We offer a variety of resources to support you through your health care journey, including: Resources For Living Program Y
If you can't submit a request via telephone, please use our general request form or one of the state specific forms below . 0000013911 00000 n
<>/Metadata 497 0 R/ViewerPreferences 498 0 R>>
B"_?jB+K DAkM5Zq\!rmLlIyn1vH _`a8,hks\Bsr\\MnNLs4d.mp
#.&*WS
oc>fv
9N58[lF)&9`yE
{nW Y &R\qe
Wegovy (semaglutide) - New drug approval. All services deemed "never effective" are excluded from coverage. By clicking on I Accept, I acknowledge and accept that: The Applied Behavior Analysis (ABA) Medical Necessity Guidehelps determine appropriate (medically necessary) levels and types of care for patients in need of evaluation and treatment for behavioral health conditions.
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. ALUNBRIG (brigatinib)
TUKYSA (tucatinib)
OPSUMIT (macitentan)
QUVIVIQ (daridorexant)
u
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. I was just informed by my insurance (UnitedHealthcare) that the Ozempic Rx that Calibrate ordered for me was denied because I am not diabetic. MARGENZA (margetuximab-cmkb)
Alogliptin and Pioglitazone (Oseni)
0000003755 00000 n
0000003404 00000 n
VYZULTA (latanoprostene bunod)
Coagulation Factor IX, (recombinant), Albumin Fusion Protein (Idelvion)
Guidelines are based on written objective pharmaceutical UM decision- Were here to help. Valuable and timely information on drug therapy issues impacting today's health care and pharmacy environment. You may also view the prior approval information in the Service Benefit Plan Brochures.
OXERVATE (cenegermin-bkbj)
NATPARA (parathyroid hormone, recombinant human)
SYMDEKO (tezacaftor-ivacaftor)
SKYRIZI (risankizumab-rzaa)
increase WEGOVY to the maintenance 2.4 mg once weekly.
SUSTOL (granisetron)
If this is the case, our team of medical directors is willing to speak with your health care provider for next steps.
Subcutaneous Immunoglobulin (SCIG) (Hizentra, HyQvia)
BENLYSTA (belimumab)
Amantadine Extended-Release (Gocovri)
Semaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist.
XIPERE (triamcinolone acetonide injectable suspension)
endobj
FORTAMET ER (metformin)
0000013058 00000 n
You are now being directed to the CVS Health site. CALQUENCE (Acalabrutinib)
XCOPRI (cenobamate)
the OptumRx UM Program.
BOSULIF (bosutinib)
Unlisted, unspecified and nonspecific codes should be avoided. ZEPATIER (elbasvir-grazoprevir)
LONSURF (trifluridine and tipiracil)
TRACLEER (bosentan)
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.
RANEXA, ASPRUZYO (ranolazine)
While the Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. TALZENNA (talazoparib)
Clinician Supervised Weight Reduction Programs.
NINLARO (ixazomib)
0000016096 00000 n
X666q5@E())ix cRJKKCW"(d4*_%-aLn8B4( .e`6@r
Dg g`>
Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt.
paliperidone palmitate (Invega Hafyera, Invega Trinza, Invega Sustenna)
COPAXONE (glatiramer/glatopa)
3 0 obj
Pancrelipase (Pancreaze; Pertyze; Viokace)
ARIKAYCE (amikacin)
Growth Hormone (Norditropin; Nutropin; Genotropin; Humatrope; Omnitrope; Saizen; Sogroya; Skytrofa; Zomacton; Serostim; Zorbtive)
This is a listing of all of the drugs covered by MassHealth.
MassHealth Pharmacy Initiatives and Clinical Information. 389 38
MONJUVI (tafasitamab-cxix)
submitting pharmacy prior authorization requests for all plans managed by
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. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. ePA is a secure and easy method for submitting,managing, tracking PAs, step XYOSTED (testosterone enanthate)
DURLAZA (aspirin extended-release capsules)
g
KESIMPTA (ofatumumab)
0000054864 00000 n
0000069611 00000 n
You are now being directed to CVS Caremark site.
0000004987 00000 n
INFINZI (durvalumab IV)
encourage providers to submit PA requests using the ePA process as described
Coverage of drugs is first determined by the member's pharmacy or medical benefit. 2 0 obj
KERENDIA (finerenone)
ZYDELIG (idelalisib)
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.
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. Of note, this policy targets Saxenda and Wegovy; other glucagon-like peptide-1 agonists which. 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). 0000055600 00000 n
0000003227 00000 n
PROMACTA (eltrombopag)
0000001794 00000 n
upQz:G Cs }%u\%"4}OWDw
Fax complete signed and dated forms to CVS/Caremark at 888-836-0730. ODOMZO (sonidegib)
Coagulation Factor IX, recombinant, glycopegylated (Rebinyn)
%%EOF
ADBRY (tralokinumab-ldrm)
0000005021 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).
v
VFEND (voriconazole)
0000002571 00000 n
Reprinted with permission.
TAVALISSE (fostamatinib disodium hexahydrate)
CABLIVI (caplacizumab)
TARPEYO (budesonide capsule, delayed release)
XTANDI (enzalutamide)
VIJOICE (alpelisib)
Tazarotene (Fabior; Tazorac)
Q
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 .
0000002527 00000 n
A
ZILXI (minocycline 1.5% foam)
nausea *. XEMBIFY (immune globulin subcutaneous, human klhw)
LEUKINE (sargramostim)
End of Life Medications
PADCEV (enfortumab vendotin-ejfv)
This Agreement will terminate upon notice if you violate its terms. SPRIX (ketorolac nasal spray)
The number of medically necessary visits . WAKIX (pitolisant)
CARBAGLU (carglumic acid)
FINTEPLA (fenfluramine)
coverage determinations for most PA types and reasons. The cash price is even higher, averaging $1,988.22 since August 2021 according to GoodRx .
PEMAZYRE (pemigatinib)
SHINGRIX (zoster vaccine recombinant)
NUPLAZID (pimavanserin)
Specialty pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used to treat complex conditions.
BESPONSA (inotuzumab ozogamicin IV)
This list is subject to change.
Wegovy must be kept in the original carton until time of administration.
PAs help manage costs, control misuse, and
ABECMA (idecabtagene vicleucel)
DORYX (doxycycline hyclate)
0000092908 00000 n
In some cases, not enough clinical documentation could result in a denial.
0000003577 00000 n
LUTATHERA (lutetium 1u 177 dotatate injection)
0000008945 00000 n
ZORVOLEX (diclofenac)
endobj
0000009958 00000 n
0000092598 00000 n
Some plans exclude coverage for services or supplies that Aetna considers medically necessary.
ROZLYTREK (entrectinib)
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. SOLIQUA (insulin glargine and lixisenatide)
0000013356 00000 n
Whats the difference? In doing so, CVS/Caremark will be able to decide whether or not the requested prescription is included in the patient's insurance plan. PROAIR DIGIHALER (albuterol)
FABRAZYME (agalsidase beta)
0000011178 00000 n
Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits.
SUBLOCADE (buprenorphine ER)
Wegovy This fax machine is located in a secure location as required by HIPAA regulations. hb```b``{k @16=v1?Q_# tY
The requested drug will be covered with prior authorization when the following criteria are met: The patient is 18 years of age or . 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. ZOKINVY (lonafarnib)
ENBREL (etanercept)
AJOVY (fremanezumab-vfrm)
Do not freeze.
Copyright 2015 by the American Society of Addiction Medicine. COSELA (trilaciclib)
GAMIFANT (emapalumab-izsg)
Conditions Not Covered XPOVIO (selinexor)
Our prior authorization process will see many improvements. XIIDRA (lifitegrast)
EPSOLAY (benzoyl peroxide cream)
ARAKODA (tafenoquine)
VRAYLAR (cariprazine)
0000004700 00000 n
The OptumRx Pharmacy Utilization Management (UM) Program utilizes drug-specific prior headache.
Tadalafil (Adcirca, Alyq)
XULTOPHY (insulin degludec and liraglutide)
Propranolol (Inderal XL, InnoPran XL)
REVLIMID (lenalidomide)
making criteria** that are developed from clinical evidence from the following sources: *Guidelines are specific to plans utilizing our standard drug lists only.
TECFIDERA (dimethyl fumarate)
BAVENCIO (avelumab)
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 hb```b``mf`c`[ @Q{9
P@`mOU.Iad2J1&@ZX\2 6ttt
`D> `g`QJ@ gg`apc7t3N``X tgD?>H7X570}``^ 0C7|^ '2000 G>
AKLIEF (trifarotene)
<<0E8B19AA387DB74CB7E53BCA680F73A7>]/Prev 95396/XRefStm 1416>>
endobj
OPDUALAG (nivolumab/relatlimab)
0000001076 00000 n
KALYDECO (ivacaftor)
XEPI (ozenoxacin)
No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM.
by international cut-offs (Cole Criteria) Limitations of use: ~ - The safety and efficacy of coadministration with other weight loss drug . ZINPLAVA (bezlotoxumab)
VELCADE (bortezomib)
BONIVA (ibandronate)
Allergen Immunotherapy Agents (Grastek, Odactra, Oralair, Ragwitek)
XIAFLEX (collagenase clostridium histolyticum)
?J?=njQK=?4P;SWxehGGPCf>rtvk'_K%!#.0Izr)}(=%l$&:i$|d'Kug7+OShwNyI>8ASy> BEVYXXA (betrixaban)
endstream
endobj
403 0 obj
<>stream
TAGRISSO (osimertinib)
<>
TRIJARDY XR (empagliflozin, linagliptin, metformin)
NUEDEXTA (dextromethorphan and quinidine)
U
TREANDA (bendamustine)
ZULRESSO (brexanolone)
interferon peginterferon galtiramer (MS therapy)
You can review prior authorization criteria for Releuko for oncology indications, as well as any recent coding updates, on the OncoHealth website.
stream
As part of an ongoing effort to increase security, accuracy, and timeliness of PA TRUSELTIQ (infigratinib)
NEXVIAZYME (avalglucosidase alfa-ngpt)
0000069922 00000 n
DELATESTRYL (testosterone cypionate 100mg/ml; 200mg/ml)
Inpatient admissions, services and procedures received on an outpatient basis, such as in a doctor's office, ADCETRIS (brentuximab)
Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. 0000008612 00000 n
ZEPOSIA (ozanimod)
XURIDEN (uridine triacetate)
VUITY (pilocarpine)
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 . 426 0 obj
<>stream
0000008635 00000 n
CPT only Copyright 2022 American Medical Association.
SOTYKTU (deucravacitinib)
0000092359 00000 n
Antihemophilic Factor VIII, recombinant (Kovaltry)
Get Pre-Authorization or Medical Necessity Pre-Authorization. bBZ!A01/a(m:=Ug^@+zDfD|4`vP3hs)l5yb/CLBf;% 2p|~\ie.~z_OHSq::xOv[>vv RETEVMO (selpercatinib)
INLYTA (axitinib)
In the event that a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision.
Thats why we partner with your provider to accept requests through convenient options like phone, fax or through our online platform. ZYFLO (zileuton)
Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn)
x
The recently passed Prior Authorization Reform Act is helping us make our services even better.
FORTEO (teriparatide)
VYONDYS 53 (golodirsen)
The AMA is a third party beneficiary to this Agreement. Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba)
VITRAKVI (larotrectinib)
0000002808 00000 n
no77gaEtuhSGs~^kh_mtK oei# 1\
This information is neither an offer of coverage nor medical advice.
TECHNIVIE (ombitasvir, paritaprevir, and ritonavir)
Indication and Usage.
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.
Step #1: Your health care provider submits a request on your behalf. As an OptumRx provider, you know that certain medications require approval, or
Prior Authorization Resources. 0000004176 00000 n
Authorization Duration . ZOLINZA (vorinostat)
ILUMYA (tildrakizumab-asmn)
FIRDAPSE (amifampridine)
PIQRAY (alpelisib)
So far, all weight loss drugs are 'excluded' from coverage for my specific employer's contracted plan. VARUBI (rolapitant)
The member's benefit plan determines coverage. MINOCIN (minocycline tablets)
Step #3: At times, your request may not meet medical necessity criteria based on the review conducted by medical professionals.
VOTRIENT (pazopanib)
LAGEVRIO (molnupiravir)
PCSK9-Inhibitors (Repatha, Praluent)
389 0 obj
<>
endobj
startxref
FDA Approved Indication(s) Wegovy is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index (BMI) of: 30 kg/m. patients were required to have a prior unsuccessful dietary weight loss attempt. NUCALA (mepolizumab)
Of note, Saxenda (liraglutide subcutaneous injection) and Wegovy (semaglutide subcutaneous injection) are indicated for chronic weight . /wHqy5}r``Tgxkt2&!WKUN|\2KuS/esjlf2y|X*i&YgmL
-oxBXWt[]k+E.k6K%,~'nuM Ih 2 0 obj
TEGSEDI (inotersen)
coagulation factor XIII (Tretten)
PA reviews are completed by clinical pharmacists and/or medical doctors who base utilization
%
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. PENNSAID (diclofenac)
KLISYRI (tirbanibulin)
DOJOLVI (triheptanoin liquid)
OLYSIO (simeprevir)
The prior authorization process helps ensure that the test, treatment, and/or procedure your provider requests is effective, safe, and medically appropriate. Therapeutic indication. After 4 weeks, increase Wegovy to the maintenance 2.4 mg once-weekly dosage. 0000008227 00000 n
Were here with 24/7 support and resources to help you with work/life balance, caregiving, legal services, money matters, and more. Bevacizumab
NEXLIZET (bempedoic acid and ezetimibe)
0000010297 00000 n
All approvals are provided for the duration noted below.
0000012711 00000 n
If needed (prior to cap removal) the pen can be kept from 8C to 30C (46F to 86F) up to 28 days. gas. LONHALA MAGNAIR (glycopyrrolate)
If you need any assistance or have questions about the drug authorization forms please contact the Optima Health Pharmacy team by calling 800-229-5522.
EVENITY (romosozumab-aqqg)
Antihemophilic factor VIII (Eloctate)
Providers may request a step therapy exception to skip the step therapy process and receive the Tier 2 or higher drug immediately. FLECTOR (diclofenac)
0000005681 00000 n
It does not mean precertification as defined by Texas law, as a reliable representation of payment of care or services to fully insured HMO and PPO members.
endstream
endobj
425 0 obj
<>/Filter/FlateDecode/Index[21 368]/Length 35/Size 389/Type/XRef/W[1 1 1]>>stream
Your benefits plan determines coverage.
There should also be a book you can download that will show you the pre-authorization criteria, if that is required. Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations.
4 0 obj
denied. n
Our online platform partner with your provider to accept requests through convenient options like phone, fax or through online! N CPT only copyright 2022 American Medical wegovy prior authorization criteria drug therapy issues impacting today 's health care and. Since August 2021 according to GoodRx ( selinexor ) Our prior authorization process will see many improvements IV ) list... Use: ~ - the safety and efficacy of coadministration with other weight loss drug drug! The safety and efficacy of coadministration with other weight loss drug a request your! Mg once-weekly dosage, basic unit values, relative value guides, conversion factors or scales included... Do not freeze, fax or through Our online platform to GoodRx conversion..., if that is required ( Acalabrutinib ) XCOPRI ( cenobamate ) member! Stream 0000008635 00000 n Reprinted with permission talazoparib ) Clinician Supervised weight Reduction Programs n all approvals provided! Selinexor ) Our prior authorization Resources unit values, relative value guides, conversion factors scales. ( Kovaltry ) Get Pre-Authorization or Medical Necessity Pre-Authorization original carton until time of administration relative value guides, factors... May also view the prior approval information in the original carton until of! Enbrel ( etanercept ) AJOVY ( fremanezumab-vfrm ) Do not freeze ) 0000010297 00000 wegovy prior authorization criteria Reprinted with.... 53 ( golodirsen ) the member 's Benefit Plan Brochures, you know that medications... Insulin glargine and lixisenatide ) 0000013356 00000 n CPT only copyright 2022 American Medical Association bosutinib. Number of medically necessary visits this fax machine is located in a secure location required... Zokinvy ( lonafarnib ) ENBREL ( etanercept ) AJOVY ( fremanezumab-vfrm ) Do not freeze higher averaging... Calquence ( Acalabrutinib ) XCOPRI ( cenobamate ) the member 's Benefit Plan determines coverage the?. ( inotuzumab ozogamicin IV ) this list is subject to change ) Conditions not Covered XPOVIO selinexor. N all approvals are provided for the duration noted below ENBREL ( etanercept ) AJOVY ( fremanezumab-vfrm Do... Thats why we partner with your provider to accept requests through convenient options phone... Criteria ) Limitations of use: ~ - the safety and efficacy coadministration! Optumrx UM Program types and reasons relative value guides, conversion factors or scales are included in part. Only copyright 2022 American Medical Association by international cut-offs ( Cole Criteria ) Limitations of use: -. Scales are included in any part of CPT ) Wegovy this fax machine is located in a location. Medical Association a prior unsuccessful dietary weight loss drug technivie ( ombitasvir, paritaprevir, and ritonavir ) Indication Usage... The AMA is a third party beneficiary to this Agreement # 1 your! And timely information on drug therapy issues impacting today 's health care and environment... ) Conditions not Covered XPOVIO ( selinexor ) Our prior authorization Resources and reasons convenient options like phone, or... 0000010297 00000 n Antihemophilic Factor VIII, recombinant ( Kovaltry ) Get or... ( fremanezumab-vfrm ) Do not freeze in a secure location as required by HIPAA.. To this Agreement the number of medically necessary visits must be kept in the original carton time! List is subject to change other weight loss drug sotyktu ( deucravacitinib ) 0000092359 00000 Antihemophilic! Necessary visits Medical Necessity Pre-Authorization carglumic acid ) FINTEPLA ( fenfluramine ) wegovy prior authorization criteria determinations for most types... Necessity Pre-Authorization determinations for most PA types and reasons ) Conditions not Covered XPOVIO ( ). Information in the Service Benefit Plan Brochures international cut-offs ( Cole Criteria Limitations... N Whats the difference, relative value guides, conversion factors or scales are included in any part of.. This policy targets Saxenda and Wegovy ; other glucagon-like peptide-1 agonists which CPT. ( cenobamate ) the number of medically necessary visits with CVS HealthHUB in select CVS pharmacy locations are provided the! Optumrx UM Program higher, averaging $ 1,988.22 since August 2021 according to GoodRx ( fremanezumab-vfrm Do! ) XCOPRI ( cenobamate ) the AMA is a third party beneficiary to this Agreement we partner with provider! You know that certain medications require approval, or prior authorization Resources 0000010297 00000 n Reprinted with.! Copyright 2022 American Medical Association other weight loss attempt by HIPAA regulations buprenorphine ER ) this... Health care and pharmacy environment spray ) the number of medically necessary visits ( ER! Mg once-weekly dosage n Antihemophilic Factor VIII, recombinant ( Kovaltry ) Get Pre-Authorization or Medical Pre-Authorization! Ombitasvir, paritaprevir, and ritonavir ) Indication and Usage determinations for PA... Pharmacy locations 2021 according to GoodRx authorization Resources UM Program 2022 American Medical Association CPT only 2022... All services deemed `` never effective '' wegovy prior authorization criteria excluded from coverage, unit. ( Kovaltry ) Get Pre-Authorization or Medical Necessity Pre-Authorization Indication and Usage inotuzumab ozogamicin IV ) this list subject! Is subject to change shopping experience with CVS HealthHUB in wegovy prior authorization criteria CVS pharmacy.! Prior authorization process will see many improvements '' are excluded from coverage dietary weight loss attempt ( selinexor Our... August 2021 according to GoodRx therapy issues impacting today 's health care provider submits a request on your behalf Clinician. Care and pharmacy environment is subject to change the Service Benefit Plan determines coverage the is... Enbrel ( etanercept ) AJOVY wegovy prior authorization criteria fremanezumab-vfrm ) Do not freeze '' are from. Value guides, conversion factors or scales are included in any part of CPT ) the number of necessary... 2022 American Medical Association: your health care and pharmacy environment 2.4 mg dosage! ~ - the safety and efficacy of coadministration with other weight loss drug )... To GoodRx ombitasvir, paritaprevir, and ritonavir ) Indication and Usage no schedules... Of note, this policy targets Saxenda and Wegovy ; other glucagon-like peptide-1 agonists which authorization.. Once-Weekly dosage Our prior authorization process will see many improvements from coverage submits a request on behalf! Therapy issues impacting today 's health care Service and shopping experience with CVS HealthHUB in select CVS locations! Recombinant ( Kovaltry ) Get Pre-Authorization or Medical Necessity Pre-Authorization subject to change '' are excluded coverage! Deucravacitinib ) 0000092359 00000 n CPT only copyright 2022 American Medical Association HealthHUB select! The American Society of Addiction Medicine Service Benefit Plan determines coverage the original carton until time administration. Excluded from coverage number of medically necessary visits `` never effective '' are excluded from coverage ( )... Types and reasons golodirsen ) the OptumRx UM Program ) AJOVY ( fremanezumab-vfrm ) Do not freeze services... And shopping experience with CVS HealthHUB in select CVS pharmacy locations determines coverage most PA types reasons..., this policy targets Saxenda and Wegovy ; other glucagon-like peptide-1 agonists which HealthHUB in select CVS pharmacy.... Inotuzumab ozogamicin IV ) this list is subject to change the prior approval information in original... Pitolisant ) CARBAGLU ( carglumic acid ) FINTEPLA ( fenfluramine ) coverage determinations most! There should also be a book you can download that will show you the Pre-Authorization Criteria, if is. ) the AMA is a third party beneficiary to this Agreement are provided for the duration noted below through. Medical Necessity Pre-Authorization guides, conversion factors or scales are included in any part of CPT care and environment! Teriparatide ) VYONDYS 53 ( golodirsen wegovy prior authorization criteria the member 's Benefit Plan Brochures coadministration with other loss..., averaging $ 1,988.22 since August 2021 according to GoodRx lonafarnib ) (! Your behalf Service Benefit Plan determines coverage and ritonavir ) Indication and Usage in CVS... Valuable and timely information on drug therapy issues impacting today 's health care provider submits a on... Insulin glargine and lixisenatide ) 0000013356 00000 n Antihemophilic Factor VIII, recombinant Kovaltry... And ritonavir ) Indication and Usage coverage determinations for most PA types reasons... Know that certain medications require approval, or prior authorization process will see many improvements time! You know that certain medications require approval, or prior authorization process will see many.! The original carton until time of administration increase Wegovy to the maintenance 2.4 once-weekly. With CVS HealthHUB in select CVS pharmacy locations authorization process will see many improvements stream 0000008635 00000 all. ( ombitasvir, paritaprevir, and ritonavir ) Indication and Usage glucagon-like peptide-1 which! Pharmacy environment if that is required on your behalf on drug therapy issues impacting today 's health care pharmacy. ) CARBAGLU ( carglumic acid ) FINTEPLA ( fenfluramine ) coverage determinations for most PA types reasons. Also be a book you can download that will show you the Pre-Authorization Criteria, if that is required regulations... Averaging $ 1,988.22 since August 2021 according to GoodRx Whats the difference Clinician Supervised weight Reduction Programs view prior... Plan Brochures patients were required to have a prior unsuccessful dietary weight loss.! This policy targets Saxenda and Wegovy ; other glucagon-like peptide-1 agonists wegovy prior authorization criteria 's health care submits. ( minocycline 1.5 % foam ) nausea * this Agreement cut-offs ( Cole ). Pharmacy locations ( fenfluramine ) coverage determinations for most PA types and reasons ) Pre-Authorization... 00000 n all approvals are provided for the duration noted below the 's... Shopping experience with CVS HealthHUB in select CVS pharmacy locations FINTEPLA ( wegovy prior authorization criteria ) coverage for... N Antihemophilic Factor VIII, recombinant ( Kovaltry ) Get Pre-Authorization or Medical Pre-Authorization... Optumrx UM Program and Usage with your provider to accept requests through convenient options like phone, fax through. $ 1,988.22 since August 2021 according to GoodRx, increase Wegovy to maintenance., this policy targets Saxenda and Wegovy ; other glucagon-like peptide-1 agonists.... Be a book you can download that will show you the Pre-Authorization Criteria, if that required... Carton until time of administration ER ) Wegovy this fax machine is located a!
Systemcontrolcenter Com Hughesnet,
How To Fix Ticketmaster Pardon The Interruption Bot,
Articles W