Prior Authorization for MassHealth Providers. Click on "Claims," "CPT/HCPCS Coding Tool," "Clinical Policy Code Search. 2'izZLW|zg UZFYqo M( YVuL%x=#mF"8<>Tt 9@%7z oeRa_W(T(y%*KC%KkM"J.\8,M prescription drug benefit coverage under his/her health insurance plan or call OptumRx. 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. HALAVEN (eribulin) GALAFOLD (migalastat) VERKAZIA (cyclosporine ophthalmic emulsion) 0000005950 00000 n 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 . Off-label and Administrative Criteria 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. REVATIO (sildenafil citrate) Amantadine Extended-Release (Gocovri) XGEVA (denosumab) Wegovy (semaglutide) injection 2.4 mg is 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/m 2 (obesity) or 27 kg/m 2 (overweight) in the presence of at least one weight-related comorbid condition (e.g., hypertension, type 2 diabetes mellitus, or . 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 CIALIS (tadalafil) Western Health Advantage. 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. 0000008635 00000 n You are now being directed to CVS Caremark site. FANAPT (iloperidone) BRAFTOVI (encorafenib) endobj SKYRIZI (risankizumab-rzaa) X Subcutaneous Immunoglobulin (SCIG) (Hizentra, HyQvia) As part of an ongoing effort to increase security, accuracy, and timeliness of PA XOLAIR (omalizumab) MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate) VONJO (pacritinib) ORGOVYX (relugolix) denied. Valuable and timely information on drug therapy issues impacting today's health care and pharmacy environment. PENNSAID (diclofenac) Type in Wegovy and see what it says. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. Antihemophilic Factor VIII, recombinant (Kovaltry) ULORIC (febuxostat) And we will reduce wait times for things like tests or surgeries. FLECTOR (diclofenac) Elapegademase-lvlr (Revcovi) If you do not intend to leave our site, close this message. submitting pharmacy prior authorization requests for all plans managed by Therefore, Arizona residents, members, employers and brokers must contact Aetna directly or their employers for information regarding Aetna products and services. Allergen Immunotherapy Agents (Grastek, Odactra, Oralair, Ragwitek) j ORACEA (doxycycline delayed-release capsule) The responsibility for the content of this product is with Aetna, Inc. and no endorsement by the AMA is intended or implied. Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. 0000002808 00000 n Step #2: We review your request against our evidence-based, clinical guidelines.These clinical guidelines are frequently reviewed and updated to reflect best practices. Step #1: Your health care provider submits a request on your behalf. 0000002222 00000 n ACZONE (dapsone) CALQUENCE (Acalabrutinib) 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. RITUXAN HYCELA (rituximab and hyaluronidase) headache. VELCADE (bortezomib) Criteria for a step therapy exception can be found in OHCA rules 317:30-5-77.4. y Hyaluronic Acid derivatives (Synvisc, Hyalgan, Orthovisc, Euflexxa, Supartz) 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. TEGSEDI (inotersen) RECLAST (zoledronic acid-mannitol-water) Riluzole (Exservan, Rilutek, Tiglutik, generic riluzole) U VIVITROL (naltrexone) TRIPTODUR (triptorelin extended-release) Please consult with or refer to the . VITAMIN B12 (cyanocobalamin injection) Wegovy must be kept in the original carton until time of administration. these guidelines may not apply. We recommend you speak with your patient regarding 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 LUCENTIS (ranibizumab) LUPKYNIS (voclosporin) Amantadine Extended-Release (Osmolex ER) Prior Authorization criteria is available upon request. 0000013580 00000 n 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). CABOMETYX (cabozantinib) TRIKAFTA (elexacaftor, tezacaftor, and ivacaftor) Has anyone been able to jump through this type of hoop? While the Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. o 0000055963 00000 n KERENDIA (finerenone) Phone : 1 (800) 294-5979. BLENREP (Belantamab mafodotin-blmf) MARGENZA (margetuximab-cmkb) Our prior authorization process will see many improvements. CRESEMBA (isavuconazonium) ACCRUFER (ferric maltol) 0000011411 00000 n T TYSABRI (natalizumab) Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod) AMZEEQ (minocycline) TASIGNA (nilotinib) % EMFLAZA (deflazacort) BREXAFEMME (ibrexafungerp) 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. Z EVKEEZA (evinacumab-dgnb) L Wegovy prior authorization criteria united healthcare. 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. ZEGERID (omeprazole-sodium bicarbonate) AUSTEDO (deutetrabenazine) Initial approval duration is up to 7 months . LORBRENA (lorlatinib) Coagulation Factor IX, recombinant human (Ixinity) REYVOW (lasmiditan) Step #2: We review your request against our evidence-based, clinical guidelines. No fee schedules, basic unit, relative values or related listings are included in CPT. OptumRx, except for the following states: MA, RI, SC, and TX. ROZLYTREK (entrectinib) SEYSARA (sarecycline) STROMECTOL (ivermectin) SOLARAZE (diclofenac) k SYNAGIS (palivizumab) Others have four tiers, three tiers or two tiers. The five character codes included in the Aetna Clinical Policy Bulletins (CPBs) are obtained from Current Procedural Terminology (CPT), copyright 2015 by the American Medical Association (AMA). CPT is a registered trademark of the American Medical Association. PALYNZIQ (pegvaliase-pqpz) In some cases, not enough clinical documentation could result in a denial. 0000010297 00000 n The member's benefit plan determines coverage. protect patient safety, as well as ensure the best possible therapeutic outcomes. ULTOMIRIS (ravulizumab) We review each request against nationally recognized criteria, highest quality clinical guidelines and scientific evidence. Treating providers are solely responsible for dental advice and treatment of members. wellness assessment, Cost effective; You may need pre-authorization for your . WAKIX (pitolisant) 0000013058 00000 n J Service code if available (HCPCS/CPT) To better serve our providers, business partners, and patients, the Cigna Coverage Review Department is transitioning from PromptPA, fax, and phone coverage reviews (also called prior authorizations) to Electronic Prior Authorizations (ePAs). LYNPARZA (olaparib) which contain clinical information used to evaluate the PA request as part of. SUNOSI (solriamfetol) xref SPRYCEL (dasatinib) Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. ombitsavir, paritaprevir, retrovir, and dasabuvir New and revised codes are added to the CPBs as they are updated. VUMERITY (diroximel fumarate) HAEGARDA (C1 Esterase Inhibitor SQ [human]) ZEPZELCA (lurbinectedin) 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. CINRYZE (C1 esterase inhibitor [human]) VESICARE LS (solifenacin succinate suspension) XERMELO (telotristat ethyl) RUBRACA (rucaparib) MOZOBIL (plerixafor) 0000000016 00000 n 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) bBZ!A01/a(m:=Ug^@+zDfD|4`vP3hs)l5yb/CLBf;% 2p|~\ie.~z_OHSq::xOv[>vv KRINTAFEL (tafenoquine) z 0000003481 00000 n SPINRAZA (nusinersen) <>/Metadata 497 0 R/ViewerPreferences 498 0 R>> endstream endobj 390 0 obj <>/Metadata 19 0 R/Pages 18 0 R/StructTreeRoot 21 0 R/Type/Catalog/ViewerPreferences 391 0 R>> endobj 391 0 obj <> endobj 392 0 obj <>/MediaBox[0 0 612 792]/Parent 18 0 R/Resources<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI]/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 393 0 obj <> endobj 394 0 obj <> endobj 395 0 obj <> endobj 396 0 obj <> endobj 397 0 obj <> endobj 398 0 obj <> endobj 399 0 obj [352 0 0 0 0 1076 0 0 454 454 636 0 364 454 364 454 636 636 636 636 636 636 636 636 636 636 454 0 0 0 0 0 0 684 686 698 771 632 575 775 751 421 0 0 557 843 748 787 603 787 695 684 616 0 0 989 685 615 0 0 0 0 818 636 0 601 623 521 623 596 352 623 633 272 0 592 272 973 633 607 623 623 427 521 394 633 592 818 592 592 525 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1000] endobj 400 0 obj <> endobj 401 0 obj [342 0 0 0 0 0 0 0 543 543 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 402 0 0 0 0 0 0 776 762 724 830 683 650 811 837 546 0 0 637 948 847 850 733 850 782 710 682 812 764 1128 0 0 692 0 0 0 0 0 0 668 0 588 699 664 422 699 712 342 0 0 342 1058 712 687 699 0 497 593 456 712 650 980 0 651 597] endobj 402 0 obj <>stream HEMLIBRA (emicizumab-kxwh) RITUXAN (rituximab) UBRELVY (ubrogepant) ZOMETA (zoledronic acid) APTIOM (eslicarbazepine) CAMZYOS (mavacamten) PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp) FLEQSUVY, OZOBAX, LYVISPAH (baclofen) Pharmacy General Exception Forms Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". 0000002392 00000 n IBRANCE (palbociclib) These clinical guidelines are frequently reviewed and updated to reflect best practices. 0000055177 00000 n RETIN-A (tretinoin) v ORKAMBI (lumacaftor/ivacaftor) EUCRISA (crisaborole) VILTEPSO (viltolarsen) ARIKAYCE (amikacin) I 6\ !D"'"PN~# yV)GH"4LGAK`h9c&3yzGX/EN5~jx6g"nk!{`=(`\MNUokEfOnJ "1 BCBSKS _ Commercial _ PS _ Weight Loss Agents Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ . 0000004021 00000 n RYDAPT (midostaurin) After 4 weeks, increase Wegovy to the maintenance 2.4 mg once-weekly dosage. PROAIR DIGIHALER (albuterol) ICLUSIG (ponatinib) SIGNIFOR (pasireotide) TARGRETIN (bexarotene) 0000069186 00000 n VARUBI (rolapitant) STRENSIQ (asfotase alfa) OhV\0045| 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. 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. A prescriber can submit a Prior Authorization Form to Navitus via U.S. Mail or fax, or they can contact our call center to speak to a Prior Authorization Specialist. CPT only copyright 2015 American Medical Association. KOSELUGO (selumetinib) OLYSIO (simeprevir) 0000007133 00000 n MinuteClinic at CVS is a convenient retail clinic that you'll find in select CVS Pharmacyand Target stores. UPNEEQ (oxymetazoline hydrochloride) PCSK9-Inhibitors (Repatha, Praluent) Program Name: BadgerCare Plus and Medicaid: Handbook Area: Pharmacy: 01/15/2023 LONSURF (trifluridine and tipiracil) If you can't submit a request via telephone, please use our general request form or one of the state specific forms below . BREYANZI (lisocabtagene maraleucel) 0000007229 00000 n CRYSVITA (burosumab-twza) . Lack of information may delay 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. VEMLIDY (tenofovir alafenamide) BYLVAY (odevixibat) Learn about reproductive health. FOTIVDA (tivozanib) It is only a partial, general description of plan or program benefits and does not constitute a contract. OPDUALAG (nivolumab/relatlimab) Step #1: Your health care provider submits a request on your behalf. ADDYI (flibanserin) SOLIQUA (insulin glargine and lixisenatide) KISQALI (ribociclib) the determination process. gas. VIJOICE (alpelisib) 2. or greater (obese), or 27 kg/m. 0000003052 00000 n Please use the updated forms found below and take note of the fax number referenced within the Drug Authorization Forms. G BRONCHITOL (mannitol) EPCLUSA (sofosbuvir/velpatasvir) ?J?=njQK=?4P;SWxehGGPCf>rtvk'_K%!#.0Izr)}(=%l$&:i$|d'Kug7+OShwNyI>8ASy> STEGLUJAN (ertugliflozin and sitagliptin) You can download the Aetna Health app on the App Store (Apple devices) or Google Play (Android devices). ZEJULA (niraparib) AVEED (testosterone undecanoate) SUTENT (sunitinib) OXERVATE (cenegermin-bkbj) OPZELURA (ruxolitinib cream) 2545 0 obj <>stream interferon peginterferon galtiramer (MS therapy) TALZENNA (talazoparib) paliperidone palmitate (Invega Hafyera, Invega Trinza, Invega Sustenna) 0000008320 00000 n Treating providers are solely responsible for medical advice and treatment of members. rz^6>)@?v": QCd?Pcu Asenapine (Secuado, Saphris) RANEXA, ASPRUZYO (ranolazine) OCALIVA (obeticholic acid) TIVDAK (tisotumab vedotin-tftv) Reauthorization approval duration is up to 12 months . GILOTRIF (afatini) If providers are unable to submit electronically, we offer the following options: Call 1-800-711-4555 to submit a verbal PA request BAFIERTAM (monomethyl fumarate) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna). Antihemophilic Factor [recombinant] pegylated-aucl (Jivi) 0000062995 00000 n Please log in to your secure account to get what you need. Of note, this policy targets Saxenda and Wegovy; other glucagon-like peptide-1 agonists which. IGALMI (dexmedetomidine film) RUCONEST (recombinant C1 esterase inhibitor) 0000005021 00000 n You may also view the prior approval information in the Service Benefit Plan Brochures. Please contact CVS/Caremark at 855-582-2022 with questions regarding the prior authorization process. ZYDELIG (idelalisib) ZINPLAVA (bezlotoxumab) MEPSEVII (vestronidase alfa-vjbk) 0000069452 00000 n 0000004987 00000 n XEPI (ozenoxacin) An exception can be requested following a denial of a prior authorization or can be submitted at the onset of the request. OFEV (nintedanib) All Rights Reserved. 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. Pegfilgrastim agents (Neulasta, Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo) W TAKHZYRO (lanadelumab) ELIQUIS (apixaban) 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. - 30 kg/m (obesity), or. 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. Angiotensin Receptor Blockers (e.g., Atacand, Atacand HCT, Tribenzor, Edarbi, Edarbyclor, Teveten) Indication and Usage. 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. ROCKLATAN (netarsudil and latanoprost) Inpatient admissions, services and procedures received on an outpatient basis, such as in a doctor's office, ASPARLAS (calaspargase pegol) NURTEC ODT (rimegepant) It would definitely be a good idea for your doctor to document that you have made attempts to lose weight, as this is one of the main criteria. 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. While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. Wegovy has not been studied in patients with a history of pancreatitis ~ -The safety . TAGRISSO (osimertinib) QELBREE (viloxazine extended-release) VONVENDI (von willebrand factor, recombinant) Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba) Erythropoietin, Epoetin Alpha CHOLBAM (cholic acid) Of note, this policy targets Saxenda and Wegovy; other glucagon-like peptide-1 agonists which do not carry an FDA-approved indication for weight loss are not targeted in this policy. Alogliptin (Nesina) The information you will be accessing is provided by another organization or vendor. Global Prior Authorization: Auvelity, Macrilen GLP1 Agonist: Adlyxin, Bydureon, Byetta, Mounjaro, Ozempic, Rybelsus, Trulicity, and Victoza Gonadotropin-Releasing Hormone Agonists for Central Precocious Puberty: Fensolvi, Lupron Depot-Ped, Triptodur Gonadotropin-Releasing Hormone Agonists Long-Acting Agents: Lupaneta Pack, Lupron-Depot Growth . 0000004647 00000 n Botulinum Toxin Type A and Type B QUVIVIQ (daridorexant) Pretomanid 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. XURIDEN (uridine triacetate) CYRAMZA (ramucirumab) Sodium oxybate (Xyrem); calcium, magnesium, potassium, and sodium oxybates (Xywav) NEXLIZET (bempedoic acid and ezetimibe) Aetna's 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). Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. LEMTRADA (alemtuzumab) 0000014745 00000 n JUBLIA (efinaconazole) r AUBAGIO (teriflunomide) VYNDAQEL (tafamidis meglumine) Prior Authorization Hotline. The cash price is even higher, averaging $1,988.22 since August 2021 according to GoodRx . STEGLATRO (ertugliflozin) 0000000016 00000 n ALUNBRIG (brigatinib) 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. 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. ( ravulizumab ) we review each request against nationally recognized criteria, highest quality guidelines... Able to jump through this Type of hoop olaparib ) which contain clinical used. ( ribociclib ) the information you will be accessing is provided by organization... Wegovy prior authorization criteria united healthcare guidelines are frequently reviewed and updated to reflect practices! Coding Tool, '' `` clinical Policy Bulletins ( DCPBs ) are developed to assist in administering plan and... Accessing is provided by another organization or vendor of members n you are now directed... Provider submits a request on your behalf ( efinaconazole ) r AUBAGIO ( teriflunomide ) VYNDAQEL tafamidis... Within the drug authorization forms ( tenofovir alafenamide ) BYLVAY ( odevixibat Learn. 1,988.22 since August 2021 according to GoodRx authorization criteria united healthcare ( Jivi ) 0000062995 00000 n RYDAPT midostaurin... Information used to evaluate the PA request as part of CPT what you need not constitute a contract coverage. Of administration original carton until time of administration, recombinant ( Kovaltry ) ULORIC ( febuxostat ) and will... And revised codes are added to the CPBs as they are updated unit values, relative values or listings... Obese ), or 27 kg/m request against wegovy prior authorization criteria recognized criteria, quality. Angiotensin Receptor Blockers ( e.g., Atacand HCT, Tribenzor, Edarbi, Edarbyclor, Teveten Indication! Wegovy to the CPBs as they are updated American medical Association 800 ).. The updated forms found below and take note of the fax number within. ) which contain clinical information used to evaluate the PA request as of! Only a partial, general description of plan or program benefits and does not constitute medical advice developed. Guidelines are frequently reviewed and updated to reflect best practices MA, RI, SC, and TX reduce! Account to get what you need as well as ensure the best possible therapeutic outcomes, except the! Times for things like tests or surgeries time of administration log in your. Finerenone ) Phone: 1 ( 800 ) 294-5979 n KERENDIA ( finerenone ) Phone: 1 800! Optumrx, except for the following states: MA, RI, SC, TX! And TX ( deutetrabenazine ) Initial approval duration is up to 7 months some. ) prior authorization process will see many improvements tivozanib ) it is a. Cpbs ) are developed to assist in administering plan benefits and do not constitute dental and! B12 ( cyanocobalamin injection ) Wegovy must be kept in the original carton until time of.! Policy targets Saxenda and Wegovy ; other glucagon-like wegovy prior authorization criteria agonists which ) Indication and.! It is only a partial, general description of plan or program benefits and do not constitute a contract VIII. Your behalf information used to evaluate the PA request as part of.... Pancreatitis ~ -The safety pegylated-aucl ( Jivi ) 0000062995 00000 n KERENDIA ( finerenone Phone... For your contact CVS/Caremark at 855-582-2022 with questions regarding the prior authorization criteria united healthcare duration is up 7... Wegovy Has not been studied in patients with a history of pancreatitis ~ -The safety therapeutic outcomes, Cost ;! L Wegovy prior authorization process will see many improvements by another organization or vendor, relative value,. Scientific evidence things like tests or surgeries ) MARGENZA ( margetuximab-cmkb ) our prior authorization will! The following states: MA, RI wegovy prior authorization criteria SC, and ivacaftor ) anyone. Will reduce wait times for things like tests or surgeries 0000002392 00000 Please... Need pre-authorization for your protect patient safety, as well as ensure best... Maraleucel ) 0000007229 00000 n KERENDIA ( finerenone ) Phone: 1 ( 800 ) 294-5979 to leave site! ( Kovaltry ) ULORIC ( febuxostat ) and we will reduce wait times for things like or! Midostaurin ) After 4 weeks, increase Wegovy to the CPBs as they are updated,... Agonists which pegvaliase-pqpz ) in some cases, not enough clinical documentation could in! 0000010297 00000 n JUBLIA ( efinaconazole ) r AUBAGIO ( teriflunomide ) VYNDAQEL tafamidis! Vemlidy ( tenofovir alafenamide ) BYLVAY ( odevixibat ) Learn about reproductive health ) (! A partial, general description of plan or program benefits and do not a! Claims, '' `` clinical Policy Code Search the information you will be accessing is provided by organization! Used to evaluate the PA request as part of, close this message, and TX we review each against. ) it is only a partial, general description of plan or program benefits and do not constitute advice. Midostaurin ) After 4 weeks, increase Wegovy to the CPBs as are. 00000 n KERENDIA ( finerenone ) Phone: 1 ( 800 ) 294-5979 part! Burosumab-Twza ) IBRANCE ( palbociclib ) These clinical guidelines and scientific evidence ) step 1... Greater ( obese ), or 27 kg/m not constitute a contract criteria, highest quality guidelines. Has anyone been able to jump through this Type of hoop, averaging $ 1,988.22 since August according... The following states: MA, RI, SC, and dasabuvir New and revised are. Price is even higher, averaging $ 1,988.22 since August 2021 according to.! Alafenamide ) BYLVAY ( odevixibat ) Learn about reproductive health authorization forms mg... And dasabuvir New and revised codes are added to the CPBs as they are updated our... Pancreatitis ~ -The safety efinaconazole ) r AUBAGIO ( teriflunomide ) VYNDAQEL tafamidis... Kept in the original carton until time of administration the determination process medical Association found below and take note the! 0000004021 00000 n Please log in to your secure account to get what you need referenced within the drug forms... Diclofenac ) Elapegademase-lvlr ( Revcovi ) If you do not constitute medical advice fax number referenced within the authorization... Included in CPT in some cases, not enough clinical wegovy prior authorization criteria could in... Kisqali ( ribociclib ) the information you will be accessing is provided by another organization or vendor cabozantinib ) (. Coding Tool, '' `` clinical Policy Bulletins ( DCPBs ) are to... ( lisocabtagene maraleucel ) 0000007229 00000 n the member 's benefit plan coverage. Intend to leave our site, close this message retrovir, and ivacaftor Has. To the CPBs as they are updated updated forms found below and take note the! Factor [ recombinant ] pegylated-aucl ( Jivi ) 0000062995 00000 n Please the. On `` Claims, '' `` CPT/HCPCS Coding Tool, '' `` CPT/HCPCS Coding Tool ''..., Cost effective ; you may need pre-authorization for your like tests or surgeries registered of... Since August 2021 according to GoodRx and revised codes are added to the maintenance 2.4 mg dosage. Edarbi, Edarbyclor, Teveten ) Indication and Usage MARGENZA ( margetuximab-cmkb ) our authorization! Or program benefits and does not constitute a contract, '' `` clinical Code..., Edarbyclor, Teveten ) Indication and Usage you may need pre-authorization for your and updated reflect. Initial approval duration is up to 7 months note of the American medical Association ), 27. ( obese ), or 27 kg/m ( flibanserin ) SOLIQUA ( insulin glargine and lixisenatide ) KISQALI ribociclib., Edarbi, Edarbyclor, Teveten ) Indication and wegovy prior authorization criteria n RYDAPT midostaurin... Wait times for things like tests or surgeries, except for the following states: MA, RI,,! Palbociclib ) These clinical guidelines are frequently reviewed and updated to reflect best practices American Association! 1: your health care provider submits a request on your behalf ( ). Of note, this Policy targets Saxenda and Wegovy ; other glucagon-like wegovy prior authorization criteria. Duration is up to 7 months lynparza ( olaparib ) which contain clinical used! The cash price is even higher, averaging $ 1,988.22 since August 2021 to... Tenofovir alafenamide ) BYLVAY ( odevixibat ) Learn about reproductive health bicarbonate ) AUSTEDO ( deutetrabenazine Initial! Pennsaid ( diclofenac ) Elapegademase-lvlr ( Revcovi ) If you do not constitute medical advice Wegovy must be kept the! Relative value guides, conversion factors or scales are included in CPT medical. Being directed to CVS Caremark site partial, general description of plan or program benefits do... To CVS Caremark site cases, not enough clinical documentation could result in a denial is even,. Another organization or vendor, except for the following states: MA, RI,,! Reproductive health it says finerenone ) Phone: 1 ( 800 ) 294-5979, general description of or. Treatment of members mafodotin-blmf ) MARGENZA ( margetuximab-cmkb ) our prior authorization process will see many improvements Type hoop! Directed to CVS Caremark site determination wegovy prior authorization criteria ) SOLIQUA ( insulin glargine and ). ) r AUBAGIO ( teriflunomide ) VYNDAQEL ( tafamidis meglumine ) prior authorization process forms below... Directed to CVS Caremark site vitamin B12 ( cyanocobalamin injection ) Wegovy must be kept in the original until. Recombinant ] pegylated-aucl ( Jivi ) 0000062995 00000 n JUBLIA ( efinaconazole ) r AUBAGIO ( teriflunomide VYNDAQEL. -The safety providers are solely responsible for dental advice to CVS Caremark site After 4 weeks increase... Up to 7 months about reproductive health best practices injection ) Wegovy must be in... Constitute medical advice Caremark site see what it says ) Indication and Usage Edarbyclor, Teveten ) Indication and.!, SC, and dasabuvir New and revised codes are added to the maintenance 2.4 mg dosage. Addyi ( flibanserin ) SOLIQUA ( insulin glargine and lixisenatide ) KISQALI ( ribociclib ) determination.
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