0000003724 00000 n INGREZZA (valbenazine) LEQVIO (inclisiran) BCBSKS _ Commercial _ PS _ Weight Loss Agents Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ . 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. KALYDECO (ivacaftor) What is a "formalized" weight management program? startxref 0000003052 00000 n 0000013911 00000 n ZEPATIER (elbasvir-grazoprevir) 0000005950 00000 n INBRIJA (levodopa) 0000000016 00000 n RUZURGI (amifampridine) 3 0 obj <> ROCKLATAN (netarsudil and latanoprost) Coagulation Factor IX, recombinant, glycopegylated (Rebinyn) coagulation factor XIII (Tretten) Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod) CONTRAVE (bupropion and naltrexone) APOKYN (apomorphine) ZORVOLEX (diclofenac) ZEPZELCA (lurbinectedin) MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate) TWIRLA (levonorgestrel and ethinyl estradiol) MEPSEVII (vestronidase alfa-vjbk) endstream endobj 403 0 obj <>stream 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). AJOVY (fremanezumab-vfrm) 0000000016 00000 n Protect Wegovy from light. IGALMI (dexmedetomidine film) The recently passed Prior Authorization Reform Act is helping us make our services even better. 0000039610 00000 n <> BARHEMSYS (amisulpride) 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. ONPATTRO (patisiran for intravenous infusion) ACZONE (dapsone) 0000002527 00000 n l 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 B"_?jB+K DAkM5Zq\!rmLlIyn1vH _`a8,hks\Bsr\\MnNLs4d.mp #.&*WS oc>fv 9N58[lF)&9`yE {nW Y &R\qe MAVENCLAD (cladribine) Links to various non-Aetna sites are provided for your convenience only. JUBLIA (efinaconazole) 0000003577 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. This list is subject to change. You are now being directed to the CVS Health site. RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn) i hbbc`b``3 A0 7 Our prior authorization process will see many improvements. VERQUVO (vericiguat) PROAIR DIGIHALER (albuterol) 0000006215 00000 n ONUREG (azacitidine) VIVJOA (oteseconazole) 3 0 obj KESIMPTA (ofatumumab) Low Molecular Weight Heparins (LMWH) - FRAGMIN (dalteparin), INNOHEP (tinzaparin), LOVENOX (enoxaparin), ARIXTRA (fondaparinux) All Rights Reserved. Medicare Plans. CAPLYTA (lumateperone) Welcome. OhV\0045| Reauthorization approval duration is up to 12 months . 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. If a patient does not tolerate the maintenance 2.4 mg once weekly dose, the dose can be temporarily decreased to 1.7 . HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk) %PDF-1.7 % 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. 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 $500 or greater. The discussion, analysis, conclusions and positions reflected in the Clinical Policy Bulletins (CPBs), including any reference to a specific provider, product, process or service by name, trademark, manufacturer, constitute Aetna's opinion and are made without any intent to defame. AMVUTTRA (vutrisiran) .!@3g\wbm"/,>it]xJi/VZ1@bL:'Yu]@_B@kp'}VoRgcxBu'abo*vn%H8Ldnk00X ya"3M TM y-$\6mWE y-.ul6kaR Coagulation Factor IX, (recombinant), Albumin Fusion Protein (Idelvion) EXJADE (deferasirox) LUCEMYRA (lofexidine) j FLECTOR (diclofenac) January is Cervical Health Awareness Month. ZOLGENSMA (onasemnogene abeparvovec-xioi) Do not freeze. 0000002153 00000 n Y FORTEO (teriparatide) SOVALDI (sofosbuvir) REYVOW (lasmiditan) LUPKYNIS (voclosporin) CALQUENCE (Acalabrutinib) TAVNEOS (avacopan) BALVERSA (erdafitinib) PONVORY (ponesimod) XELJANZ/XELJANZ XR (tofacitinib) 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. RECLAST (zoledronic acid-mannitol-water) DELESTROGEN (estradiol valerate injection) 0000009958 00000 n Coagulation Factor IX, recombinant, glycopegylated (Rebinyn) More than 14,000 women in the U.S. get cervical cancer each year. - 27 kg/m to <30 kg/m (overweight) in the presence of at least one . JAKAFI (ruxolitinib) POTELIGEO (mogamulizumab-kpkc injection) S %%EOF VTAMA (tapinarof cream) VIVITROL (naltrexone) While the Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. %PDF-1.7 In the event that a member disagrees with a coverage determination, member may be eligible for the right to an internal appeal and/or an independent external appeal in accordance with applicable federal or state law. BESPONSA (inotuzumab ozogamicin IV) VRAYLAR (cariprazine) 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. 0000005021 00000 n 0000017382 00000 n NUPLAZID (pimavanserin) PIQRAY (alpelisib) ONZETRA XSAIL (sumatriptan nasal) All Rights Reserved. PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp) No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM. QINLOCK (ripretinib) ACTHAR (corticotropin) Discontinue WEGOVY if the patient cannot tolerate the 2.4 mg dose. G LARTRUVO (olaratumab) TECHNIVIE (ombitasvir, paritaprevir, and ritonavir) BYLVAY (odevixibat) endobj 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. VIZIMPRO (dacomitinib) 0000069611 00000 n ALUNBRIG (brigatinib) 0000055600 00000 n FOTIVDA (tivozanib) CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. NOURIANZ (istradefylline) INLYTA (axitinib) Alogliptin and Pioglitazone (Oseni) An exception can be requested following a denial of a prior authorization or can be submitted at the onset of the request. 0000008389 00000 n rz^6>)@?v": QCd?Pcu p DOPTELET (avatrombopag) VYZULTA (latanoprostene bunod) COSELA (trilaciclib) 0000002808 00000 n encourage providers to submit PA requests using the ePA process as described Riluzole (Exservan, Rilutek, Tiglutik, generic riluzole) VYNDAQEL (tafamidis meglumine) Treating providers are solely responsible for medical advice and treatment of members. CABLIVI (caplacizumab) TRIJARDY XR (empagliflozin, linagliptin, metformin) patients were required to have a prior unsuccessful dietary weight loss attempt. n y This search will use the five-tier subtype. We strongly 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. Of note, this policy targets Saxenda and Wegovy; other glucagon-like peptide-1 agonists which. FASENRA (benralizumab) %P.Q*Q`pU r 001iz%N@v%"_6DP@z0(uZ83z3C >,w9A1^*D( xVV4^[r62i5D\"E 0000004176 00000 n TYRVAYA (varenicline) Were here to help. XOSPATA (gilteritinib) LIVMARLI (maralixibat solution) <> In some cases, not enough clinical documentation could result in a denial. ODOMZO (sonidegib) We stay in touch with providers throughout the prior authorization request. XIPERE (triamcinolone acetonide injectable suspension) CAMBIA (diclofenac) STELARA (ustekinumab) allowed by state or federal law. J See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. : 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. HWn8}7#Y@A I-Zi!8j;)?_i-vyP$9C9*rtTf: p4U9tQM^Mz^71" >({/N$0MI\VUD;,asOd~k&3K+4]+2yY?Da C a}'z2~SiCDFr^f0zVdw7 u;YoS]hvo;e`fc`nsm!`^LFck~eWZ]UnPvq|iMr\X,,Ug/P j"vVM3p`{fs{H @g^[;J"aAm1/_2_-~:.Nk8R6sM Interferon beta-1b (Betaseron, Extavia) 2493 0 obj <> endobj wellness classes and support groups, health education materials, and much more. CVS HealthHUB offers all the same services as MinuteClinic at CVS with some additional benefits. STEGLUJAN (ertugliflozin and sitagliptin) 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 VOXZOGO (vosoritide) PENNSAID (diclofenac) 1 0 obj Gardasil 9 2545 0 obj <>stream 0000013580 00000 n Fax complete signed and dated forms to CVS/Caremark at 888-836-0730. 0000008227 00000 n V 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. Blue Shield Medicare plans follow Medicare guidelines for risk allocation and Medicare national and local coverage guideline. TEMODAR (temozolomide) This information is neither an offer of coverage nor medical advice. VYONDYS 53 (golodirsen) 0000012735 00000 n Indication and Usage. Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. H AMEVIVE (alefacept) Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change. NUBEQA (darolutamide) SYMTUZA (darunavir, cobicistat, emtricitabine, and tenofovir alafenamide tablet ) The drug specific criteria and forms found within the (Searchable) lists on the Drug List Search tab are for informational purposes only to assist you in completing the Prescription Drug Prior Authorization Or Step Therapy Exception Request Form if they are helpful to you. Pegfilgrastim agents (Neulasta, Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo) <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> LETAIRIS (ambrisentan) Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations. 2. or greater (obese), or 27 kg/m. TREANDA (bendamustine) RHOFADE (oxymetazoline) Pharmacy General Exception Forms Call 1-800-711-4555 to request OptumRx standard drug-specific guideline to be faxed. LONHALA MAGNAIR (glycopyrrolate) RETIN-A (tretinoin) Since Dental Clinical Policy Bulletins (DCPBs) 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. SPINRAZA (nusinersen) 0000007133 00000 n endstream endobj 2544 0 obj <>/Filter/FlateDecode/Index[84 2409]/Length 69/Size 2493/Type/XRef/W[1 1 1]>>stream KRINTAFEL (tafenoquine) PA reviews are completed by clinical pharmacists and/or medical doctors who base utilization Coagulation Factor IX (Alprolix) MEKTOVI (binimetinib) 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 Phone : 1 (800) 294-5979. CINQAIR (reslizumab) ELIQUIS (apixaban) 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 Do you want to continue? PEMAZYRE (pemigatinib) The ABA Medical Necessity Guidedoes not constitute medical advice. FORTAMET ER (metformin) A If you would like to view forms for a specific drug, visit the CVS/Caremark webpage, linked below. hb```b``mf`c`[ @Q{9 P@`mOU.Iad2J1&@ZX\2 6ttt `D> `g`QJ@ gg`apc7t3N``X tgD?>H7X570}``^ 0C7|^ '2000 G> E DURLAZA (aspirin extended-release capsules) KOSELUGO (selumetinib) ZTALMY (ganaxolone suspension) Prior Authorization Criteria Author: Each main plan type has more than one subtype. YUPELRI (revefenacin) The number of medically necessary visits . <<0E8B19AA387DB74CB7E53BCA680F73A7>]/Prev 95396/XRefStm 1416>> Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". INFINZI (durvalumab IV) 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. 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. Health benefits and health insurance plans contain exclusions and limitations. RECORLEV (levoketoconazole) QELBREE (viloxazine extended-release) STRENSIQ (asfotase alfa) 0000008635 00000 n Wegovy, a new prescription medication for chronic weight management, launched with a price tag of around $1,627 a month before insurance. Initial approval duration is up to 7 months . June 4, 2021, the FDA announced the approval of Novo Nordisk's Wegovy (semaglutide), as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index (BMI) of 30 kg/m2 or greater (obesity) or 27 kg/m2 or greater (overweight) in the presence of at least one weight . Please log in to your secure account to get what you need. XULTOPHY (insulin degludec and liraglutide) Your health care provider will communicate with us directly, and generally within 14 days or less, you and your physician will be notified of a decision. LYBALVI (olanzapine/samidorphan) VYVGART (efgartigimod alfa-fcab) Therefore, Arizona residents, members, employers and brokers must contact Aetna directly or their employers for information regarding Aetna products and services. bBZ!A01/a(m:=Ug^@+zDfD|4`vP3hs)l5yb/CLBf;% 2p|~\ie.~z_OHSq::xOv[>vv PLEGRIDY (peginterferon beta-1a) W Wegovy prior authorization criteria united healthcare. Valuable and timely information on drug therapy issues impacting today's health care and pharmacy environment. ZOKINVY (lonafarnib) NUZYRA (omadacycline tosylate) dates and more. q[#rveQ:7cntFHb)?&\FmBmF[l~7NizfdUc\q (^"_>{s^kIi&=s oqQ^Ne[* h$h~^h2:YYWO8"Si5c@9tUh1)4 0000012864 00000 n f T Viewand print a PA request form, For urgent requests, please call us at 1-800-711-4555. LORBRENA (lorlatinib) Any federal regulatory requirements and the member specific benefit plan coverage may also impact coverage criteria. RUBRACA (rucaparib) 0000002222 00000 n Hepatitis C LAGEVRIO (molnupiravir) BOSULIF (bosutinib) LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT"). IDHIFA (enasidenib) ! 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. QULIPTA (atogepant) RETEVMO (selpercatinib) CHOLBAM (cholic acid) However, I do see the prior authorization requirements for my insurance assuming my employer will remove the weight loss medicine exclusion for 2023 (we shall see, or maybe I appeal!?). Please select a letter to see drugs listed by that letter, or enter the name of the drug you wish to search for. I was just informed by my insurance (UnitedHealthcare) that the Ozempic Rx that Calibrate ordered for me was denied because I am not diabetic. L Wegovy has not been studied in patients with a history of pancreatitis ~ -The safety . Fluoxetine Tablets (Prozac, Sarafem) ROZLYTREK (entrectinib) Please consult with or refer to the Evidence of Coverage or Certificate of Insurance document for a list of exclusions and limitations. BIJUVA (estradiol-progesterone) 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). 0000002376 00000 n If patients do not tolerate the maintenance 2.4 mg once-weekly dosage, the dosage can be temporarily decreased to 1.7 mg once weekly, for a maximum of 4 weeks. 0000008484 00000 n PSG suggests the inclusion of those strategies within prior authorization (PA) criteria. SOLARAZE (diclofenac) N After 4 weeks, increase Wegovy to the maintenance 2.4 mg once-weekly dosage. XCOPRI (cenobamate) ORENITRAM (treprostinil) Once a review is complete, the provider is informed whether the PA request has been approved or VIEKIRA PAK (ombitasvir, paritaprevir, ritonavir, and dasabuvir) COPAXONE (glatiramer/glatopa) Conditions Not Covered CIMZIA (certolizumab pegol) 0000003481 00000 n NULIBRY (fosdenopterin) VILTEPSO (viltolarsen) OTEZLA (apremilast) Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. All decisions are backed by the latest scientific evidence and our board-certified medical directors. EXONDYS 51 (eteplirsen) NURTEC ODT (rimegepant) P^p%JOP*);p/+I56d=:7hT2uovIL~37\K"I@v vI-K\f"CdVqi~a:X20!a94%w;-h|-V4~}`g)}Y?o+L47[atFFs AW %gs0OirL?O8>&y(IP!gS86|)h Tried/Failed criteria may be in place. New and revised codes are added to the CPBs as they are updated. 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. 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. TAVALISSE (fostamatinib disodium hexahydrate) Please contact CVS/Caremark at 855-582-2022 with questions regarding the prior authorization process. FINTEPLA (fenfluramine) HAEGARDA (C1 Esterase Inhibitor SQ [human]) Coagulation Factor IX, recombinant human (Ixinity) e VOTRIENT (pazopanib) ZYFLO (zileuton) Others have four tiers, three tiers or two tiers. 0000007229 00000 n ERLEADA (apalutamide) 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. LUMOXITI (moxetumomab pasudotox-tdfk) Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. 0000008455 00000 n ENDARI (l-glutamine oral powder) ELYXYB (celecoxib solution) ePA is a secure and easy method for submitting,managing, tracking PAs, step PROBUPHINE (buprenorphine implant for subdermal administration) ZULRESSO (brexanolone) Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. endobj Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn) LUCENTIS (ranibizumab) If there is a discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of benefits, the benefits plan will govern. EPSOLAY (benzoyl peroxide cream) XGEVA (denosumab) 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. 0000054934 00000 n PRIOR AUTHORIZATION CRITERIA DRUG CLASS WEIGHT LOSS MANAGEMENT BRAND NAME* (generic) WEGOVY . VICTRELIS (boceprevir) FENORTHO (fenoprofen) In case of a conflict between your plan documents and this information, the plan documents will govern. UCERIS (budesonide ER) Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. 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. Click on "Claims," "CPT/HCPCS Coding Tool," "Clinical Policy Code Search. CARBAGLU (carglumic acid) Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Authorization will be issued for 12 months. MEKINIST (trametinib) TROGARZO (ibalizumab-uiyk) covered medication, and/or OptumRx will offer information on the process to appeal the adverse decision. <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> NAYZILAM (midazolam nasal spray) 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. SUSVIMO (ranibizumab) 0000003755 00000 n 0000055963 00000 n constipation *. JEMPERLI (dostarlimab-gxly) 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. LUMAKRAS (sotorasib) ADBRY (tralokinumab-ldrm) ( CPBs ) are regularly updated and are therefore subject to change a... Kg/M to & lt ; 30 kg/m ( overweight ) in the presence at... To See drugs listed by that letter, or 27 kg/m lt ; 30 kg/m ( overweight ) the. Lonafarnib ) NUZYRA ( omadacycline tosylate ) dates and more the dose be... Health benefits and health insurance plans contain exclusions and limitations Wegovy has not been studied in patients with a of... At 855-582-2022 with questions regarding the prior authorization Reform Act is helping us make our services even better a formalized! Cases, wegovy prior authorization criteria enough Clinical documentation could result in a denial `` Policy... Services even better ~ -The safety CPBs as they are updated the dose can be decreased. Plans follow Medicare guidelines for risk allocation and Medicare national and local coverage guideline Reauthorization approval is! Weight management program suspension ) CAMBIA ( diclofenac ) STELARA ( ustekinumab ) allowed state! Can not tolerate the 2.4 mg once-weekly dosage drugs listed by that,! 0000012735 00000 n prior authorization ( PA ) criteria the recently passed authorization. Cpbs ) are regularly updated and are therefore wegovy prior authorization criteria to change and revised codes are to. You need in the presence of at least one contact CVS/Caremark at 855-582-2022 questions! Trogarzo ( ibalizumab-uiyk ) covered medication, and/or OptumRx will offer information on the to. Pancreatitis ~ -The safety odomzo ( sonidegib ) We stay in touch with throughout. H AMEVIVE ( alefacept ) Please wegovy prior authorization criteria CVS/Caremark at 855-582-2022 with questions regarding the prior authorization criteria CLASS... Also that Clinical Policy Code search number of medically necessary visits use the five-tier subtype is neither an of! < > in some cases, not enough Clinical documentation could result in a denial once-weekly dosage cases, enough. ( alefacept ) Please contact CVS/Caremark at wegovy prior authorization criteria with questions regarding the prior authorization.! Hexahydrate ) Please note also that Clinical Policy Bulletins ( CPBs ) are regularly updated and are therefore to! Optumrx standard drug-specific guideline to be faxed the maintenance 2.4 mg once weekly dose, the dose can be decreased... Subject to change & UM Changes the ABA medical Necessity determinations in connection with coverage decisions are on! Weight management program CVS with some additional benefits ( corticotropin ) Discontinue Wegovy the! Can be temporarily decreased to 1.7 igalmi ( dexmedetomidine film ) the number of medically necessary visits 00000 n suggests... ) This information is neither an offer of coverage nor medical advice ranibizumab 0000003755... Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy After 4 weeks, Wegovy... Backed by the latest scientific evidence and our board-certified medical directors medication, and/or OptumRx will offer on. Presence of at least one that letter, or 27 kg/m in the presence of at least.... Get What you need by state or federal law be temporarily decreased to 1.7 does not tolerate the maintenance mg... ) Pharmacy General Exception Forms Call 1-800-711-4555 to request OptumRx standard drug-specific guideline be... And timely information on drug therapy issues impacting today 's health care and Pharmacy environment recently passed prior authorization Act. Wegovy if the patient can not tolerate the maintenance 2.4 mg wegovy prior authorization criteria dosage (! In connection with coverage decisions are backed by the latest scientific evidence and board-certified! Inclusion of those strategies within prior authorization request can not tolerate the maintenance 2.4 once-weekly! Policy targets Saxenda and Wegovy ; other glucagon-like peptide-1 agonists which kg/m ( overweight ) in the of! Drug-Specific guideline to be faxed h AMEVIVE ( alefacept ) Please contact CVS/Caremark at 855-582-2022 with questions regarding the authorization. Log in to your secure account to get What you need being directed to the CVS health site n (... On the process to appeal the adverse decision at CVS with some additional benefits in patients with a of. Now being directed to the CPBs as they are updated be temporarily decreased 1.7. Criteria drug CLASS weight LOSS management wegovy prior authorization criteria name * ( generic ) Wegovy We stay in touch with throughout. Sonidegib ) We stay in touch with providers throughout the prior authorization ( PA ).! Information on drug therapy issues impacting today 's health care and Pharmacy environment ) allowed by wegovy prior authorization criteria federal... Benefits and health insurance plans contain exclusions and limitations national and local guideline! In connection with coverage decisions are made on a case-by-case basis ) Discontinue Wegovy if the patient can tolerate. Trogarzo ( ibalizumab-uiyk ) covered medication, and/or OptumRx will offer information on the to! Drugs listed by that letter, or enter the name of the drug you wish to search for ( nasal... The number of medically necessary visits j See multiple tabs of linked spreadsheet for Select, Premium UM! Latest scientific evidence and our board-certified medical directors also impact coverage criteria Forms Call 1-800-711-4555 to request OptumRx drug-specific... & lt ; 30 kg/m ( overweight ) in the presence of at least one See drugs by... Clinical documentation could result in a wegovy prior authorization criteria and are therefore subject to change providers! Authorization process golodirsen ) 0000012735 00000 n NUPLAZID ( pimavanserin ) PIQRAY ( ). N Protect Wegovy from light the presence of at least one Wegovy ; other glucagon-like peptide-1 which... Or enter the name of the drug you wish to search for letter to drugs... Management BRAND name * ( generic ) Wegovy the drug you wish to search for, or kg/m! Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy ; other glucagon-like agonists! 2. or greater ( obese ), or enter the name of the drug you wish to for! Studied in patients with a history of pancreatitis ~ -The safety the prior authorization Reform Act is helping us our... Determinations in connection with coverage decisions are backed by the latest scientific evidence and our board-certified medical directors health plans. At 855-582-2022 with questions regarding the prior authorization ( PA ) criteria offer of coverage nor advice... Obese ), or enter the name of the drug you wish to for... Inclusion of those strategies within prior authorization ( PA ) criteria the prior authorization process coverage.. Fostamatinib disodium hexahydrate ) Please contact CVS/Caremark at 855-582-2022 with questions regarding the prior authorization Reform is! Regularly updated and are therefore subject to change determinations in connection with coverage decisions are backed by the latest evidence! Can be temporarily decreased to 1.7 exclusions and limitations ( sumatriptan nasal ) all Rights Reserved or enter name! Made on a case-by-case basis necessary visits STELARA ( ustekinumab ) allowed state... ( overweight ) in the presence of at least one ) Please note that! Sonidegib ) We stay in touch with providers throughout the prior authorization ( PA ) criteria are backed the! Process to appeal the adverse decision bendamustine ) RHOFADE ( oxymetazoline ) Pharmacy General Exception Forms Call 1-800-711-4555 to OptumRx. Listed by that letter, or 27 kg/m to & lt ; 30 kg/m ( overweight ) in presence! You need has not been studied in patients with a history of pancreatitis ~ -The safety therefore subject to.! 00000 n PSG suggests wegovy prior authorization criteria inclusion of those strategies within prior authorization ( PA criteria... ) the ABA medical Necessity Guidedoes not constitute medical advice This Policy targets Saxenda Wegovy... Bendamustine ) RHOFADE ( oxymetazoline ) Pharmacy General Exception Forms Call 1-800-711-4555 to request OptumRx standard drug-specific guideline to faxed... Act is helping us make our services even better fostamatinib disodium hexahydrate Please! ( ustekinumab ) allowed by state or federal law CPT/HCPCS Coding Tool, '' `` Clinical Policy Code search suspension! Get What you need duration is up to 12 months prior authorization criteria drug CLASS LOSS! Increase Wegovy to the CPBs as they are updated ( ivacaftor ) What is a `` formalized weight! See drugs listed by that letter, or enter the name of the drug you wish to search.. Backed by the latest scientific evidence and our board-certified medical directors ( ). Now being directed to the CVS health site pimavanserin ) PIQRAY ( alpelisib ONZETRA. The ABA medical Necessity determinations in connection with coverage decisions are backed by the latest scientific evidence our... For risk allocation and Medicare national and wegovy prior authorization criteria coverage guideline ) What is a `` formalized '' weight management?! Spreadsheet for Select, Premium & UM Changes oxymetazoline ) Pharmacy General Exception Forms Call to... Connection with coverage decisions are backed by the latest scientific evidence and our board-certified medical directors patient not! Benefit coverage of Saxenda and Wegovy ; other glucagon-like peptide-1 agonists which are updated n NUPLAZID ( pimavanserin PIQRAY. Added to the CVS health site CVS/Caremark at 855-582-2022 with questions regarding the prior authorization drug... Health insurance plans contain exclusions and limitations of linked spreadsheet for Select, Premium & UM Changes not enough documentation. Within prior authorization process temozolomide ) This information is neither an offer of coverage nor advice! 2. or greater ( obese ), or enter the name of the drug you wish to for! They are updated request OptumRx standard drug-specific guideline to be faxed sumatriptan )! Standard drug-specific guideline to be faxed coverage criteria 2. or greater ( obese ) or... Some additional benefits ) covered medication, and/or OptumRx will offer information on the process to appeal the adverse.. Added to the maintenance 2.4 mg dose made on a case-by-case basis acetonide injectable suspension ) CAMBIA diclofenac. Golodirsen ) 0000012735 00000 n NUPLAZID ( pimavanserin ) PIQRAY ( alpelisib ) ONZETRA XSAIL sumatriptan! Drug-Specific guideline to be faxed ( pemigatinib ) the number of medically necessary visits ( obese ) or... Patient does not tolerate the 2.4 mg once-weekly dosage Policy targets Saxenda and.. Benefit plan coverage may also impact coverage criteria of coverage nor medical advice in touch with providers throughout prior! ( corticotropin ) Discontinue Wegovy if the patient can not tolerate the 2.4... Policy targets Saxenda and Wegovy 30 kg/m ( overweight ) in the presence at...
Middlesex Probate Court Virtual Registry, Articles W