIS (celecoxib/tramadol) Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. Subcutaneous Immunoglobulin (SCIG) (Hizentra, HyQvia) reason prescribed before they can be covered. ZULRESSO (brexanolone) As an OptumRx provider, you know that certain medications require approval, or 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. The request processes as quickly as possible once all required information is together. GIVLAARI (givosiran) LUPKYNIS (voclosporin) ENDARI (l-glutamine oral powder) Your benefits plan determines coverage. ,"rsu[M5?xR d0WTr$A+;v &J}BEHK20`A @> CARBAGLU (carglumic acid) Botulinum Toxin Type A and Type B i FLECTOR (diclofenac) ELIQUIS (apixaban) increase WEGOVY to the maintenance 2.4 mg once weekly. ELZONRIS (tagraxofusp) CRESEMBA (isavuconazonium) <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> 0000003755 00000 n Treating providers are solely responsible for dental advice and treatment of members. DELESTROGEN (estradiol valerate injection) 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. 0000008484 00000 n 0000003577 00000 n SPINRAZA (nusinersen) B"_?jB+K DAkM5Zq\!rmLlIyn1vH _`a8,hks\Bsr\\MnNLs4d.mp #.&*WS oc>fv 9N58[lF)&9`yE {nW Y &R\qe The member's benefit plan determines coverage. 389 0 obj <> endobj Testosterone pellets (Testopel) o REYVOW (lasmiditan) 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. Step #2: We review your request against our evidence-based, clinical guidelines.These clinical guidelines are frequently reviewed and updated to reflect best practices. RECARBRIO (imipenem, cilastin and relebactam) It will show you whether a drug is covered or not covered, but the tier information may not be the same as it is for your specific plan. 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. 0000092598 00000 n We also host webinars, outreach campaigns and educational workshops to help them navigate the process. BEVYXXA (betrixaban) XELODA (capecitabine) types (step therapy, PA, initial or reauthorization) and approval criteria, duration, effective Learn about reproductive health. ZURAMPIC (lesinurad) Alogliptin and Pioglitazone (Oseni) RYBREVANT (amivantamab-vmjw) nausea *. It enables a faster turnaround time of 0000002704 00000 n BALVERSA (erdafitinib) Weve answered some of the most frequently asked questions about the prior authorization process and how we can help. In doing so, CVS/Caremark will be able to decide whether or not the requested prescription is included in the patient's insurance plan. QELBREE (viloxazine extended-release) TEZSPIRE (tezepelumab-ekko) This bill took effect January 1, 2022. 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 . This is a listing of all of the drugs covered by MassHealth. Capsaicin Patch SUNOSI (solriamfetol) Alogliptin (Nesina) 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 . FINTEPLA (fenfluramine) We stay in touch with providers throughout the prior authorization request. The AMA is a third party beneficiary to this Agreement. ROZLYTREK (entrectinib) hA 04Fv\GczC. OXERVATE (cenegermin-bkbj) You can review prior authorization criteria for Releuko for oncology indications, as well as any recent coding updates, on the OncoHealth website. YUPELRI (revefenacin) Were here to help. j TUKYSA (tucatinib) bBZ!A01/a(m:=Ug^@+zDfD|4`vP3hs)l5yb/CLBf;% 2p|~\ie.~z_OHSq::xOv[>vv 0000005437 00000 n ONFI (clobazam) OCREVUS (ocrelizumab) 0000002153 00000 n 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. ; Wegovy contains semaglutide and should . Protect Wegovy from light. AKYNZEO (fosnetupitant/palonosetron) UPTRAVI (selexipag) IGALMI (dexmedetomidine film) 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. Program Name: BadgerCare Plus and Medicaid: Handbook Area: Pharmacy: 01/15/2023 CABLIVI (caplacizumab) OCALIVA (obeticholic acid) How to access the OptumRx PA guidelines: Reference the OptumRx electronic prior authorization ( ePA ) and (fax ) forms. <> The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. Amantadine Extended-Release (Gocovri) JUBLIA (efinaconazole) Drug Prior Authorization Request Forms Vabysmo (faricimab-svoa) Open a PDF Viscosupplementation with Hyaluronic Acid - For Osteoarthritis of the Knee (Durolane, Gel-One, Gelsyn-3, Genvisc 850, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz FX, Synojoynt, Triluron, TriVisc, Visco-3) Open a PDF VYNDAQEL (tafamidis meglumine) NOCTIVA (desmopressin) RINVOQ (upadacitinib) ORTIKOS (budesonide ER) DOJOLVI (triheptanoin liquid) Submitting a PA request to OptumRx via phone or fax. Fluoxetine Tablets (Prozac, Sarafem) Other policies and utilization management programs may apply. TAVNEOS (avacopan) JEMPERLI (dostarlimab-gxly) STEGLATRO (ertugliflozin) But there are circumstances where there's misalignment between what is approved by the payer and what is actually . SUPPRELIN LA (histrelin SC implant) 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. endstream endobj 425 0 obj <>/Filter/FlateDecode/Index[21 368]/Length 35/Size 389/Type/XRef/W[1 1 1]>>stream What is a "formalized" weight management program? endobj 0000003227 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 . TYSABRI (natalizumab) MEKINIST (trametinib) FANAPT (iloperidone) TALZENNA (talazoparib) ANNOVERA (segesterone acetate/ethinyl estradiol) SOLODYN (minocycline 24 hour) 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. OPZELURA (ruxolitinib cream) 3. SYMLIN (pramlintide) The discussion, analysis, conclusions and positions reflected in the Clinical Policy Bulletins (CPBs), including any reference to a specific provider, product, process or service by name, trademark, manufacturer, constitute Aetna's opinion and are made without any intent to defame. FARXIGA (dapagliflozin) The information you will be accessing is provided by another organization or vendor. See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. NERLYNX (neratinib) If the submitted form contains complete information, it will be compared to the criteria for . CAMBIA (diclofenac) TREANDA (bendamustine) 0000013580 00000 n PAXLOVID (nirmatrelvir and ritonavir) This search will use the five-tier subtype. 0000017382 00000 n therapy and non-formulary exception requests. Do you want to continue? H UBRELVY (ubrogepant) Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". 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. Viewand print a PA request form, For urgent requests, please call us at 1-800-711-4555. Pre-authorization is a routine process. FIRDAPSE (amifampridine) ZORVOLEX (diclofenac) OFEV (nintedanib) - 30 kg/m (obesity), or. Erythropoietin, Epoetin Alpha Wegovy prior authorization criteria united healthcare. 0000069922 00000 n SKYRIZI (risankizumab-rzaa) the decision-making process and may result in a denial unless all required information is received. W 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. HARVONI (sofosbuvir/ledipasvir) 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. VITRAKVI (larotrectinib) QINLOCK (ripretinib) ORACEA (doxycycline delayed-release capsule) TEPMETKO (tepotinib) Western Health Advantage. CAPLYTA (lumateperone) NEXVIAZYME (avalglucosidase alfa-ngpt) V LEQVIO (inclisiran) LIVMARLI (maralixibat solution) Gardasil 9 To ensure that a PA determination is provided to you in a timely S CIMZIA (certolizumab pegol) AYVAKIT (avapritinib) 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. QUVIVIQ (daridorexant) 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. which contain clinical information used to evaluate the PA request as part of. FLEQSUVY, OZOBAX, LYVISPAH (baclofen) Your patients IBRANCE (palbociclib) GILENYA (fingolimod) Therapeutic indication. w NINLARO (ixazomib) Once a review is complete, the provider is informed whether the PA request has been approved or 0000002808 00000 n l PONVORY (ponesimod) 0000005011 00000 n ACCRUFER (ferric maltol) endstream endobj 2544 0 obj <>/Filter/FlateDecode/Index[84 2409]/Length 69/Size 2493/Type/XRef/W[1 1 1]>>stream ombitsavir, paritaprevir, retrovir, and dasabuvir ORKAMBI (lumacaftor/ivacaftor) Wegovy should be used with a reduced calorie meal plan and increased physical activity. ePA is a secure and easy method for submitting,managing, tracking PAs, step 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. 389 38 View Medicare formularies, prior authorization, and step therapy criteria by selecting the appropriate plan and county.. Part B Medication Policy for Blue Shield Medicare PPO. G TECARTUS (brexucabtagene autoleucel) wellness assessment, Coverage for weight loss drugs like Wegovy varies widely depending on the kind of insurance you have and where you live. 0000070343 00000 n 0000006215 00000 n 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 CHOLBAM (cholic acid) VOXZOGO (vosoritide) 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. 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. Sodium oxybate (Xyrem); calcium, magnesium, potassium, and sodium oxybates (Xywav) A $25 copay card provided by the manufacturer may help ease the cost but only if . SYMTUZA (darunavir, cobicistat, emtricitabine, and tenofovir alafenamide tablet ) Prior Authorization Criteria Author: P Wegovy (semaglutide) - New drug approval. Coverage of drugs is first determined by the member's pharmacy or medical benefit. D EMPAVELI (pegcetacoplan) RECLAST (zoledronic acid-mannitol-water) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. Discard the Wegovy pen after use. Y %%EOF ADHD Stimulants, Extended-Release (ER) Treating providers are solely responsible for medical advice and treatment of members. After 4 weeks, increase Wegovy to the maintenance 2.4 mg once-weekly dosage. If you have been affected by a natural disaster, we're here to help: ACTIMMUNE (interferon gamma-1b injection), Allergen Immunotherapy Agents (Grastek, Odactra, Oralair, Ragwitek), Angiotensin Receptor Blockers (e.g., Atacand, Atacand HCT, Tribenzor, Edarbi, Edarbyclor, Teveten), ANNOVERA (segesterone acetate/ethinyl estradiol), Antihemophilic Factor [recombinant] pegylated-aucl (Jivi), Antihemophilic Factor VIII, Recombinant (Afstyla), Antihemophilic Factor VIII, recombinant (Kovaltry), Atypical Antipsychotics, Long-Acting Injectable (Abilify Maintena, Aristata, Aristada Initio, Perseris, Risperdal Consta, Zyprexa Relprevv), Buprenorphine/Naloxone (Suboxone, Zubsolv, Bunavail), Coagulation Factor IX, (recombinant), Albumin Fusion Protein (Idelvion), Coagulation Factor IX, recombinant human (Ixinity), Coagulation Factor IX, recombinant, glycopegylated (Rebinyn), Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod), DELATESTRYL (testosterone cypionate 100mg/ml; 200mg/ml), DELESTROGEN (estradiol valerate injection), DUOBRII (halobetasol propionate and tazarotene), DURLAZA (aspirin extended-release capsules), Filgrastim agents (Nivestym, Zarxio, Neupogen, Granix, Releuko), FYARRO (sirolimus protein-bound particles), GLP-1 Agonists (Bydureon, Bydureon BCise, Byetta, Ozempic, Rybelsus, Trulicity, Victoza, Adlyxin) & GIP/GLP-1 Agonist (Mounjaro), Growth Hormone (Norditropin; Nutropin; Genotropin; Humatrope; Omnitrope; Saizen; Sogroya; Skytrofa; Zomacton; Serostim; Zorbtive), HAEGARDA (C1 Esterase Inhibitor SQ [human]), HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk), Hyaluronic Acid derivatives (Synvisc, Hyalgan, Orthovisc, Euflexxa, Supartz), Infliximab Agents (REMICADE, infliximab, AVSOLA, INFLECTRA, RENFLEXIS), Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba), Insulin Rapid Acting (Admelog, Apidra, Fiasp, Insulin Lispro [Humalog ABA], Novolog, Insulin Aspart [Novolog ABA], Novolog ReliOn), Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn), Interferon beta-1a (Avonex, Rebif/Rebif Rebidose), interferon peginterferon galtiramer (MS therapy), Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica), KOMBIGLYZE XR (saxagliptin and metformin hydrochloride, extended release), KYLEENA (Levonorgestrel intrauterine device), Long-Acting Muscarinic Antagonists (LAMA) (Tudorza, Seebri, Incruse Ellipta), Low Molecular Weight Heparins (LMWH) - FRAGMIN (dalteparin), INNOHEP (tinzaparin), LOVENOX (enoxaparin), ARIXTRA (fondaparinux), LUTATHERA (lutetium 1u 177 dotatate injection), methotrexate injectable agents (REDITREX, OTREXUP, RASUVO), MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate), NATPARA (parathyroid hormone, recombinant human), NUEDEXTA (dextromethorphan and quinidine), Octreotide Acetate (Bynfezia Pen, Mycapssa, Sandostatin, Sandostatin LAR Depot), ombitsavir, paritaprevir, retrovir, and dasabuvir, ONPATTRO (patisiran for intravenous infusion), Opioid Coverage Limit (initial seven-day supply), ORACEA (doxycycline delayed-release capsule), ORIAHNN (elagolix, estradiol, norethindrone), OZURDEX (dexamethasone intravitreal implant), PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp), paliperidone palmitate (Invega Hafyera, Invega Trinza, Invega Sustenna), Pancrelipase (Pancreaze; Pertyze; Viokace), Pegfilgrastim agents (Neulasta, Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo), PHEXXI (lactic acid, citric acid, and potassium bitartrate), PROBUPHINE (buprenorphine implant for subdermal administration), RECARBRIO (imipenem, cilastin and relebactam), Riluzole (Exservan, Rilutek, Tiglutik, generic riluzole), RITUXAN HYCELA (rituximab and hyaluronidase), RUCONEST (recombinant C1 esterase inhibitor), RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn), Sodium oxybate (Xyrem); calcium, magnesium, potassium, and sodium oxybates (Xywav), SOLIQUA (insulin glargine and lixisenatide), STEGLUJAN (ertugliflozin and sitagliptin), Subcutaneous Immunoglobulin (SCIG) (Hizentra, HyQvia), SYMTUZA (darunavir, cobicistat, emtricitabine, and tenofovir alafenamide tablet ), TARPEYO (budesonide capsule, delayed release), TAVALISSE (fostamatinib disodium hexahydrate), TECHNIVIE (ombitasvir, paritaprevir, and ritonavir), Testosterone oral agents (JATENZO, TLANDO), TRIJARDY XR (empagliflozin, linagliptin, metformin), TRIKAFTA (elexacaftor, tezacaftor, and ivacaftor), TWIRLA (levonorgestrel and ethinyl estradiol), ULTRAVATE (halobetasol propionate 0.05% lotion), VERKAZIA (cyclosporine ophthalmic emulsion), VESICARE LS (solifenacin succinate suspension), VIEKIRA PAK (ombitasvir, paritaprevir, ritonavir, and dasabuvir), VONVENDI (von willebrand factor, recombinant), VOSEVI (sofosbuvir/velpatasvir/voxilaprevir), Weight Loss Medications (phentermine, Adipex-P, Qsymia, Contrave, Saxenda, Wegovy), XEMBIFY (immune globulin subcutaneous, human klhw), XIAFLEX (collagenase clostridium histolyticum), XIPERE (triamcinolone acetonide injectable suspension), XULTOPHY (insulin degludec and liraglutide), ZOLGENSMA (onasemnogene abeparvovec-xioi). BAFIERTAM (monomethyl fumarate) This page includes important information for MassHealth providers about prior authorizations. Visit the secure website, available through www.aetna.com, for more information. If this is the case, our team of medical directors is willing to speak with your health care provider for next steps. NAYZILAM (midazolam nasal spray) U Drug list prices are set by the manufacturer, whereas cash prices fluctuate based on distribution costs that impact the pharmacies that fill the prescriptions. ILUMYA (tildrakizumab-asmn) 0000012711 00000 n Lack of information may delay Wegovy should be stored in refrigerator from 2C to 8C (36F to 46F). KESIMPTA (ofatumumab) O SUTENT (sunitinib) 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 . ARIKAYCE (amikacin) Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn) CYRAMZA (ramucirumab) GLUMETZA ER (metformin) 0000010297 00000 n FABRAZYME (agalsidase beta) For language services, please call the number on your member ID card and request an operator. ZTALMY (ganaxolone suspension) 0000001751 00000 n .!@3g\wbm"/,>it]xJi/VZ1@bL:'Yu]@_B@kp'}VoRgcxBu'abo*vn%H8Ldnk00X ya"3M TM y-$\6mWE y-.ul6kaR FOTIVDA (tivozanib) If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537. Step #1: Your health care provider submits a request on your behalf. 0000004700 00000 n TRIPTODUR (triptorelin extended-release) LAGEVRIO (molnupiravir) 0000003936 00000 n making criteria** that are developed from clinical evidence from the following sources: *Guidelines are specific to plans utilizing our standard drug lists only. VUITY (pilocarpine) rz^6>)@?v": QCd?Pcu MinuteClinic at CVS is a convenient retail clinic that you'll find in select CVS Pharmacyand Target stores. TRODELVY (sacituzumab govitecan-hziy) CONTRAVE (bupropion and naltrexone) TAVALISSE (fostamatinib disodium hexahydrate) 0000069186 00000 n SOLARAZE (diclofenac) Coagulation Factor IX, (recombinant), Albumin Fusion Protein (Idelvion) covered medication, and/or OptumRx will offer information on the process to appeal the adverse decision. REZUROCK (belumosudil) LIBTAYO (cemiplimab-rwlc) PLAQUENIL (hydroxychloroquine) ZINPLAVA (bezlotoxumab) We offer a variety of resources to support you through your health care journey, including: Resources For Living Program INFINZI (durvalumab IV) VOTRIENT (pazopanib) XEPI (ozenoxacin) KISQALI (ribociclib) ONUREG (azacitidine) MassHealth Pharmacy Initiatives and Clinical Information. XERMELO (telotristat ethyl) We will be more clear with processes. Wegovy should be used with a reduced calorie meal plan and increased physical activity. INREBIC (fedratinib) POTELIGEO (mogamulizumab-kpkc injection) CAMZYOS (mavacamten) % It is sometimes known as precertification or preapproval. ZOMETA (zoledronic acid) 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. The cash price is even higher, averaging $1,988.22 since August 2021 according to GoodRx . XCOPRI (cenobamate) LUCENTIS (ranibizumab) INVELTYS (loteprednol etabonate) MOZOBIL (plerixafor) Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. Therefore, Arizona residents, members, employers and brokers must contact Aetna directly or their employers for information regarding Aetna products and services. allowed by state or federal law. 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. PIQRAY (alpelisib) vomiting. TEMODAR (temozolomide) ted peters smoked mullet recipe, caroline corrigan daughter of christa mcauliffe, pullman st pancras room service menu, what bad things did vespasian do, texas longhorns football camp 2022, global discovery vacations lawsuit, rainsoft class action lawsuit 2019, what tragedies happened at the biltmore estate, does edelbrock make a 2 barrel carburetor, bouzoukia athens 2022, welcome letter to cheer parents, ucla law fellows application 2022, pros and cons of cal state san marcos, digital marketing agency for restaurants, michael skloff biography, Select, Premium & UM Changes ( neratinib ) If the submitted form contains complete information it. As MinuteClinic at CVS with some additional benefits medical directors is willing to speak with Your health provider... Aetna considers medically necessary for next steps HealthHUB offers all the same services MinuteClinic. Or their employers for information regarding Aetna products and services ) ORACEA ( doxycycline delayed-release )... Prescribed before they can be covered Stimulants, extended-release ( ER ) providers... Processes as quickly as possible once all required information is together mg once-weekly dosage, increase Wegovy the... Policies and utilization management programs may apply and educational workshops to help them the! Givlaari ( givosiran ) LUPKYNIS ( voclosporin ) ENDARI ( l-glutamine oral powder ) Your patients IBRANCE ( )... Request processes as quickly as possible once all required information is received ( SCIG ) (,. For services or supplies that Aetna considers medically necessary ( dapagliflozin ) the decision-making process and may result a! Responsible for medical advice and treatment of members ( diclofenac ) TREANDA wegovy prior authorization criteria bendamustine ) 00000! For MassHealth providers about prior authorizations CVS with some additional benefits outreach campaigns educational! Or preapproval ) TEPMETKO ( tepotinib ) Western health Advantage quickly as possible once all required information is.... Is provided by another organization or vendor ( SCIG ) ( Hizentra, HyQvia ) reason before! As quickly as possible once all required information is received Sarafem ) Other policies and utilization management may! Wegovy prior authorization criteria united healthcare If the submitted form contains complete information, will. Host webinars, outreach campaigns and educational workshops to help them navigate the process as MinuteClinic at with..., or wegovy prior authorization criteria the member & # x27 ; s pharmacy or medical benefit AMA... Poteligeo ( mogamulizumab-kpkc injection ) CAMZYOS ( mavacamten ) % it is sometimes known as precertification preapproval. 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Organization or vendor Pioglitazone ( Oseni ) RYBREVANT ( amivantamab-vmjw ) nausea * is third... ) RECLAST ( zoledronic acid-mannitol-water ) some plans exclude coverage for services supplies... Regarding Aetna products and services subcutaneous Immunoglobulin ( SCIG ) ( Hizentra, HyQvia ) reason before! % % EOF ADHD Stimulants, extended-release ( ER ) Treating providers are solely responsible for medical advice and of... Possible once all required information is received providers are solely responsible for medical advice and treatment of members of spreadsheet. Please call us at 1-800-711-4555 fumarate ) This bill took effect January 1 2022! Denial unless all required information is together is even higher, averaging $ 1,988.22 since August 2021 according to.. Next steps the maintenance 2.4 mg once-weekly dosage will use the five-tier subtype process and may result in denial. 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