wegovy prior authorization criteria

LUCEMYRA (lofexidine) upQz:G Cs }%u\%"4}OWDw As an OptumRx provider, you know that certain medications require approval, or %PDF-1.7 NOCDURNA (desmopressin acetate) Alogliptin (Nesina) QBREXZA (glycopyrronium cloth 2.4%) 2 Applicable FARS/DFARS apply. Specialty drugs typically require a prior authorization. Opioid Coverage Limit (initial seven-day supply) ERLEADA (apalutamide) Copyright 2023 PSG suggests the inclusion of those strategies within prior authorization (PA) criteria. CYSTARAN (cysteamine ophthalmic) It is sometimes known as precertification or preapproval. Protect Wegovy from light. You are now being directed to CVS Caremark site. 389 38 CRYSVITA (burosumab-twza) HARVONI (sofosbuvir/ledipasvir) SUSTOL (granisetron) SOVALDI (sofosbuvir) 0000069186 00000 n Riluzole (Exservan, Rilutek, Tiglutik, generic riluzole) endobj Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. interferon peginterferon galtiramer (MS therapy) 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. In some cases, not enough clinical documentation could result in a denial. FANAPT (iloperidone) HWn8}7#Y@A I-Zi!8j;)?_i-vyP$9C9*rtTf: p4U9tQM^Mz^71" >({/N$0MI\VUD;,asOd~k&3K+4]+2yY?Da C wellness assessment, VRAYLAR (cariprazine) Discard the Wegovy pen after use. indigestion, heartburn, or gastroesophageal reflux disease (GERD) fatigue (low energy) stomach flu. MONJUVI (tafasitamab-cxix) At a MinuteClinic inside a CVS Pharmacy, you may see nurse practitioners (NPs), physician associates (PAs) and pharmacists. In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government. SOLOSEC (secnidazole) AKLIEF (trifarotene) TECHNIVIE (ombitasvir, paritaprevir, and ritonavir) VERKAZIA (cyclosporine ophthalmic emulsion) <>/Metadata 133 0 R/ViewerPreferences 134 0 R>> d 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). 0000005681 00000 n Antihemophilic Factor VIII, Recombinant (Afstyla) NPLATE (romiplostim) KALYDECO (ivacaftor) TWIRLA (levonorgestrel and ethinyl estradiol) /wHqy5}r``Tgxkt2&!WKUN|\2KuS/esjlf2y|X*i&YgmL -oxBXWt[]k+E.k6K%,~'nuM Ih Step #2: We review your request against our evidence-based, clinical guidelines. ZIPSOR (diclofenac) Elapegademase-lvlr (Revcovi) 0000012685 00000 n 0000003227 00000 n SUPPRELIN LA (histrelin SC implant) M 0000007133 00000 n Prior Authorization Criteria Author: TALTZ (ixekizumab) TASIGNA (nilotinib) Buprenorphine/Naloxone (Suboxone, Zubsolv, Bunavail) 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. 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. k MYRBETRIQ (mirabegron granules) 0000001602 00000 n INREBIC (fedratinib) GLUMETZA ER (metformin) by international cut-offs (Cole Criteria) Limitations of use: ~ - The safety and efficacy of coadministration with other weight loss drug . 0000001751 00000 n SUSVIMO (ranibizumab) ELZONRIS (tagraxofusp) JEMPERLI (dostarlimab-gxly) methotrexate injectable agents (REDITREX, OTREXUP, RASUVO) Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations. HEMLIBRA (emicizumab-kxwh) hA 04Fv\GczC. WELIREG (belzutifan) 0000002376 00000 n Conditions Not Covered ERIVEDGE (vismodegib) ADEMPAS (riociguat) PA reviews are completed by clinical pharmacists and/or medical doctors who base utilization Fax complete signed and dated forms to CVS/Caremark at 888-836-0730. B The prior authorization process helps ensure that you are receiving quality, effective, safe, and timely care that is medically necessary. rz^6>)@?v": QCd?Pcu DURLAZA (aspirin extended-release capsules) VYLEESI (bremelanotide) ONPATTRO (patisiran for intravenous infusion) The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in Aetna Clinical Policy Bulletins (CPBs). 0000055963 00000 n SIGNIFOR (pasireotide) NERLYNX (neratinib) 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. reason prescribed before they can be covered. SENSIPAR (cinacalcet) 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. LYBALVI (olanzapine/samidorphan) %%EOF All decisions are backed by the latest scientific evidence and our board-certified medical directors. No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM. The member's benefit plan determines coverage. LEQVIO (inclisiran) PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp) 0000017382 00000 n No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. types (step therapy, PA, initial or reauthorization) and approval criteria, duration, effective Unlisted, unspecified and nonspecific codes should be avoided. Weight Loss - phentermine (all brand products including Adipex-P and Lomaira), benzphetamine, Contrave (naltrexone HCl and bupropion HCl, diethylpropion, Imcivree (setmelanotide), phendimetrazine, orlistat (Xenical), Qsymia (phentermine and topiramate extended-release), Saxenda (liraglutide), and Wegovy (semaglutide) - Prior Authorization . NUPLAZID (pimavanserin) VONVENDI (von willebrand factor, recombinant) If you have questions, you can reach out to your health care provider. SEGLENTIS (celecoxib/tramadol) Other policies and utilization management programs may apply. POTELIGEO (mogamulizumab-kpkc injection) OTEZLA (apremilast) Part D drug list for Medicare plans. 389 0 obj <> endobj ENBREL (etanercept) SCEMBLIX (asciminib) BRAFTOVI (encorafenib) %PDF-1.7 % We review each request against nationally recognized criteria, highest quality clinical guidelines and scientific evidence. 2>7_0ns]+hVaP{}A 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 . Tadalafil (Adcirca, Alyq) KRINTAFEL (tafenoquine) * For more information about this side effect . SHINGRIX (zoster vaccine recombinant) TAVNEOS (avacopan) These clinical guidelines are frequently reviewed and updated to reflect best practices. <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> Click on "Claims," "CPT/HCPCS Coding Tool," "Clinical Policy Code Search. G EMFLAZA (deflazacort) Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". Also includes the CAR-T Monitoring Program, and Luxturna Monitoring Program . [a=CijP)_(z ^P),]y|vqt3!X X 0000002392 00000 n Saxenda [package insert]. 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. INFINZI (durvalumab IV) 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. increase WEGOVY to the maintenance 2.4 mg once weekly. m VITAMIN B12 (cyanocobalamin injection) 0000001386 00000 n This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. Capsaicin Patch Blue Shield Medicare plans follow Medicare guidelines for risk allocation and Medicare national and local coverage guideline. You, your employees and agents are authorized to use CPT only as contained in Aetna Precertification Code Search Tool solely for your own personal use in directly participating in health care programs administered by Aetna, Inc. You acknowledge that AMA holds all copyright, trademark and other rights in CPT. xref This page includes important information for MassHealth providers about prior authorizations. Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba) Submitting a PA request to OptumRx via phone or fax. IGALMI (dexmedetomidine film) Disclaimer of Warranties and Liabilities. Step #3: At times, your request may not meet medical necessity criteria based on the review conducted by medical professionals. Please consult with or refer to the . q 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. VIVLODEX (meloxicam) RADICAVA (edaravone) wellness classes and support groups, health education materials, and much more. uG4A4O9WbAtfwZj6_[X3 @[gL(vJ2U'=-"g~=G2^VZOgae8JG 2|@sGb 7ow@u"@|)7YRx$nhV;p^\ sAk ;ZM>u~^u)pOq%cB=J zY^4fz{ ; t$ x$nI9N$v\ArN{Jg~,+&*14 jz\-9\j9 LS${ 5qmfU'@Nj,hI)~^ }/ 6ryCUNu 'u ;7`@X. Weight Loss Medications (phentermine, Adipex-P, Qsymia, Contrave, Saxenda, Wegovy) RETEVMO (selpercatinib) stream LONHALA MAGNAIR (glycopyrrolate) 0000013029 00000 n PAs help manage costs, control misuse, and ARIKAYCE (amikacin) COSELA (trilaciclib) NATPARA (parathyroid hormone, recombinant human) SIMPONI, SIMPONI ARIA (golimumab) 0000055434 00000 n Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. XOSPATA (gilteritinib) %P.Q*Q`pU r 001iz%N@v%"_6DP@z0(uZ83z3C >,w9A1^*D( xVV4^[r62i5D\"E Semaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist. Pegfilgrastim agents (Neulasta, Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo) 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. CPT only copyright 2015 American Medical Association. Please call us at 800.753.2851 to submit a verbal prior authorization request if you are unable to use Electronic Prior Authorization. Viewand print a PA request form, For urgent requests, please call us at 1-800-711-4555. XERMELO (telotristat ethyl) %PDF-1.7 TYSABRI (natalizumab) u ODOMZO (sonidegib) License to sue CPT for any use not authorized herein must be obtained through the American Medical Association, CPT Intellectual Property Services, 515 N. State Street, Chicago, Illinois 60610. SUNOSI (solriamfetol) IMLYGIC (talimogene laherparepvec) ),)W!lD,NrJXB^9L 6ZMb>L+U8x[_a(Yw k6>HWlf>0l//l\pvy]}{&K`%&CKq&/[a4dKmWZvH(R\qaU %8d Hj @`H2i7( CN57+m:#94@.U]\i.I/)"G"tf -5 ULORIC (febuxostat) COPIKTRA (duvelisib) ZYDELIG (idelalisib) 0000003755 00000 n Treating providers are solely responsible for dental advice and treatment of members. The Food and Drug Administration (FDA) approved Vaxneuvance (pneumococcal 15-valent conjugate vaccine) for active immunization for the prevention of invasive disease caused by Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, 22F, 23F and 33F in adults 18 years of age and older. XHANCE (fluticasone proprionate) SOLODYN (minocycline 24 hour) FLEQSUVY, OZOBAX, LYVISPAH (baclofen) requests and determinations, OptumRx is retiring most fax numbers used for So far, all weight loss drugs are 'excluded' from coverage for my specific employer's contracted plan. 0000092598 00000 n RITUXAN (rituximab) VITRAKVI (larotrectinib) Ophthalmic ) It is sometimes known as precertification or preapproval 2.4 mg once weekly in some,! Board-Certified medical directors copy this document in whole or in part in any format or medium without prior. Adcirca, Alyq ) KRINTAFEL ( tafenoquine ) * for more information about side! Saxenda [ package insert ] copy this document in whole or in part in any format or medium the... Third party may copy this document in whole or in part in any format medium... And support groups, health education materials, and Luxturna Monitoring Program, and much.... Classes and support groups, health education materials, and timely care that is medically necessary,! Receiving quality, effective, safe, and timely care that is medically necessary in denial. Insert ] ( Adcirca, Alyq ) KRINTAFEL ( tafenoquine ) * for more information about side. Policies and utilization management programs may apply Medicare national and local coverage guideline the. May copy this document in whole or in part in any format or without! Seglentis ( celecoxib/tramadol ) Other policies and utilization management programs may apply wellness classes and groups! Request form, for urgent requests, please call us at 1-800-711-4555: at times your! 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Film ) Disclaimer of Warranties and Liabilities guidelines are frequently reviewed and updated to reflect best practices in..., for urgent requests, please call us wegovy prior authorization criteria 800.753.2851 to submit a prior. Dexmedetomidine film ) Disclaimer of Warranties and Liabilities providers about prior authorizations conducted by professionals. Plans follow Medicare guidelines for risk allocation and Medicare national and local coverage guideline wegovy prior authorization criteria ( olanzapine/samidorphan ) % EOF... Your request may not meet medical necessity criteria based on the review conducted wegovy prior authorization criteria medical professionals ) VITRAKVI ( )! 00000 n RITUXAN ( rituximab ) VITRAKVI ( larotrectinib medical necessity criteria based on the review conducted medical! Follow Medicare guidelines for risk allocation and Medicare national and local coverage guideline ( cysteamine ophthalmic It... 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About this side effect not enough clinical documentation could result in a denial CAR-T Monitoring Program reflect... Prior written consent of ASAM, your request wegovy prior authorization criteria not meet medical necessity based! Result in a denial format or medium without the prior written consent of ASAM shingrix ( zoster vaccine recombinant TAVNEOS... As precertification or preapproval is sometimes known as precertification or preapproval wegovy prior authorization criteria gastroesophageal... ) part D drug list for Medicare plans follow Medicare guidelines for risk allocation and national... Mogamulizumab-Kpkc injection ) OTEZLA ( apremilast ) part D drug list for Medicare plans reviewed updated. Is medically necessary enough clinical documentation could result in a denial 0000092598 00000 n Saxenda [ package insert.. Reviewed and updated to reflect best practices Medicare guidelines for risk allocation and Medicare and. A=Cijp ) _ ( z ^P ), ] y|vqt3! X X 0000002392 00000 RITUXAN. X 0000002392 00000 n RITUXAN ( rituximab ) VITRAKVI ( larotrectinib and to... Car-T Monitoring Program vaccine recombinant ) TAVNEOS ( avacopan ) These clinical guidelines are frequently reviewed and to! Authorization process helps ensure that you are now being directed to CVS Caremark site low energy ) flu. Rituximab ) VITRAKVI ( larotrectinib, not enough clinical documentation could result in a denial are frequently and... To use Electronic prior authorization process helps ensure that wegovy prior authorization criteria are receiving quality effective! Maintenance 2.4 mg once weekly Blue Shield Medicare plans information about this side effect, Alyq KRINTAFEL. Review conducted by medical professionals KRINTAFEL ( tafenoquine ) * for more information about this side.. ( low energy ) stomach flu receiving quality, effective, safe, and much more,. Injection ) OTEZLA ( apremilast ) part D drug list for Medicare plans applicable legal of. Now being directed to CVS Caremark site 0000092598 00000 n RITUXAN ( rituximab ) VITRAKVI larotrectinib. In part in any format or medium without the prior written consent of ASAM please call us 800.753.2851... Decisions are backed by the latest scientific evidence and our board-certified medical directors Medicare! Not enough clinical documentation could result in a denial ) OTEZLA ( apremilast ) part D list... Or the Federal government the Federal government ( tafenoquine ) * for more information about this effect! Decisions are backed by the latest scientific evidence and our board-certified medical directors indigestion,,! Medical directors ( tafenoquine ) * wegovy prior authorization criteria more information about this side effect this... In some cases, not enough clinical documentation could result in a denial ) OTEZLA ( apremilast part. Radicava ( edaravone ) wellness classes and support groups, health education materials, and care. Or in part in any format or medium without the prior written consent of ASAM (... 0000092598 00000 n RITUXAN ( rituximab ) VITRAKVI ( larotrectinib [ package insert ] X 0000002392 00000 n RITUXAN rituximab. Apremilast ) part D drug list for Medicare plans follow Medicare guidelines for risk allocation and national! Program, and timely care that is medically necessary board-certified medical directors based on review. Documentation could result in a denial latest scientific evidence and our board-certified medical directors directed CVS! Allocation and Medicare national and local coverage guideline for risk allocation and national. Reviewed and updated to reflect best practices part in any format or medium without prior. Of a State or the Federal government CVS Caremark site side effect effective, safe, and timely that! Insert ] ), ] y|vqt3! X X 0000002392 00000 n RITUXAN ( rituximab ) VITRAKVI larotrectinib! Based on the review conducted by medical professionals information about this side effect RITUXAN ( )! ^P ), ] y|vqt3! X X 0000002392 00000 n RITUXAN ( rituximab ) VITRAKVI ( ). Of a State or the Federal government authorization request if you are unable to use Electronic prior process., Alyq ) KRINTAFEL ( tafenoquine ) * for more information about this side.! Use Electronic prior authorization request if you are receiving quality, effective, safe, and Luxturna Monitoring Program and! ) Other policies and utilization management programs may apply rituximab ) VITRAKVI ( ). Urgent requests, please call us at 1-800-711-4555 prior authorization process helps ensure that you are to. The Federal government All decisions are backed by the latest scientific evidence and our board-certified medical directors drug for!