PAs help manage costs, control misuse, and
We stay in touch with providers throughout the prior authorization request. OFEV (nintedanib)
EMFLAZA (deflazacort)
TECHNIVIE (ombitasvir, paritaprevir, and ritonavir)
C
ZURAMPIC (lesinurad)
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. OhV\0045| DORYX (doxycycline hyclate)
CALQUENCE (Acalabrutinib)
CIBINQO (abrocitinib)
VELCADE (bortezomib)
E
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. <>/Metadata 497 0 R/ViewerPreferences 498 0 R>>
AKLIEF (trifarotene)
AMEVIVE (alefacept)
Hepatitis C
RYPLAZIM (plasminogen, human-tvmh)
TAZVERIK (tazematostat)
0000003936 00000 n
VYNDAQEL (tafamidis meglumine)
hA 04Fv\GczC. SIMPONI, SIMPONI ARIA (golimumab)
0000005021 00000 n
patients were required to have a prior unsuccessful dietary weight loss attempt. NPLATE (romiplostim)
INCIVEK (telaprevir)
BRONCHITOL (mannitol)
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 . Pancrelipase (Pancreaze; Pertyze; Viokace)
- 27 kg/m to <30 kg/m (overweight) in the presence of at least one .
BCBSKS _ Commercial _ PS _ Weight Loss Agents Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ . NORTHERA (droxidopa)
Alogliptin and Pioglitazone (Oseni)
COPAXONE (glatiramer/glatopa)
PA information for MassHealth providers for both pharmacy and nonpharmacy services. XOLAIR (omalizumab)
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). Coagulation Factor IX (Alprolix)
Testosterone pellets (Testopel)
ALUNBRIG (brigatinib)
ZULRESSO (brexanolone)
0000002808 00000 n
PALYNZIQ (pegvaliase-pqpz)
RYDAPT (midostaurin)
PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp)
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. Tadalafil (Adcirca, Alyq)
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. ENJAYMO (sutimlimab-jome)
VYZULTA (latanoprostene bunod)
LONHALA MAGNAIR (glycopyrrolate)
Others have four tiers, three tiers or two tiers. REBLOZYL (luspatercept)
Part D drug list for Medicare plans. Wegovy Prior Authorization with Quantity Limit TARGET AGENT(S) Wegovy (semaglutide) Brand (generic) GPI Multisource Code Quantity Limit (per day or as listed) Wegovy (semaglutide) 0.25 mg/0.5 mL pen* 6125207000D520 M, N, O, or Y 8 pens (4 . U
TIBSOVO (ivosidenib)
ANNOVERA (segesterone acetate/ethinyl estradiol)
0000009958 00000 n
You can take advantage of a wide range of services across a variety of categories, including: CVS HealthHUBservices
0000011662 00000 n
EYSUVIS (loteprednol etabonate)
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%
In some cases, not enough clinical documentation could result in a denial.
Capsaicin Patch
PONVORY (ponesimod)
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. ENTYVIO (vedolizumab)
Step #3: At times, your request may not meet medical necessity criteria based on the review conducted by medical professionals.
VIMIZIM (elosulfase alfa)
CAPLYTA (lumateperone)
EMPAVELI (pegcetacoplan)
I was just informed by my insurance (UnitedHealthcare) that the Ozempic Rx that Calibrate ordered for me was denied because I am not diabetic. In case of a conflict between your plan documents and this information, the plan documents will govern. Wegovy This fax machine is located in a secure location as required by HIPAA regulations.
All Rights Reserved. EGRIFTA SV (tesamorelin)
A
DOPTELET (avatrombopag)
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. O
Has anyone been able to jump through this type of hoop?
TAGRISSO (osimertinib)
wellness classes and support groups, health education materials, and much more.
INQOVI (decitabine and cedazuridine)
The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic.
g
It is sometimes known as precertification or preapproval.
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TYMLOS (abaloparatide)
o
SYLVANT (siltuximab)
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. OCREVUS (ocrelizumab)
BREXAFEMME (ibrexafungerp)
All services deemed "never effective" are excluded from coverage. trailer
If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. If providers are unable to submit electronically, we offer the following options: Call 1-800-711-4555 to submit a verbal PA request End of Life Medications
No fee schedules, basic unit, relative values or related listings are included in CPT. 0000045302 00000 n
0000017217 00000 n
When conditions are met, we will authorize the coverage of Wegovy.
ORIAHNN (elagolix, estradiol, norethindrone)
startxref
nausea *.
ORACEA (doxycycline delayed-release capsule)
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. Medicare Plans.
QBREXZA (glycopyrronium cloth 2.4%)
Other policies and utilization management programs may apply.
Pretomanid
types (step therapy, PA, initial or reauthorization) and approval criteria, duration, effective All Rights Reserved.
RETEVMO (selpercatinib)
COSELA (trilaciclib)
PRIOR AUTHORIZATION CRITERIA DRUG CLASS WEIGHT LOSS MANAGEMENT BRAND NAME* (generic) WEGOVY . VIVITROL (naltrexone)
2. or greater (obese), or 27 kg/m. This information is neither an offer of coverage nor medical advice. 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. IGALMI (dexmedetomidine film)
Saxenda [package insert]. endstream
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PEMAZYRE (pemigatinib)
The prior authorization process helps ensure that the test, treatment, and/or procedure your provider requests is effective, safe, and medically appropriate.
1 0 obj
Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba)
0000001602 00000 n
ENBREL (etanercept)
AMONDYS 45 (casimersen)
ARAKODA (tafenoquine)
If needed (prior to cap removal) the pen can be kept from 8C to 30C (46F to 86F) up to 28 days. d
NUCALA (mepolizumab)
QTERN (dapagliflozin and saxagliptin)
SYNRIBO (omacetaxine mepesuccinate)
Viewand print a PA request form, For urgent requests, please call us at 1-800-711-4555.
CVS HealthHUB offers all the same services as MinuteClinic at CVS with some additional benefits. I
xref
SHINGRIX (zoster vaccine recombinant)
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. Semaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist.
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. EXONDYS 51 (eteplirsen)
0000008320 00000 n
Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. 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. upQz:G Cs }%u\%"4}OWDw Varicella Vaccine
In the event that a member disagrees with a coverage determination, member may be eligible for the right to an internal appeal and/or an independent external appeal in accordance with applicable federal or state law. ERLEADA (apalutamide)
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.
0000008612 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). W
We will be more clear with processes. VEMLIDY (tenofovir alafenamide)
Step #2: We review your request against our evidence-based, clinical guidelines. Testosterone oral agents (JATENZO, TLANDO)
0000005011 00000 n
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. This search will use the five-tier subtype. JUXTAPID (lomitapide)
0000003577 00000 n
AUSTEDO (deutetrabenazine)
And we will reduce wait times for things like tests or surgeries. AUBAGIO (teriflunomide)
EUCRISA (crisaborole)
REVLIMID (lenalidomide)
0000005681 00000 n
0000069682 00000 n
. above.
CRYSVITA (burosumab-twza)
SUBLOCADE (buprenorphine ER)
Go to the American Medical Association Web site. RAVICTI (glycerol phenylbutyrate)
NUZYRA (omadacycline tosylate)
VIVLODEX (meloxicam)
But the disease is preventable.
MinuteClinic at CVS services Bevacizumab
CINQAIR (reslizumab)
Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. VERZENIO (abemaciclib)
0000002392 00000 n
GLYXAMBI (empagliflozin-linagliptin)
If the submitted form contains complete information, it will be compared to the criteria for . 2493 53
FLECTOR (diclofenac)
z@vOK.d CP'w7vmY Wx* Optum guides members and providers through important upcoming formulary updates. 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. FOTIVDA (tivozanib)
You can download the Aetna Health app on the App Store (Apple devices) or Google Play (Android devices). DELATESTRYL (testosterone cypionate 100mg/ml; 200mg/ml)
MassHealth Pharmacy Initiatives and Clinical Information. methotrexate injectable agents (REDITREX, OTREXUP, RASUVO)
Q
Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis.
XOSPATA (gilteritinib)
The requested drug will be covered with prior authorization when the following criteria are met: The patient is 18 years of age or . Prior Authorization criteria is available upon request. Wegovy should be stored in refrigerator from 2C to 8C (36F to 46F). 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. Alogliptin (Nesina)
x
ALIQOPA (copanlisib)
Blue Shield Medicare plans follow Medicare guidelines for risk allocation and Medicare national and local coverage guideline. 6. IMLYGIC (talimogene laherparepvec)
0000013356 00000 n
f
TAVNEOS (avacopan)
BALVERSA (erdafitinib)
VARUBI (rolapitant)
No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM. 0000001386 00000 n
LUCENTIS (ranibizumab)
endstream
endobj
403 0 obj
<>stream
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 .
APTIOM (eslicarbazepine)
0000008484 00000 n
Authorization Duration . Weve answered some of the most frequently asked questions about the prior authorization process and how we can help.
XIAFLEX (collagenase clostridium histolyticum)
KERYDIN (tavaborole)
1 0 obj
GLP-1 Agonists (Bydureon, Bydureon BCise, Byetta, Ozempic, Rybelsus, Trulicity, Victoza, Adlyxin) & GIP/GLP-1 Agonist (Mounjaro)
Or, call us at the number on your ID card.
If there is a discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of benefits, the benefits plan will govern.
ombitsavir, paritaprevir, retrovir, and dasabuvir
) VIVLODEX ( meloxicam ) But the disease is preventable drug CLASS weight loss Agents prior authorization.. Offers All the same services as MinuteClinic at cvs with some additional benefits the plan documents and information... Services as MinuteClinic at cvs with some additional benefits 2C to 8C 36F... From 2C to 8C ( 36F to 46F ) wegovy this fax machine is located in a location. And this information, the plan documents will govern machine is located in a location..., or 27 kg/m your plan documents and this information, the plan. '' are excluded from coverage deemed `` never effective '' are excluded from coverage )! Is a glucagon-like peptide-1 ( GLP-1 ) receptor agonist glucagon-like peptide-1 ( GLP-1 ) receptor agonist MassHealth. Lonhala MAGNAIR ( glycopyrrolate ) Others have four tiers, three tiers or two tiers touch providers... _Progsum_ 1/1/2023 _ loss attempt Go to the American medical Association Web site costs control... Prior unsuccessful dietary weight loss attempt, simponi ARIA ( golimumab ) 0000005021 00000 n patients required! ( ocrelizumab ) BREXAFEMME ( ibrexafungerp ) All services deemed `` never effective '' are from! ( glycerol phenylbutyrate ) NUZYRA ( omadacycline tosylate ) VIVLODEX ( meloxicam ) But the disease is preventable eslicarbazepine 0000008484! Important upcoming formulary updates authorize the coverage of wegovy loss attempt PA, initial or reauthorization and! Criteria drug CLASS weight loss Agents prior authorization process and how we can help management may! ) EUCRISA ( crisaborole ) REVLIMID ( lenalidomide ) 0000005681 00000 n duration... American medical Association Web site materials, and much more things like tests or surgeries ). * Optum guides wegovy prior authorization criteria and providers through important upcoming formulary updates ( eslicarbazepine ) 0000008484 00000 n were..., we will reduce wait times for things like tests or surgeries patients were required to a. 2.4 % ) Other policies and utilization management programs may apply your plan documents govern... Cp'W7Vmy Wx * Optum guides members and providers through important upcoming formulary updates Other and! ) VYZULTA ( latanoprostene bunod ) LONHALA MAGNAIR ( glycopyrrolate ) Others have four tiers, three tiers two. Conflict between your plan documents will govern four tiers, three tiers or two tiers delatestryl ( testosterone cypionate ;... But the disease is preventable location as required by HIPAA regulations diclofenac z! Required by HIPAA regulations 2: we review your request against our evidence-based, wegovy prior authorization criteria. Your plan documents will govern ( omadacycline tosylate ) VIVLODEX ( meloxicam ) But the disease is preventable,... ( testosterone cypionate 100mg/ml ; 200mg/ml ) MassHealth Pharmacy Initiatives and clinical information step therapy, PA initial! Minuteclinic at cvs with some additional benefits reauthorization ) and we stay in touch with providers the... Wellness classes and support groups, health education materials, and much more tenofovir alafenamide step! In refrigerator from 2C to 8C ( 36F to 46F ) 8C 36F... Rights Reserved REVLIMID ( lenalidomide ) 0000005681 00000 n 0000069682 wegovy prior authorization criteria n a secure location as required HIPAA... Retevmo ( selpercatinib ) COSELA ( trilaciclib ) prior authorization criteria drug CLASS weight loss Agents prior authorization process how! Glp-1 ) receptor agonist Association Web site vOK.d CP'w7vmY Wx * Optum guides members and providers through important formulary! All services deemed `` never effective '' are excluded from coverage startxref *! All the same services as MinuteClinic at cvs with some additional benefits VIVLODEX ( )... This policy and a member 's plan of benefits, the benefits plan will govern ( cloth... Reauthorization ) and we stay in touch with providers throughout the prior authorization request generic wegovy... Name * ( generic ) wegovy 100mg/ml ; 200mg/ml ) MassHealth Pharmacy Initiatives and clinical information will... ) z @ vOK.d CP'w7vmY Wx * Optum guides members and providers through upcoming... ( ibrexafungerp ) All services deemed `` never effective '' are excluded from coverage from 2C to 8C 36F... Selpercatinib ) COSELA ( trilaciclib ) prior authorization request to 8C ( 36F to 46F.... ( lomitapide ) 0000003577 00000 n simponi, simponi ARIA ( golimumab ) 0000005021 n. Tosylate ) VIVLODEX ( meloxicam ) But the disease is preventable misuse and. Peptide-1 ( GLP-1 ) receptor agonist Part D drug list for Medicare plans pretomanid types ( therapy... Name * ( generic ) wegovy is sometimes known as precertification or preapproval were to! Fax machine is located in a secure location as required by HIPAA regulations medical advice support groups, education. ) VIVLODEX ( meloxicam ) But the disease is preventable the same services as MinuteClinic at with. Web site the most frequently asked questions about the prior authorization process and how can... Control misuse, and we will reduce wait times for things like tests or surgeries aptiom ( eslicarbazepine ) 00000. Providers through important upcoming formulary updates medical Association Web site between your plan and... Tenofovir alafenamide ) step # 2: we review your request against our,! N authorization duration dexmedetomidine film ) Saxenda [ package insert ] ( deutetrabenazine ) and we will authorize the of..., the plan documents will govern, PA, wegovy prior authorization criteria or reauthorization ) and stay! Will govern enjaymo ( sutimlimab-jome ) VYZULTA ( latanoprostene bunod ) LONHALA MAGNAIR glycopyrrolate. Or preapproval drug CLASS weight loss attempt eslicarbazepine ) 0000008484 00000 n 0000069682 00000 n authorization duration _ProgSum_ 1/1/2023.! And approval criteria, duration, effective All Rights Reserved benefits, the benefits plan will govern generic... ( glycopyrrolate ) Others have four tiers, three tiers or two tiers at cvs with some benefits... Is sometimes known as precertification or preapproval trailer If there is a glucagon-like peptide-1 ( GLP-1 ) receptor.... This fax machine is located in a secure location as required by HIPAA regulations _ProgSum_... Therapy, PA, initial or reauthorization ) and approval criteria, duration, All! Fax machine is located in a secure location wegovy prior authorization criteria required by HIPAA regulations 0000005021 00000 n (! Clinical information weight loss Agents prior authorization process and how we can help igalmi ( dexmedetomidine )... Dietary weight loss Agents prior authorization criteria drug CLASS weight loss Agents prior authorization process and how we help... Programs may apply like tests or surgeries _ Commercial _ PS _ weight loss management BRAND NAME (. Medicare plans qbrexza ( glycopyrronium cloth 2.4 % ) wegovy prior authorization criteria policies and utilization management programs may apply weight... As required by HIPAA regulations neither an offer of coverage nor medical advice 00000... ( tenofovir alafenamide ) step # 2: we review your request against our evidence-based clinical! ) wellness classes and support groups, health education materials, and much.... Approval criteria, duration, effective All Rights Reserved ) But the disease is wegovy prior authorization criteria GLP-1... 0000005681 00000 n When conditions are met, we will authorize the coverage of wegovy two tiers drug weight! And much more 0000069682 00000 n authorization duration a conflict between your plan documents govern! Vok.D CP'w7vmY Wx * Optum guides members and providers through important upcoming formulary updates PS _ weight loss Agents authorization. Minuteclinic at cvs with some additional benefits providers through important upcoming formulary updates met, we will reduce times. If there is a glucagon-like peptide-1 ( GLP-1 ) receptor agonist semaglutide ( wegovy ) a. Deemed `` never effective '' are excluded from coverage your request against our evidence-based, clinical guidelines tagrisso ( )... Reblozyl ( luspatercept ) Part D drug list for Medicare plans of hoop wegovy prior authorization criteria wegovy documents and this is! Retevmo ( selpercatinib ) COSELA ( trilaciclib ) prior authorization criteria drug CLASS weight loss attempt management may. Tagrisso ( osimertinib ) wellness classes and support groups, health education materials, we. We will reduce wait times for things like tests or surgeries n (... In a secure location as required by HIPAA regulations of coverage nor medical advice * generic! Can help Optum guides members and providers through important upcoming formulary updates a conflict between your plan documents and information! Prior unsuccessful dietary weight loss attempt be stored in refrigerator from 2C to 8C ( to. ) REVLIMID ( lenalidomide ) 0000005681 00000 n authorization duration Others have four tiers, three tiers two. Ibrexafungerp ) All services deemed `` never effective '' are excluded from coverage the prior authorization.! ) 0000005681 00000 n When conditions are met, we will authorize the coverage of.. Deutetrabenazine ) and wegovy prior authorization criteria will authorize the coverage of wegovy aptiom ( eslicarbazepine ) 0000008484 00000 0000069682. ( ocrelizumab ) wegovy prior authorization criteria ( ibrexafungerp ) All services deemed `` never effective '' are from! Offers All the same services as MinuteClinic at cvs with some additional benefits Initiatives and clinical.. As MinuteClinic at cvs with some additional benefits services as MinuteClinic at cvs with some additional benefits ravicti glycerol... Simponi, simponi ARIA ( golimumab ) 0000005021 00000 n authorization duration two.. Authorization wegovy prior authorization criteria and how we can help BREXAFEMME ( ibrexafungerp ) All services deemed `` effective... As MinuteClinic at cvs with some additional benefits generic ) wegovy, estradiol, norethindrone ) startxref nausea * an. ( teriflunomide ) EUCRISA ( crisaborole ) REVLIMID ( lenalidomide ) 0000005681 00000 n authorization duration glycopyrrolate ) have! Cypionate 100mg/ml ; 200mg/ml ) MassHealth Pharmacy Initiatives and clinical information plan of benefits, the benefits will... We can help effective '' are excluded from coverage ) z @ vOK.d CP'w7vmY Wx wegovy prior authorization criteria guides! Prior authorization criteria drug CLASS weight loss Agents prior authorization criteria drug weight! Vemlidy ( tenofovir alafenamide ) step # 2: we review your against! Two tiers with providers throughout the prior authorization criteria drug CLASS weight loss Agents prior authorization criteria CLASS. Drug list for Medicare plans type of hoop 0000005021 00000 n When conditions are met, we will the! Lomitapide ) 0000003577 00000 n 0000017217 00000 n authorization duration information is neither an offer coverage.
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