Any use of CPT outside of Aetna Precertification Code Search Tool should refer to the most Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. MEKTOVI (binimetinib)
SUSTOL (granisetron)
Alogliptin and Pioglitazone (Oseni)
ZIPSOR (diclofenac)
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 You can review prior authorization criteria for Releuko for oncology indications, as well as any recent coding updates, on the OncoHealth website. 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 CARVYKTI (ciltacabtagene autoleucel)
x
This bill took effect January 1, 2022.
This information is neither an offer of coverage nor medical advice. TALZENNA (talazoparib)
But there are circumstances where there's misalignment between what is approved by the payer and what is actually . 0000009958 00000 n
PROLIA (denosumab)
You are now being directed to the CVS Health site. ROZLYTREK (entrectinib)
KORSUVA (difelikefalin)
NEXAVAR (sorafenib)
requests and determinations, OptumRx is retiring most fax numbers used for EPIDIOLEX (cannabidiol)
Amantadine Extended-Release (Gocovri)
Guidelines are based on written objective pharmaceutical UM decision-
RITUXAN HYCELA (rituximab and hyaluronidase)
The number of medically necessary visits . Members should discuss any matters related to their coverage or condition with their treating provider. SOVALDI (sofosbuvir)
BELSOMRA (suvorexant)
dates and more.
Learn about reproductive health. Get Pre-Authorization or Medical Necessity Pre-Authorization.
XTANDI (enzalutamide)
Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. 0000004647 00000 n
The member's benefit plan determines coverage. Has lost at least 5% of baseline (prior to the initiation of Wegovy) body weight (only required once) 4. Growth Hormone (Norditropin; Nutropin; Genotropin; Humatrope; Omnitrope; Saizen; Sogroya; Skytrofa; Zomacton; Serostim; Zorbtive)
MOZOBIL (plerixafor)
Riluzole (Exservan, Rilutek, Tiglutik, generic riluzole)
The AMA is a third party beneficiary to this Agreement. Wegovy should be used with a reduced calorie meal plan and increased physical activity. FLECTOR (diclofenac)
ENBREL (etanercept)
0000013029 00000 n
SEGLUROMET (ertugliflozin and metformin)
0000092908 00000 n
AUSTEDO (deutetrabenazine)
The information you will be accessing is provided by another organization or vendor. headache. 0000002222 00000 n
CALQUENCE (Acalabrutinib)
P
RHOPRESSA (netarsudil solution)
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.
TECARTUS (brexucabtagene autoleucel)
BENLYSTA (belimumab)
This list is subject to change.
TASIGNA (nilotinib)
OFEV (nintedanib)
KRINTAFEL (tafenoquine)
GLUMETZA ER (metformin)
Erythropoietin, Epoetin Alpha
Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. AKYNZEO (fosnetupitant/palonosetron)
LYNPARZA (olaparib)
interferon peginterferon galtiramer (MS therapy)
methotrexate injectable agents (REDITREX, OTREXUP, RASUVO)
0000012711 00000 n
KADCYLA (Ado-trastuzumab emtansine)
Aetna has reached these conclusions based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors).
VONJO (pacritinib)
Treating providers are solely responsible for medical advice and treatment of members. 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. HUMIRA (adalimumab)
XIIDRA (lifitegrast)
0000012735 00000 n
You may also view the prior approval information in the Service Benefit Plan Brochures. FLEQSUVY, OZOBAX, LYVISPAH (baclofen)
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).
ADUHELM (aducanumab-avwa)
BALVERSA (erdafitinib)
Disclaimer of Warranties and Liabilities. Wegovy should be used with a reduced calorie meal plan and increased physical activity. 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. 0000069417 00000 n
You, your employees and agents are authorized to use CPT only as contained in Aetna Clinical Policy Bulletins (CPBs) solely for your own personal use in directly participating in healthcare programs administered by Aetna, Inc. You acknowledge that AMA holds all copyright, trademark and other rights in CPT. Criteria for a step therapy exception can be found in OHCA rules 317:30-5-77.4. ORILISSA (elagolix)
SOLIQUA (insulin glargine and lixisenatide)
Testosterone oral agents (JATENZO, TLANDO)
As an OptumRx provider, you know that certain medications require approval, or Specialty pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used to treat complex conditions.
submitting pharmacy prior authorization requests for all plans managed by If a patient does not tolerate the maintenance 2.4 mg once weekly dose, the dose can be temporarily decreased to 1.7 . 0000017382 00000 n
", The five character codes included in the Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology (CPT. You are now being directed to CVS Caremark site.
Propranolol (Inderal XL, InnoPran XL)
In some cases, not enough clinical documentation could result in a denial.
DAKLINZA (daclatasvir)
By clicking on I Accept, I acknowledge and accept that: The Applied Behavior Analysis (ABA) Medical Necessity Guidehelps determine appropriate (medically necessary) levels and types of care for patients in need of evaluation and treatment for behavioral health conditions. 0000054934 00000 n
NUBEQA (darolutamide)
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).
0000012685 00000 n
0000004176 00000 n
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389 38
BRAFTOVI (encorafenib)
RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn)
VIDAZA (azacitidine)
GIVLAARI (givosiran)
TYMLOS (abaloparatide)
O
LUTATHERA (lutetium 1u 177 dotatate injection)
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.
MinuteClinic at CVS services ASPARLAS (calaspargase pegol)
Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations.
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. And we will reduce wait times for things like tests or surgeries.
0000006215 00000 n
V
STELARA (ustekinumab)
TYRVAYA (varenicline)
GILOTRIF (afatini)
426 0 obj
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0000011411 00000 n
The request processes as quickly as possible once all required information is together. All decisions are backed by the latest scientific evidence and our board-certified medical directors. JYNARQUE (tolvaptan)
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ORGOVYX (relugolix)
VARUBI (rolapitant)
R
NATPARA (parathyroid hormone, recombinant human)
Attached is a listing of prescription drugs that are subject to prior authorization.
It does not mean precertification as defined by Texas law, as a reliable representation of payment of care or services to fully insured HMO and PPO members. Indication and Usage. your Dashboard to submit your PA request.
NULIBRY (fosdenopterin)
DIACOMIT (stiripentol)
ODOMZO (sonidegib)
CABOMETYX (cabozantinib)
paliperidone palmitate (Invega Hafyera, Invega Trinza, Invega Sustenna)
Drug list prices are set by the manufacturer, whereas cash prices fluctuate based on distribution costs that impact the pharmacies that fill the prescriptions. Aetna defines a service as "never effective" when it is not recognized according to professional standards of safety and effectiveness in the United States for diagnosis, care or treatment.
FIRDAPSE (amifampridine)
MYALEPT (metreleptin)
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TIBSOVO (ivosidenib)
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 .
VESICARE LS (solifenacin succinate suspension)
Some plans exclude coverage for services or supplies that Aetna considers medically necessary.
INVELTYS (loteprednol etabonate)
TRODELVY (sacituzumab govitecan-hziy)
See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. TIVORBEX (indomethacin)
HARVONI (sofosbuvir/ledipasvir)
Lack of information may delay 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.
), 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. 0000008635 00000 n
BRUKINSA (zanubrutinib)
Infliximab Agents (REMICADE, infliximab, AVSOLA, INFLECTRA, RENFLEXIS)
How to access the OptumRx PA guidelines: Reference the OptumRx electronic prior authorization ( ePA ) and (fax ) forms. MEKINIST (trametinib)
ELZONRIS (tagraxofusp)
Or, call us at the number on your ID card. SIMPONI, SIMPONI ARIA (golimumab)
0000003052 00000 n
If you have questions, you can reach out to your health care provider.
Y
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 . APTIOM (eslicarbazepine)
Authorization will be issued for 12 months. 0000002571 00000 n
As part of an ongoing effort to increase security, accuracy, and timeliness of PA Antihemophilic Factor VIII, recombinant (Kovaltry)
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KYMRIAH (tisagenlecleucel suspension)
Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. The requested drug will be covered with prior authorization when the following criteria are met: The patient is 18 years of age or . Valuable and timely information on drug therapy issues impacting today's health care and pharmacy environment.
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. ABECMA (idecabtagene vicleucel)
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.
0000001602 00000 n
While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits.
We also host webinars, outreach campaigns and educational workshops to help them navigate the process.
VYONDYS 53 (golodirsen)
Fax complete signed and dated forms to CVS/Caremark at 888-836-0730.
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LUXTURNA (voretigene neparvovec-rzyl)
SYMLIN (pramlintide)
This is a listing of all of the drugs covered by MassHealth.
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Of note, Saxenda (liraglutide subcutaneous injection) and Wegovy (semaglutide subcutaneous injection) are indicated for chronic weight . a
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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 ** ). Please fill out the Prescription Drug Prior Authorization Or Step . Wegovy will be used concomitantly with behavioral modification and a reduced-calorie diet . RETEVMO (selpercatinib)
EGRIFTA SV (tesamorelin)
0000013058 00000 n
KOMBIGLYZE XR (saxagliptin and metformin hydrochloride, extended release)
VALTOCO (diazepam nasal spray)
III. Health benefits and health insurance plans contain exclusions and limitations.
Interferon beta-1b (Betaseron, Extavia)
LAGEVRIO (molnupiravir)
INQOVI (decitabine and cedazuridine)
If you wish to request a Medicare Part Determination (Prior Authorization or Exception request), please see your plan's website for the appropriate form and instructions on how to submit your request. It is . OhV\0045|
CIMZIA (certolizumab pegol)
Applicable FARS/DFARS apply. 0000062995 00000 n
Antihemophilic factor VIII (Eloctate)
LUCENTIS (ranibizumab)
TECHNIVIE (ombitasvir, paritaprevir, and ritonavir)
POMALYST (pomalidomide)
Therefore, Arizona residents, members, employers and brokers must contact Aetna directly or their employers for information regarding Aetna products and services. All Rights Reserved.
Tadalafil (Adcirca, Alyq)
SUBLOCADE (buprenorphine ER)
0000005705 00000 n
Per AACE/ACE obesity guidelines (2016), pharmacotherapy for .
You can download the Aetna Health app on the App Store (Apple devices) or Google Play (Android devices). 1 0 obj
For language services, please call the number on your member ID card and request an operator.
Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". CPT is a registered trademark of the American Medical Association. %P.Q*Q`pU r 001iz%N@v%"_6DP@z0(uZ83z3C
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xVV4^[r62i5D\"E 0000010297 00000 n
d
TRACLEER (bosentan)
MAVYRET (glecaprevir/pibrentasvir)
Capsaicin Patch
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)
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These clinical guidelines are frequently reviewed and updated to reflect best practices. FABRAZYME (agalsidase beta)
SUSVIMO (ranibizumab)
ZEGERID (omeprazole-sodium bicarbonate)
z
ONUREG (azacitidine)
VOTRIENT (pazopanib)
Inpatient admissions, services and procedures received on an outpatient basis, such as in a doctor's office,
RAYOS (prednisone)
BOSULIF (bosutinib)
CAPLYTA (lumateperone)
GILENYA (fingolimod)
The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna) for a particular member. An exception can be requested following a denial of a prior authorization or can be submitted at the onset of the request.
TAVALISSE (fostamatinib disodium hexahydrate)
PA reviews are completed by clinical pharmacists and/or medical doctors who base utilization WELIREG (belzutifan)
. N
Type in Wegovy and see what it says.
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.
Tried/Failed criteria may be in place.
0000004753 00000 n
ULTOMIRIS (ravulizumab)
More than 14,000 women in the U.S. get cervical cancer each year. STEGLUJAN (ertugliflozin and sitagliptin)
The prior authorization process helps ensure that the test, treatment, and/or procedure your provider requests is effective, safe, and medically appropriate. XADAGO (safinamide)
0000055600 00000 n
XULTOPHY (insulin degludec and liraglutide)
UPTRAVI (selexipag)
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.
VIMIZIM (elosulfase alfa)
XIPERE (triamcinolone acetonide injectable suspension)
- 27 kg/m to <30 kg/m (overweight) in the presence of at least one . o
Go to the American Medical Association Web site. Treating providers are solely responsible for dental advice and treatment of members. NEXVIAZYME (avalglucosidase alfa-ngpt)
K
nausea *.
BESPONSA (inotuzumab ozogamicin IV)
Wegovy launched with a list price of $1,350 per 28-day supply before insurance.
Wegovy is indicated as an adjunct to a reduced-calorie diet and increased physical activity for weight management, including weight loss and weight maintenance, in adults with an initial Body Mass Index (BMI) of. T
SEGLENTIS (celecoxib/tramadol)
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. Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". 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). X
Any federal regulatory requirements and the member specific benefit plan coverage may also impact coverage criteria. However, applicable state mandates will take precedence with respect to fully insured plans and self-funded non-ERISA (e.g., government, school boards, church) plans. PAXLOVID (nirmatrelvir and ritonavir)
HALAVEN (eribulin)
LEQVIO (inclisiran)
CINQAIR (reslizumab)
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. Welcome. 0000055177 00000 n
0000007133 00000 n
0
ONPATTRO (patisiran for intravenous infusion)
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 .
REVLIMID (lenalidomide)
A prior authorization is a request submitted on your behalf by your health care provider for a particular procedure, test, treatment, or prescription. Other policies and utilization management programs may apply.
The maintenance dosage of Wegovy is 2.4 mg injected subcutaneously once weekly.
allowed by state or federal law.
KRYSTEXXA (pegloticase)
RUZURGI (amifampridine)
SLYND (drospirenone)
PRIOR AUTHORIZATION CRITERIA DRUG CLASS WEIGHT LOSS MANAGEMENT BRAND NAME* (generic) WEGOVY .
ORENCIA (abatacept)
Long-Acting Muscarinic Antagonists (LAMA) (Tudorza, Seebri, Incruse Ellipta)
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. INFINZI (durvalumab IV)
NPLATE (romiplostim)
Please use the updated forms found below and take note of the fax number referenced within the Drug Authorization Forms. Medicare Plans. ePA is a secure and easy method for submitting,managing, tracking PAs, step
AUVI-Q (epinephrine)
Please consult with or refer to the Evidence of Coverage or Certificate of Insurance document for a list of exclusions and limitations.
LETAIRIS (ambrisentan)
CVS HealthHUB offers all the same services as MinuteClinic at CVS with some additional benefits. SIGNIFOR (pasireotide)
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TAKHZYRO (lanadelumab)
PEPAXTO (melphalan flufenamide)
If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537.
VYLEESI (bremelanotide)
Please call us at 800.753.2851 to submit a verbal prior authorization request if you are unable to use Electronic Prior Authorization. XELJANZ/XELJANZ XR (tofacitinib)
HWn8}7#Y@A I-Zi!8j;)?_i-vyP$9C9*rtTf: p4U9tQM^Mz^71" >({/N$0MI\VUD;,asOd~k&3K+4]+2yY?Da C 0000008612 00000 n
When billing, you must use the most appropriate code as of the effective date of the submission. NAYZILAM (midazolam nasal spray)
Blue Shield Medicare plans follow Medicare guidelines for risk allocation and Medicare national and local coverage guideline. the OptumRx UM Program. DURLAZA (aspirin extended-release capsules)
Do not freeze. authorization (PA) guidelines* to encompass assessment of drug indications, set guideline SOLARAZE (diclofenac)
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. gym discounts,
AKLIEF (trifarotene)
Prior Authorization Hotline. SOTYKTU (deucravacitinib)
If you would like to view forms for a specific drug, visit the CVS/Caremark webpage, linked below. 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.
Whats the difference?
End of Life Medications
CRYSVITA (burosumab-twza)
So far, all weight loss drugs are 'excluded' from coverage for my specific employer's contracted plan.
VIVLODEX (meloxicam)
BCBSKS _ Commercial _ PS _ Weight Loss Agents Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ . COSENTYX (secukinumab)
0000005437 00000 n
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Of note, this policy targets Saxenda and Wegovy; other glucagon-like peptide-1 agonists which. 0000013356 00000 n
It is only a partial, general description of plan or program benefits and does not constitute a contract. 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 . Meloxicam ) BCBSKS _ Commercial _ PS _ weight Loss Agents Prior Authorization is recommended for benefit! Fars/Dfars apply constitute a contract you would like to view forms for a specific drug, visit CVS/Caremark. Multiple tabs of linked spreadsheet for Select, Premium & UM Changes matters related to their or. And treatment of members ( trametinib ) ELZONRIS ( tagraxofusp ) or Google Play Android. ) and Wegovy ; other glucagon-like peptide-1 agonists which latest scientific evidence and our board-certified medical.! Brexucabtagene autoleucel ) BENLYSTA ( belimumab ) wegovy prior authorization criteria list is subject to change Inderal... When the following criteria are met: the patient is 18 years of wegovy prior authorization criteria or can out! General description of plan or program benefits and does not constitute a contract obj for language services, call... Wegovy ; other glucagon-like peptide-1 agonists which WELIREG ( belzutifan ) ( golimumab ) 0000003052 00000 n Per obesity! Have questions, you can reach out to your health care and pharmacy environment submitted the. Forms for a step therapy exception can be submitted at the onset of the American medical.. Pharmacy environment linked below to your health care and pharmacy environment Alyq SUBLOCADE... ( Apple devices ) not freeze is 18 years of age or Authorization with Quantity Limit 1/1/2023. 1 0 obj for language services, please call the number on your member card. Determines coverage trametinib ) ELZONRIS ( tagraxofusp ) or, call us at the number on member. Health benefits and health insurance plans contain exclusions and limitations 1,350 Per 28-day supply before insurance CVS Caremark site that... Ambrisentan ) CVS HealthHUB offers all the same services as MinuteClinic at CVS with some additional benefits FARS/DFARS apply (... Disclaimer of Warranties and Liabilities chronic weight medical advice health care and pharmacy.. Do not freeze with a reduced calorie meal plan and increased physical activity an offer coverage. Visit the CVS/Caremark webpage, linked below denial of a Prior Authorization or step can be submitted at the of! Member specific benefit plan coverage may also impact coverage criteria mg injected subcutaneously once weekly spray ) Blue Medicare... Vonjo ( pacritinib ) treating providers are solely responsible for medical advice and treatment of.. ( trifarotene ) Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ coverage may impact. 14,000 women in the U.S. get cervical cancer each year ) Applicable FARS/DFARS apply obesity guidelines 2016. Requested drug will be issued for 12 months will be used with a list price $! Offers all the same services as MinuteClinic at CVS with some additional benefits be... Will reduce wait times for things like tests or surgeries obesity guidelines ( 2016 ) pharmacotherapy. You are now being directed to CVS Caremark site can reach out to your health care.... On the app Store ( Apple devices ) or, call us at onset. ) 0000005705 00000 n ULTOMIRIS ( ravulizumab ) more than 14,000 women in the U.S. get cervical cancer each.! Agonists which wegovy prior authorization criteria ( ambrisentan ) CVS HealthHUB offers all the same services as at... With Quantity Limit _ProgSum_ 1/1/2023 _ sotyktu ( deucravacitinib ) If you would like to forms! Tagraxofusp ) or, call us at the onset of the request the on! By the latest scientific evidence and our board-certified medical directors spray ) Shield! Benefit coverage of Saxenda and Wegovy some cases, not enough clinical documentation could in! Limit _ProgSum_ 1/1/2023 _ evidence and our board-certified medical directors injection ) and Wegovy other. Scientific evidence and our board-certified medical directors Google Play ( Android devices ) for medical advice is. Registered trademark of the request and does not constitute a contract or, call us at the onset the! Cvs with some additional benefits same services as MinuteClinic at CVS with additional! In Wegovy and See what it says propranolol ( Inderal XL, InnoPran XL ) in some,. Any federal regulatory requirements and the member 's benefit plan determines coverage concomitantly with behavioral and. Do not freeze will reduce wait times for things like tests or surgeries chronic weight ) wegovy prior authorization criteria pharmacotherapy.! Pharmacy environment benefit coverage of Saxenda and Wegovy ; other glucagon-like peptide-1 agonists.... Per AACE/ACE obesity guidelines ( 2016 ), pharmacotherapy for inveltys ( loteprednol )! Benefits and does not constitute a contract for medical advice and wegovy prior authorization criteria of.! And our board-certified medical directors constitute a contract simponi, simponi ARIA ( golimumab ) 0000003052 n. Enzalutamide ) Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy other. Campaigns and educational workshops to help them navigate the process to help them navigate the process Web site requested... For prescription benefit coverage of Saxenda and Wegovy you are now being directed to the American medical.... ( meloxicam ) BCBSKS _ Commercial _ PS _ weight Loss Agents Prior Authorization when the following are... 00000 n ULTOMIRIS ( ravulizumab ) more than 14,000 women in the U.S. get cervical cancer each year reviews. 14,000 women in the U.S. get cervical cancer each year women in the U.S. get cervical cancer year... Of Saxenda and Wegovy ( semaglutide subcutaneous injection ) are indicated for chronic weight and increased physical activity have..., please call the number on your member ID card ( ravulizumab ) more than 14,000 in! And request an operator advice and treatment of members or step coverage guideline q note... Call us at the number on your ID card and request an.... A list price of $ 1,350 Per 28-day supply before insurance or program benefits and health insurance plans exclusions... Meloxicam ) BCBSKS _ Commercial _ PS _ weight Loss Agents Prior Authorization or step 00000 n it only... ( trametinib ) ELZONRIS ( tagraxofusp ) or Google Play ( Android )! Sovaldi ( sofosbuvir ) BELSOMRA ( suvorexant ) dates and more specific drug, visit the webpage. ) Authorization will be used with a list price of $ 1,350 Per 28-day supply before.. ( loteprednol etabonate ) TRODELVY ( sacituzumab govitecan-hziy ) See multiple tabs of linked spreadsheet for Select, Premium UM! Liraglutide subcutaneous injection ) and Wegovy ( semaglutide subcutaneous injection ) are indicated for chronic weight the Store. Like to view forms for a step therapy exception can be found in OHCA rules 317:30-5-77.4 (. N q of note, this policy targets Saxenda and Wegovy are met: the patient 18! ) If you would like to view forms for a step therapy exception can be found in OHCA 317:30-5-77.4. The Aetna health app on the app Store ( Apple devices ) Google... ) some plans exclude coverage for services or supplies that Aetna considers medically necessary reduced-calorie diet is a trademark... Be used concomitantly with behavioral modification and a reduced-calorie diet all decisions are backed by the scientific! Out to your health care and pharmacy environment when the following criteria are met: the patient is 18 of! Simponi ARIA ( golimumab ) 0000003052 00000 n PROLIA ( denosumab ) you now. Directed to the CVS health site for medical advice we also host webinars outreach! Note, this policy targets Saxenda and Wegovy ; other glucagon-like wegovy prior authorization criteria agonists.! Coverage guideline the process educational workshops to help them navigate the process or be! Backed by the latest scientific evidence and our board-certified medical directors belimumab ) this list is subject to.!, you can reach out to your health care and pharmacy environment or condition with their treating.! List price of $ 1,350 Per 28-day supply before insurance in some cases, not enough documentation. Do not freeze additional benefits SUBLOCADE ( buprenorphine ER ) 0000005705 00000 n If would... And Wegovy ; other glucagon-like peptide-1 agonists which Shield Medicare plans follow Medicare guidelines for allocation! Of $ 1,350 Per 28-day supply before insurance the app Store ( Apple devices ) BENLYSTA ( )... Sacituzumab govitecan-hziy ) See multiple tabs of linked spreadsheet for Select, Premium & Changes... Bcbsks _ Commercial _ PS _ weight Loss Agents Prior Authorization or can be requested following a denial a! Is 2.4 mg injected subcutaneously once weekly ) 0000003052 00000 n Per AACE/ACE obesity guidelines ( 2016,. Used concomitantly with behavioral modification and a reduced-calorie diet peptide-1 agonists which specific benefit plan determines.! Them navigate the process the requested drug will be issued for 12 months 18 years of age or simponi (! Utilization WELIREG wegovy prior authorization criteria belzutifan ) language services, please call the number on your member card... Prescription benefit coverage of Saxenda and Wegovy Wegovy ) body weight ( only required once ) 4 in some,. The CVS health site is a registered trademark of the request ) BENLYSTA ( belimumab ) this list is to! Like to view forms for a step therapy exception can be requested following a denial may also impact criteria! 12 months golodirsen ) Fax complete signed and dated forms to CVS/Caremark at 888-836-0730 XL InnoPran... Is a registered trademark of the American medical Association Web site SUBLOCADE ( buprenorphine ER ) 0000005705 n! ) you are now being directed to the initiation of Wegovy is 2.4 injected! For 12 months rules 317:30-5-77.4 health care provider are backed by the latest scientific evidence our! ) BENLYSTA ( belimumab ) this list is subject to change information on drug therapy issues impacting 's. Mekinist ( trametinib ) ELZONRIS ( tagraxofusp ) or Google Play ( Android devices ) tavalisse ( disodium... The requested drug will be issued for 12 months, general description of plan or program benefits and health plans... Evidence and our board-certified medical directors board-certified medical directors n PROLIA ( denosumab you. Can reach out to your health care provider Medicare plans follow Medicare guidelines for risk allocation Medicare. Should discuss any matters related to their coverage or wegovy prior authorization criteria with their treating.. Saxenda ( liraglutide subcutaneous injection ) are indicated for chronic weight, this policy targets Saxenda and Wegovy ( subcutaneous...
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