wegovy prior authorization criteria

making criteria** that are developed from clinical evidence from the following sources: *Guidelines are specific to plans utilizing our standard drug lists only. ILUMYA (tildrakizumab-asmn) See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. KOMBIGLYZE XR (saxagliptin and metformin hydrochloride, extended release) ZOKINVY (lonafarnib) ONFI (clobazam) ADEMPAS (riociguat) 4 0 obj MINOCIN (minocycline tablets) NAYZILAM (midazolam nasal spray) 0000002222 00000 n REVATIO (sildenafil citrate) This Agreement will terminate upon notice if you violate its terms. LEUKINE (sargramostim) AMZEEQ (minocycline) Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. 0000008455 00000 n 0000004987 00000 n HEPLISAV-B (hepatitis B vaccine) H The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. HAEGARDA (C1 Esterase Inhibitor SQ [human]) ILUVIEN (fluocinolone acetonide) wellness assessment, 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. Angiotensin Receptor Blockers (e.g., Atacand, Atacand HCT, Tribenzor, Edarbi, Edarbyclor, Teveten) VRAYLAR (cariprazine) 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. Other times, medical necessity criteria might not be met. AYVAKIT (avapritinib) gym discounts, 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. SPRAVATO (esketamine) Others have four tiers, three tiers or two tiers. HALAVEN (eribulin) Health benefits and health insurance plans contain exclusions and limitations. ACTEMRA (tocilizumab) Phone : 1 (800) 294-5979. SUNOSI (solriamfetol) 0000005011 00000 n 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. 0000069452 00000 n PONVORY (ponesimod) FORTEO (teriparatide) XEPI (ozenoxacin) QTERN (dapagliflozin and saxagliptin) Some subtypes have five tiers of coverage. upQz:G Cs }%u\%"4}OWDw 0000054864 00000 n gas. RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn) RAVICTI (glycerol phenylbutyrate) While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. KERENDIA (finerenone) Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. LAGEVRIO (molnupiravir) Visit the secure website, available through www.aetna.com, for more information. prior authorization (PA), to ensure that they are medically necessary and appropriate for the Prior Authorization for MassHealth Providers. 0000092598 00000 n All Rights Reserved. TYVASO (treprostinil) When conditions are met, we will authorize the coverage of Wegovy. BENLYSTA (belimumab) VYEPTI (epitinexumab-jjmr) SOLODYN (minocycline 24 hour) QULIPTA (atogepant) 0000055600 00000 n VFEND (voriconazole) 6\ !D"'"PN~# yV)GH"4LGAK`h9c&3yzGX/EN5~jx6g"nk!{`=(`\MNUokEfOnJ "1 Subcutaneous Immunoglobulin (SCIG) (Hizentra, HyQvia) January is Cervical Health Awareness Month. ACCRUFER (ferric maltol) EXJADE (deferasirox) CINQAIR (reslizumab) NULIBRY (fosdenopterin) Pharmacy General Exception Forms CABLIVI (caplacizumab) protect patient safety, as well as ensure the best possible therapeutic outcomes. D VARUBI (rolapitant) Each main plan type has more than one subtype. 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. Pre-authorization is a routine process. K If you have questions, you can reach out to your health care provider. CVS HealthHUB offers all the same services as MinuteClinic at CVS with some additional benefits. IGALMI (dexmedetomidine film) Allergen Immunotherapy Agents (Grastek, Odactra, Oralair, Ragwitek) covered medication, and/or OptumRx will offer information on the process to appeal the adverse decision. TARPEYO (budesonide capsule, delayed release) Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. 2493 0 obj <> endobj NUEDEXTA (dextromethorphan and quinidine) We offer a variety of resources to support you through your health care journey, including: Resources For Living Program BONIVA (ibandronate) 1 0 obj 0000003052 00000 n coverage determinations for most PA types and reasons. RHOPRESSA (netarsudil solution) ORIAHNN (elagolix, estradiol, norethindrone) It enables a faster turnaround time of FENORTHO (fenoprofen) TREMFYA (guselkumab) NURTEC ODT (rimegepant) EVENITY (romosozumab-aqqg) LIVMARLI (maralixibat solution) VYNDAQEL (tafamidis meglumine) The requested drug will be covered with prior authorization when the following criteria are met: The patient is 18 years of age or . Interferon beta-1b (Betaseron, Extavia) 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. x You can review prior authorization criteria for Releuko for oncology indications, as well as any recent coding updates, on the OncoHealth website. ABECMA (idecabtagene vicleucel) Antihemophilic Factor VIII, Recombinant (Afstyla) Coverage for weight loss drugs like Wegovy varies widely depending on the kind of insurance you have and where you live. ELIQUIS (apixaban) RYDAPT (midostaurin) EMPAVELI (pegcetacoplan) ADHD Stimulants, Extended-Release (ER) RECLAST (zoledronic acid-mannitol-water) NUBEQA (darolutamide) hA 04Fv\GczC. Blue Shield Medicare plans follow Medicare guidelines for risk allocation and Medicare national and local coverage guideline. Links to various non-Aetna sites are provided for your convenience only. CPT is a registered trademark of the American Medical Association. SYMDEKO (tezacaftor-ivacaftor) Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. therapy and non-formulary exception requests. CIMZIA (certolizumab pegol) TECARTUS (brexucabtagene autoleucel) VELCADE (bortezomib) 3 0 obj Testosterone pellets (Testopel) RINVOQ (upadacitinib) And we will reduce wait times for things like tests or surgeries. 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). End of Life Medications 0000008484 00000 n This information is neither an offer of coverage nor medical advice. PCSK9-Inhibitors (Repatha, Praluent) G Explore differences between MinuteClinic and HealthHUB. MOZOBIL (plerixafor) ENBREL (etanercept) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. Therapeutic indication. 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. VIJOICE (alpelisib) EUCRISA (crisaborole) ; Wegovy contains semaglutide and should . BELSOMRA (suvorexant) 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 . 2 0 obj U Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. 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. HWn8}7#Y 0MCFME"R+$Yrp yN.oHC Dhx4iE$D;NP&+Xi:!WB>|\_ 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. 0 The American Medical Association (AMA) does not directly or indirectly practice medicine or dispense medical services. Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations. Coagulation Factor IX, (recombinant), Albumin Fusion Protein (Idelvion) RANEXA, ASPRUZYO (ranolazine) 0000005681 00000 n TURALIO (pexidartinib) ePA is a secure and easy method for submitting,managing, tracking PAs, step 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). 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. MONJUVI (tafasitamab-cxix) *Praluent is typically excluded from coverage. 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). Filgrastim agents (Nivestym, Zarxio, Neupogen, Granix, Releuko) GILOTRIF (afatini) m So far, all weight loss drugs are 'excluded' from coverage for my specific employer's contracted plan. OhV\0045| How to access the OptumRx PA guidelines: Reference the OptumRx electronic prior authorization ( ePA ) and (fax ) forms. Elapegademase-lvlr (Revcovi) 0000006215 00000 n by international cut-offs (Cole Criteria) Limitations of use: ~ - The safety and efficacy of coadministration with other weight loss drug . 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 . KRYSTEXXA (pegloticase) 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. Wegovy; Xenical; Initial approval criteria for covered drugs with prior authorization: Patient must meet the age limit indicated in the FDA-approved label of the requested drug AND; Documented failure of at least a three-month trial on a low-calorie diet AND; A regimen of increased physical activity unless medically contraindicated by co . A prior authorization is a request submitted on your behalf by your health care provider for a particular procedure, test, treatment, or prescription. Pretomanid TALZENNA (talazoparib) AMVUTTRA (vutrisiran) Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn) 3. 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. What is a "formalized" weight management program? 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. Riluzole (Exservan, Rilutek, Tiglutik, generic riluzole) 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 . Wegovy This fax machine is located in a secure location as required by HIPAA regulations. SLYND (drospirenone) 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. BEVYXXA (betrixaban) 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. Blood Glucose Test Strips NATPARA (parathyroid hormone, recombinant human) VUMERITY (diroximel fumarate) XTAMPZA ER (oxycodone) PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp) VABYSMO (faricimab) Copyright 2023 POMALYST (pomalidomide) CPT is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physicians. FOTIVDA (tivozanib) All approvals are provided for the duration noted below. PALYNZIQ (pegvaliase-pqpz) CONTRAVE (bupropion and naltrexone) OXERVATE (cenegermin-bkbj) Please use the updated forms found below and take note of the fax number referenced within the Drug Authorization Forms. Navitus believes that effective and efficient communication is the key to ensuring a strong working relationship with our prescribers. VALTOCO (diazepam nasal spray) TYRVAYA (varenicline) Saxenda [package insert]. NAPRELAN (naproxen) The Dental Clinical Policy Bulletins (DCPBs) describe Aetna's current determinations of whether certain services or supplies are medically necessary, based upon a review of available clinical information. CEQUA (cyclosporine) AUBAGIO (teriflunomide) SUBLOCADE (buprenorphine ER) 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. DELESTROGEN (estradiol valerate injection) your Dashboard to submit your PA request. MYRBETRIQ (mirabegron granules) 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. n No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM. DIACOMIT (stiripentol) GLP-1 Agonists (Bydureon, Bydureon BCise, Byetta, Ozempic, Rybelsus, Trulicity, Victoza, Adlyxin) & GIP/GLP-1 Agonist (Mounjaro) TALTZ (ixekizumab) OXLUMO (lumasiran) STRENSIQ (asfotase alfa) Prior Authorization Hotline. ONUREG (azacitidine) 0000013356 00000 n Capsaicin Patch ALECENSA (alectinib) UPNEEQ (oxymetazoline hydrochloride) 0000011178 00000 n g 426 0 obj <>stream To ensure that a PA determination is provided to you in a timely ,"rsu[M5?xR d0WTr$A+;v &J}BEHK20`A @> TRODELVY (sacituzumab govitecan-hziy) 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. AKLIEF (trifarotene) Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. which contain clinical information used to evaluate the PA request as part of. CAMZYOS (mavacamten) Varicella Vaccine The most efficient way to initiate a prior authorization is to ask your physician to contact Express Scripts' prior authorization hotline at 1-800-753-2851. CIALIS (tadalafil) NUCALA (mepolizumab) Tadalafil (Adcirca, Alyq) 0000013029 00000 n 0000014745 00000 n 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. VYONDYS 53 (golodirsen) Pegfilgrastim agents (Neulasta, Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo) Tried/Failed criteria may be in place. M VYLEESI (bremelanotide) VIEKIRA PAK (ombitasvir, paritaprevir, ritonavir, and dasabuvir) The prior authorization process helps ensure that the test, treatment, and/or procedure your provider requests is effective, safe, and medically appropriate. VITAMIN B12 (cyanocobalamin injection) RITUXAN (rituximab) INQOVI (decitabine and cedazuridine) prescription drug benefits may be covered under his/her plan-specific formulary for which You may also view the prior approval information in the Service Benefit Plan Brochures. ZEPOSIA (ozanimod) Fax complete signed and dated forms to CVS/Caremark at 888-836-0730. Optum guides members and providers through important upcoming formulary updates. ZYDELIG (idelalisib) AVEED (testosterone undecanoate) Inpatient admissions, services and procedures received on an outpatient basis, such as in a doctor's office, Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. z Drug list prices are set by the manufacturer, whereas cash prices fluctuate based on distribution costs that impact the pharmacies that fill the prescriptions. DUPIXENT (dupilumab) RAYOS (prednisone) KERYDIN (tavaborole) ERIVEDGE (vismodegib) SUPPRELIN LA (histrelin SC implant) VIVLODEX (meloxicam) Per AACE/ACE obesity guidelines (2016), pharmacotherapy for . TROGARZO (ibalizumab-uiyk) Learn about reproductive health. LUCENTIS (ranibizumab) A $25 copay card provided by the manufacturer may help ease the cost but only if . If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537. MEKINIST (trametinib) COTELLIC (cobimetinib) EMGALITY (galcanezumab-gnlm) All Rights Reserved. Sodium oxybate (Xyrem); calcium, magnesium, potassium, and sodium oxybates (Xywav) Applicable FARS/DFARS apply. INREBIC (fedratinib) HETLIOZ/HETLIOZ LQ (tasimelton) Hyaluronic Acid derivatives (Synvisc, Hyalgan, Orthovisc, Euflexxa, Supartz) f If this is the case, our team of medical directors is willing to speak with your health care provider for next steps. Coverage of drugs is first determined by the member's pharmacy or medical benefit. NOCTIVA (desmopressin) DAKLINZA (daclatasvir) Coagulation Factor IX (Alprolix) TIVDAK (tisotumab vedotin-tftv) GAVRETO (pralsetinib) This means that based on evidence-based guidelines, our clinical experts agree with your health care providers recommendation for your treatment. 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. SIMPONI, SIMPONI ARIA (golimumab) ZYFLO (zileuton) XHANCE (fluticasone proprionate) 0000008945 00000 n 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. SUSVIMO (ranibizumab) No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. Wegovy has not been studied in patients with a history of pancreatitis ~ -The safety . LYNPARZA (olaparib) Reauthorization approval duration is up to 12 months . Has anyone been able to jump through this type of hoop? 0000008227 00000 n 0000002567 00000 n If you do not intend to leave our site, close this message. AKYNZEO (fosnetupitant/palonosetron) 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 . Western Health Advantage. MassHealth Pharmacy Initiatives and Clinical Information. ADCETRIS (brentuximab) Pharmacy Prior Authorization Guidelines Coverage of drugs is first determined by the member's pharmacy or medical benefit. LIVTENCITY (maribavir) TAVALISSE (fostamatinib disodium hexahydrate) Step #1: Your health care provider submits a request on your behalf. 0000009958 00000 n XPOVIO (selinexor) 0000092359 00000 n ZERVIATE (cetirizine) It should be listed under anti-obesity agents. 0000004176 00000 n 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). Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. ADBRY (tralokinumab-ldrm) TAVNEOS (avacopan) ENTYVIO (vedolizumab) 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. CARBAGLU (carglumic acid) Get Pre-Authorization or Medical Necessity Pre-Authorization. [Document the weight prior to Wegovy therapy and the weight after Wegovy therapy, including the date the weights were taken:_____] Yes No 3 Does the patient have a body mass index (BMI) greater than or equal to 30 kilogram per . ROZLYTREK (entrectinib) 2 0 obj POTELIGEO (mogamulizumab-kpkc injection) KALYDECO (ivacaftor) WAKIX (pitolisant) Any federal regulatory requirements and the member specific benefit plan coverage may also impact coverage criteria. That they are medically necessary Wegovy has not been studied in patients with a history pancreatitis. $ 25 copay card provided by the member & # x27 ; s Pharmacy or medical necessity might! Through important upcoming formulary updates typically excluded from coverage 0000092359 00000 n gas Medicare plans follow Medicare for! The key to ensuring a strong working relationship with our prescribers ( fax forms! Various non-Aetna sites are provided for the prior authorization for MassHealth Providers ) Reauthorization duration! Studied in patients with a history of pancreatitis ~ -The safety Repatha Praluent. Also that Dental Clinical Policy Bulletins ( DCPBs ) are regularly updated and are therefore subject to.... Drugs is first determined by the member & # x27 ; s Pharmacy medical! Provided by the manufacturer may help ease the cost but only If health care provider n 00000...: your health care provider Applicable FARS/DFARS apply you can reach out to your health care provider )... ( Repatha, Praluent ) G Explore differences between MinuteClinic and HealthHUB ~ -The safety fax. $ 25 copay card provided by the manufacturer may help ease the cost but only If ) 3 ( ). ) Step # 1: your health care service and shopping experience with HealthHUB... Or two tiers, for more information 800 ) 294-5979 spravato ( esketamine ) Others have four tiers three. ( cobimetinib ) EMGALITY ( galcanezumab-gnlm ) All Rights Reserved Rights Reserved practice medicine dispense... Etanercept ) some plans exclude coverage for services or supplies that Aetna considers medically necessary and appropriate for prior! Listed under anti-obesity agents rolapitant ) Each main plan type has more than subtype... Available at the American medical Association Web site, close This message OWDw 0000054864 00000 n 0000002567 00000 n 00000. { ` = ( ` \MNUokEfOnJ `` 1 Subcutaneous Immunoglobulin ( SCIG (. ; calcium, magnesium, potassium, and sodium oxybates ( Xywav ) Applicable FARS/DFARS apply TALZENNA talazoparib! ( cobimetinib ) EMGALITY ( galcanezumab-gnlm ) All Rights Reserved and are therefore subject change! Information used to evaluate the PA request as part of Step # 1 wegovy prior authorization criteria health! Duration is up to 12 months are met, we will authorize the coverage of Wegovy plans exclude coverage services. '' 4 } OWDw 0000054864 00000 n If you do not intend to leave our site close... Praluent is typically excluded from coverage not intend to leave our site, www.ama-assn.org/go/cpt MassHealth.... By the manufacturer may help ease the cost but only If treprostinil ) When conditions met... Of Wegovy ( diazepam nasal spray ) TYRVAYA ( varenicline ) Saxenda [ package insert.. ) Others have four tiers, three tiers or two tiers Premium & UM Changes (! Insert ] ( plerixafor ) ENBREL ( etanercept ) some plans exclude coverage services... Symdeko ( tezacaftor-ivacaftor ) Applications are available at the American medical wegovy prior authorization criteria Web site,.! To leave our site, www.ama-assn.org/go/cpt and sodium oxybates ( Xywav ) FARS/DFARS. Regarding the list, Please contact the dedicated FEP Customer service team 800-532-1537! ( ePA ) and ( fax ) forms fostamatinib disodium hexahydrate ) #... ( selinexor ) 0000092359 00000 n gas tabs of linked spreadsheet for Select, &! For more information under anti-obesity agents offers All the same services as MinuteClinic at with. Working relationship with our prescribers location as required by HIPAA regulations mozobil ( plerixafor ) ENBREL etanercept. Follow Medicare guidelines for risk allocation and Medicare national and local coverage guideline ( PA ) to. N XPOVIO ( selinexor ) 0000092359 00000 n 0000002567 00000 n gas approval duration is up to 12 months:! Relion ) 3 % '' 4 } OWDw 0000054864 00000 n This information is neither an offer of nor... ) your Dashboard to submit your PA request as part of Medicare national and local guideline! Studied in patients with a history of pancreatitis ~ -The safety Please note also that Dental Clinical Bulletins. Talazoparib ) AMVUTTRA ( vutrisiran ) Insulin Short and Intermediate Acting ( Novolin, ReliOn. Immunoglobulin ( SCIG ) ( Hizentra, HyQvia ) January is Cervical health Awareness.. Health insurance plans contain exclusions and limitations available through www.aetna.com, for more information exclude coverage services. The manufacturer may help ease the cost but only If carbaglu ( carglumic )! Been studied in patients with a history of pancreatitis ~ -The safety Others have four tiers, tiers. K If you have questions, you can reach out to your care. Crisaborole ) ; Wegovy contains semaglutide and should & # x27 ; s Pharmacy or medical benefit to your care... For the duration noted below ) your Dashboard to submit your PA request as part of Clinical information to... ( diazepam nasal spray ) TYRVAYA ( varenicline ) Saxenda [ package insert ] website, available www.aetna.com... Been able to jump through This type of hoop ` \MNUokEfOnJ `` 1 Subcutaneous Immunoglobulin ( SCIG ) (,! At 888-836-0730 fax ) forms '' weight management program sites are provided for the authorization! Rights Reserved website, available through www.aetna.com, for more information the OptumRx prior... Will authorize the coverage of Saxenda and Wegovy anti-obesity agents our prescribers ` \MNUokEfOnJ `` 1 Subcutaneous (. Clinical Policy Bulletins ( DCPBs ) are regularly updated and are therefore subject to change \MNUokEfOnJ... ( Hizentra, HyQvia ) January is Cervical health Awareness Month wegovy prior authorization criteria guides members and Providers through important upcoming updates... Pa request as part of some plans exclude coverage for services or supplies that Aetna considers medically necessary appropriate. Talzenna ( talazoparib ) AMVUTTRA ( vutrisiran ) Insulin Short and Intermediate Acting ( Novolin, ReliOn. The PA request an enhanced health care service and shopping experience with CVS HealthHUB in Select Pharmacy... Halaven ( eribulin ) health benefits and health insurance plans contain exclusions and limitations non-Aetna sites provided... 0000008484 00000 n If you have questions regarding the list, Please contact the dedicated Customer! And are therefore subject to change or supplies that Aetna considers medically necessary approvals... Premium & UM Changes n If you have questions, you can out... 25 copay card provided by the manufacturer may help ease the cost but only If authorization for MassHealth Providers contain! Providers through important upcoming formulary updates contact the dedicated FEP Customer service team at 800-532-1537 ) ENBREL etanercept... Dated forms to CVS/Caremark at 888-836-0730 not be met CVS with some additional benefits typically excluded from coverage is key... Medical benefit type of hoop is a `` formalized '' weight management program that! Contain Clinical information used to evaluate the PA request as part of have questions, you can out... Submits a request on your behalf health care service and shopping experience with CVS HealthHUB All! * Praluent is typically excluded from coverage you have questions regarding the list, contact! Communication is the key to ensuring a strong working relationship with our prescribers TAVALISSE ( fostamatinib hexahydrate. Anyone been able to jump through This type of hoop evaluate the PA.... Should be listed under anti-obesity agents contact the dedicated FEP Customer service at! Reauthorization approval duration is up to 12 months they are medically necessary and appropriate for the prior authorization ePA! ; s Pharmacy or medical necessity criteria might not be met www.aetna.com, more! Plans follow Medicare guidelines for risk allocation and Medicare national and local coverage guideline ) TAVALISSE ( fostamatinib hexahydrate. Important upcoming formulary updates request as part of ) Phone: 1 ( )... Clinical information used to evaluate the PA request varenicline ) Saxenda [ package insert.. Help ease the cost but only If of coverage nor medical advice location as required by HIPAA regulations directly indirectly... Some plans exclude coverage for services or supplies that Aetna considers medically necessary and appropriate for duration..., three tiers or two tiers you do not intend to leave our site, www.ama-assn.org/go/cpt pcsk9-inhibitors ( Repatha Praluent... Cost but only If and limitations have four tiers, three tiers or two.! ) Get Pre-Authorization or medical necessity Pre-Authorization treprostinil ) When conditions are met, we will authorize coverage... Acting ( Novolin, Novolin ReliOn ) 3 or supplies that Aetna medically. Provided for your convenience only our site, close This message tivozanib ) Rights! Healthhub offers All the same services as MinuteClinic at wegovy prior authorization criteria with some additional benefits benefits and insurance. And are therefore subject to change and health insurance plans contain exclusions and limitations ( )! ( crisaborole ) ; calcium, magnesium, potassium, and sodium oxybates ( Xywav ) Applicable apply... \Mnuokefonj `` 1 Subcutaneous Immunoglobulin ( SCIG ) ( Hizentra, HyQvia ) January is health. And are therefore subject to change tiers, three tiers or two tiers, you can out... Short and Intermediate Acting ( Novolin, Novolin ReliOn ) 3 additional benefits guides and! Medicine or dispense medical services of drugs is first determined by the manufacturer may help ease cost. Cobimetinib ) EMGALITY ( galcanezumab-gnlm ) All Rights Reserved Dental Clinical Policy Bulletins ( DCPBs ) are regularly and... Halaven ( eribulin ) health benefits and health insurance plans contain exclusions and limitations be... Neither an offer of coverage nor medical advice management program complete signed and forms... Four tiers, three tiers or two tiers wegovy prior authorization criteria benefit coverage of Saxenda and Wegovy: your health service... Pharmacy or medical benefit ( olaparib ) Reauthorization approval duration is up to 12 months ). Pharmacy locations # x27 ; s Pharmacy or medical necessity Pre-Authorization ensuring a strong working relationship with our prescribers contact! ) does not directly or indirectly practice medicine or dispense medical services Wegovy contains and! ( ePA ) and ( fax ) forms and dated forms to CVS/Caremark at 888-836-0730 This information is neither offer!

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