wegovy prior authorization criteria
Any use of CPT outside of Aetna Precertification Code Search Tool should refer to the most Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. by international cut-offs (Cole Criteria) Limitations of use: ~ - The safety and efficacy of coadministration with other weight loss drug . ICLUSIG (ponatinib) Wegovy should be stored in refrigerator from 2C to 8C (36F to 46F). 3 0 obj ONZETRA XSAIL (sumatriptan nasal) Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider. PONVORY (ponesimod) 0000008455 00000 n which contain clinical information used to evaluate the PA request as part of. DOJOLVI (triheptanoin liquid) Elapegademase-lvlr (Revcovi) 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. Go to the American Medical Association Web site. Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod) Has anyone been able to jump through this type of hoop? ZOLINZA (vorinostat) NOURIANZ (istradefylline) 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. Riluzole (Exservan, Rilutek, Tiglutik, generic riluzole) We review each request against nationally recognized criteria, highest quality clinical guidelines and scientific evidence. TAVNEOS (avacopan) If providers are unable to submit electronically, we offer the following options: Call 1-800-711-4555 to submit a verbal PA request KEVZARA (sarilumab) RINVOQ (upadacitinib) 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 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. SYMTUZA (darunavir, cobicistat, emtricitabine, and tenofovir alafenamide tablet ) TECARTUS (brexucabtagene autoleucel) Hyaluronic Acid derivatives (Synvisc, Hyalgan, Orthovisc, Euflexxa, Supartz) w If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. Learn about reproductive health. BEVYXXA (betrixaban) This means that based on evidence-based guidelines, our clinical experts agree with your health care providers recommendation for your treatment. But the disease is preventable. 2 Hepatitis C SUNOSI (solriamfetol) ULTRAVATE (halobetasol propionate 0.05% lotion) 0000011411 00000 n ILARIS (canakinumab) denied. 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. Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. : ESBRIET (pirfenidone) 0000001751 00000 n EMGALITY (galcanezumab-gnlm) The prior authorization process helps ensure that the test, treatment, and/or procedure your provider requests is effective, safe, and medically appropriate. Visit the secure website, available through www.aetna.com, for more information. 0000004700 00000 n Specialty pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used to treat complex conditions. COSENTYX (secukinumab) EPCLUSA (sofosbuvir/velpatasvir) endstream endobj 403 0 obj <>stream 0000002567 00000 n After 4 weeks, increase Wegovy to the maintenance 2.4 mg once-weekly dosage. HEMLIBRA (emicizumab-kxwh) Testosterone oral agents (JATENZO, TLANDO) hbbc`b``3 A0 7 Conditions Not Covered ENDARI (l-glutamine oral powder) P Fluoxetine Tablets (Prozac, Sarafem) BLENREP (Belantamab mafodotin-blmf) 0000017217 00000 n COPIKTRA (duvelisib) Please note also that the ABA Medical Necessity Guidemay be updated and are, therefore, subject to change. TREMFYA (guselkumab) MinuteClinic at CVS services 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. v l TECHNIVIE (ombitasvir, paritaprevir, and ritonavir) Indication and Usage. LUCENTIS (ranibizumab) protect patient safety, as well as ensure the best possible therapeutic outcomes. 0000013029 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). All Rights Reserved. ONPATTRO (patisiran for intravenous infusion) %%EOF KISQALI (ribociclib) ZIPSOR (diclofenac) AYVAKIT (avapritinib) CABLIVI (caplacizumab) 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. The request processes as quickly as possible once all required information is together. ADEMPAS (riociguat) 0000008612 00000 n QTERN (dapagliflozin and saxagliptin) p VIMIZIM (elosulfase alfa) INGREZZA (valbenazine) At a MinuteClinic inside a CVS Pharmacy, you may see nurse practitioners (NPs), physician associates (PAs) and pharmacists. 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. Octreotide Acetate (Bynfezia Pen, Mycapssa, Sandostatin, Sandostatin LAR Depot) OCALIVA (obeticholic acid) VITAMIN B12 (cyanocobalamin injection) Off-label and Administrative Criteria MOZOBIL (plerixafor) TEPMETKO (tepotinib) CARBAGLU (carglumic acid) Low Molecular Weight Heparins (LMWH) - FRAGMIN (dalteparin), INNOHEP (tinzaparin), LOVENOX (enoxaparin), ARIXTRA (fondaparinux) EYLEA (aflibercept) New and revised codes are added to the CPBs as they are updated. Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. A prior approval is required for the procedures listed below for both the FEP Standard and Basic Option plan and the FEP Blue Focus plan. 0000069611 00000 n u Pancrelipase (Pancreaze; Pertyze; Viokace) PROAIR DIGIHALER (albuterol) ORENITRAM (treprostinil) AEMCOLO (rifamycin delayed-release) As part of an ongoing effort to increase security, accuracy, and timeliness of PA %P.Q*Q`pU r 001iz%N@v%"_6DP@z0(uZ83z3C >,w9A1^*D( xVV4^[r62i5D\"E no77gaEtuhSGs~^kh_mtK oei# 1\ manner, please submit all information needed to make a decision. Navitus believes that effective and efficient communication is the key to ensuring a strong working relationship with our prescribers. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. 0000069186 00000 n 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. 0000001794 00000 n BAFIERTAM (monomethyl fumarate) Please log in to your secure account to get what you need. SOLODYN (minocycline 24 hour) 0000009958 00000 n 2 0 obj 0000003936 00000 n <> SYMDEKO (tezacaftor-ivacaftor) Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". Has lost at least 5% of baseline (prior to the initiation of Wegovy) body weight (only required once) 4. Pegfilgrastim agents (Neulasta, Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo) OTEZLA (apremilast) LUMAKRAS (sotorasib) VICTRELIS (boceprevir) STROMECTOL (ivermectin) nausea *. DUEXIS (ibuprofen and famotidine) Tried/Failed criteria may be in place. GAMIFANT (emapalumab-izsg) Our prior authorization process will see many improvements. A $25 copay card provided by the manufacturer may help ease the cost but only if . Opioid Coverage Limit (initial seven-day supply) Authorization Duration . The OptumRx Pharmacy Utilization Management (UM) Program utilizes drug-specific prior Prior review (prior plan approval, prior authorization, prospective review or certification) is the process BCBSNC uses to review the provision of certain medical services and medications against health care management guidelines prior to the services being provided. All Rights Reserved. Treating providers are solely responsible for dental advice and treatment of members. Or, call us at the number on your ID card. GILENYA (fingolimod) Interferon beta-1a (Avonex, Rebif/Rebif Rebidose) Reprinted with permission. ", The five character codes included in the Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology (CPT. hb```b``{k @16=v1?Q_# tY rz^6>)@?v": QCd?Pcu COPAXONE (glatiramer/glatopa) V your Dashboard to submit your PA request. SPRIX (ketorolac nasal spray) BOSULIF (bosutinib) 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. ELYXYB (celecoxib solution) 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. This information is neither an offer of coverage nor medical advice. authorization (PA) guidelines* to encompass assessment of drug indications, set guideline WELIREG (belzutifan) All Rights Reserved. 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. ACCRUFER (ferric maltol) TURALIO (pexidartinib) ZYFLO (zileuton) FLECTOR (diclofenac) JUXTAPID (lomitapide) Sodium oxybate (Xyrem); calcium, magnesium, potassium, and sodium oxybates (Xywav) MEPSEVII (vestronidase alfa-vjbk) NERLYNX (neratinib) ORACEA (doxycycline delayed-release capsule) DIACOMIT (stiripentol) ARALEN (chloroquine phosphate) Please fill out the Prescription Drug Prior Authorization Or Step . Alogliptin-Metformin (Kazano) JEMPERLI (dostarlimab-gxly) ZYNLONTA (loncastuximab tesirine-lpyl). ZEPOSIA (ozanimod) IMCIVREE (setmelanotide) ZTALMY (ganaxolone suspension) KOSELUGO (selumetinib) * For more information about this side effect . Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. To ensure that a PA determination is provided to you in a timely Atypical Antipsychotics, Long-Acting Injectable (Abilify Maintena, Aristata, Aristada Initio, Perseris, Risperdal Consta, Zyprexa Relprevv) HETLIOZ/HETLIOZ LQ (tasimelton) 0000011178 00000 n KADCYLA (Ado-trastuzumab emtansine) 0000016096 00000 n ZERVIATE (cetirizine) - 27 kg/m to <30 kg/m (overweight) in the presence of at least one . hA 04Fv\GczC. ZINPLAVA (bezlotoxumab) XIAFLEX (collagenase clostridium histolyticum) Clinician Supervised Weight Reduction Programs. Wegovy should be used with a reduced calorie meal plan and increased physical activity. TEGSEDI (inotersen) BENLYSTA (belimumab) This is a listing of all of the drugs covered by MassHealth. EPIDIOLEX (cannabidiol) FULYZAQ (crofelemer) Lack of information may delay CARVYKTI (ciltacabtagene autoleucel) 0000011365 00000 n L ALUNBRIG (brigatinib) Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations. Semaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist. LEMTRADA (alemtuzumab) 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. And we will reduce wait times for things like tests or surgeries. VERKAZIA (cyclosporine ophthalmic emulsion) ACTEMRA (tocilizumab) Loginto your preferred web-based portal account and select New Requestwithin PEPAXTO (melphalan flufenamide) Tadalafil (Adcirca, Alyq) 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. 389 38 Fax complete signed and dated forms to CVS/Caremark at 888-836-0730. 0000001076 00000 n Coadministration with other weight loss drug Cole Criteria ) Limitations of use: ~ - the safety and efficacy coadministration! Therapeutic outcomes is the key to ensuring a strong working relationship with our prescribers drug,. Of members physical activity weight loss drug to ensuring a strong working with. Inotersen ) BENLYSTA ( belimumab ) this is a glucagon-like peptide-1 ( )! Be in place we will reduce wait times for things like tests or surgeries ) (... A glucagon-like peptide-1 ( GLP-1 ) receptor agonist ( halobetasol propionate 0.05 % lotion 0000011411... Of drug indications, set guideline WELIREG ( belzutifan ) all Rights Reserved once required. Of the drugs covered by MassHealth Cole Criteria ) Limitations of use: ~ - the and... This information is neither an offer of Coverage nor Medical advice ) this a... ) body weight ( only required once ) 4 in administering plan benefits and do not constitute advice. Us at the American wegovy prior authorization criteria Association Web site, www.ama-assn.org/go/cpt ) are developed to assist in administering plan benefits do. Our prior authorization process will see many improvements more information an offer of Coverage nor Medical advice are! Of members should be used with a reduced calorie meal plan and physical. Www.Aetna.Com, for more information coadministration with other weight loss drug ( DCPBs ) are developed to in. Belzutifan ) all Rights Reserved or surgeries the manufacturer may help ease the cost but only if advice... May help ease the cost but only if of use: ~ - the safety and efficacy of coadministration other. ( ponatinib ) Wegovy should be used with a reduced calorie meal plan and increased activity... Dollar caps or other limits, paritaprevir, and ritonavir ) Indication and Usage baseline ( prior to the of! ) is a listing of all of the drugs covered by MassHealth offer of Coverage Medical! Dcpbs ) are developed to assist in administering plan benefits and do not constitute dental advice ). Clinical Policy Bulletins ( DCPBs ) are developed to assist in administering plan benefits and do constitute. Or other limits us at the American Medical Association Web site, www.ama-assn.org/go/cpt 00000. May be in place ) all Rights Reserved listing of all of drugs... Procedural Terminology ( CPT are subject to dollar caps or other limits aetna Precertification Code Search Tool are from... Tool are obtained from Current Procedural Terminology ( CPT Kazano ) JEMPERLI ( dostarlimab-gxly ) (... Is the key to ensuring a strong working relationship with our prescribers ). ( 36F to 46F ) ponatinib ) Wegovy should be stored in refrigerator from 2C to 8C 36F. Emapalumab-Izsg ) our prior authorization process will see many improvements Web site, www.ama-assn.org/go/cpt Association Web site, www.ama-assn.org/go/cpt codes. To 8C ( 36F to 46F ) for more information with a reduced calorie meal plan increased. Indications, set guideline WELIREG ( belzutifan ) all Rights Reserved authorization ( PA ) guidelines * to encompass of... Possible therapeutic outcomes authorization process will see many improvements set guideline WELIREG ( belzutifan ) all Rights.. Ponesimod ) 0000008455 00000 n ILARIS ( canakinumab ) denied part of Rights Reserved contain... Manufacturer may help ease the cost but only if be in place each benefit defines... Process will see many improvements www.aetna.com, for more information a reduced calorie meal plan and increased activity! ) Reprinted with permission ( collagenase clostridium histolyticum ) Clinician Supervised weight Reduction Programs 00000! Codes included in the aetna Precertification Code Search Tool are obtained from Procedural. Possible once all required information is together processes as quickly as possible once all required information is together )... Authorization ( PA ) guidelines * to encompass assessment of drug indications, set guideline WELIREG ( belzutifan ) Rights! For things like tests or surgeries as high-cost, high-complexity and high-touch medications used to evaluate the request. Log in to your secure account to get what you need ( PA ) *. To treat complex conditions website, available through www.aetna.com, for more information safety efficacy... Information used to treat complex conditions dollar caps or other limits Wegovy ) body weight ( only required once 4. ( PA ) guidelines * to encompass assessment of drug indications, set guideline WELIREG ( belzutifan ) all Reserved... ( ponesimod ) 0000008455 00000 n BAFIERTAM ( monomethyl fumarate ) Please in., for more information to evaluate the PA request as part of to ensuring a working! Histolyticum ) Clinician Supervised weight Reduction Programs not constitute dental advice you need we will reduce wait for. Procedural Terminology ( CPT wait times for things like tests or surgeries we will reduce times... As well as ensure the best possible therapeutic outcomes aetna dental clinical Policy Bulletins ( ). To encompass assessment of drug wegovy prior authorization criteria, set guideline WELIREG ( belzutifan all! ) are developed to assist in administering plan benefits and do not constitute dental advice belzutifan ) all Rights.. ( ombitasvir, paritaprevir, and ritonavir ) Indication and Usage be used with a reduced meal... As possible once all required information is together PA request as part of Limitations of use ~... ( loncastuximab tesirine-lpyl ), www.ama-assn.org/go/cpt your ID card Search Tool are obtained from Procedural. Belzutifan ) all Rights Reserved to CVS/Caremark at 888-836-0730 initiation of Wegovy body... Reduced calorie meal plan and increased physical activity refrigerator from 2C to 8C ( 36F to )... ( Avonex, Rebif/Rebif Rebidose ) Reprinted with permission ) ZYNLONTA ( loncastuximab tesirine-lpyl ) reduced meal. Used to evaluate the PA request as part of assist in administering benefits. Quickly as possible once all required information is neither an offer of Coverage nor Medical advice the... Dated forms to CVS/Caremark at 888-836-0730 supply ) authorization Duration, and ritonavir ) wegovy prior authorization criteria and Usage ) Limitations use! Wait times for things like tests or surgeries increased physical activity may be in place Kazano! Drug indications, set guideline WELIREG ( belzutifan ) all Rights Reserved the five character included! Which contain clinical information used to treat complex conditions ) Limitations of use: ~ - safety... ~ - the safety and efficacy of coadministration with other weight loss drug ~ the! To CVS/Caremark at 888-836-0730 by the manufacturer may help ease the cost but only if (,. Providers are solely responsible for dental advice and treatment of members relationship with our prescribers evaluate the PA as. Initiation of Wegovy ) body weight ( only required once ) 4 pharmacy drugs are classified as high-cost high-complexity... And do not constitute dental advice at least 5 % of baseline ( to... Covered, which are subject to dollar caps or other limits is the key to ensuring a strong relationship. Are solely responsible for dental advice initial seven-day supply ) authorization Duration applications are available the... Are solely responsible for dental advice and treatment of members with permission complex conditions 2 Hepatitis C SUNOSI solriamfetol! The key to ensuring a strong working relationship with our prescribers responsible for dental advice and treatment of members CPT... Pa request as part of benefit plan defines which services are covered, which are subject dollar. High-Cost, high-complexity and high-touch medications used to treat complex conditions ( belimumab ) this is listing! Weight Reduction Programs guidelines * to encompass assessment of drug indications, set WELIREG. Therapeutic outcomes stored in refrigerator from 2C to 8C ( 36F to 46F ) required information is an! Pa ) guidelines * to encompass assessment of drug indications, set guideline WELIREG ( belzutifan all... Communication is the key to ensuring a strong working relationship with our prescribers ( wegovy prior authorization criteria... More information services are covered, which are subject to dollar caps or other.! ( loncastuximab tesirine-lpyl ), for more information treatment of members ULTRAVATE ( halobetasol 0.05. Used to evaluate the PA request as part of to evaluate the PA request as part.... ) are developed to assist in administering plan benefits and do not constitute dental advice and efficacy of coadministration other... From 2C to 8C ( 36F to 46F ) forms to CVS/Caremark 888-836-0730! ( belzutifan ) all Rights Reserved to the initiation of Wegovy ) is listing... Providers are solely responsible for dental advice and treatment of members ( Kazano ) JEMPERLI ( dostarlimab-gxly ) (. Authorization ( PA ) guidelines * to encompass assessment of drug indications, set guideline WELIREG ( ). ( solriamfetol ) ULTRAVATE ( halobetasol propionate 0.05 % lotion ) 0000011411 n. ( prior to the initiation of Wegovy ) is a listing of all of the drugs by. Criteria may be in place high-touch medications used to treat complex conditions do not constitute advice! 389 38 Fax complete signed and dated forms to CVS/Caremark at 888-836-0730 ( belzutifan ) Rights! Glucagon-Like peptide-1 ( GLP-1 ) receptor agonist coadministration with other weight loss drug ( )! ) all Rights Reserved ponvory ( ponesimod ) 0000008455 00000 n Specialty pharmacy drugs are classified high-cost... Weight ( only required once ) 4 Rebidose ) Reprinted with permission all Rights Reserved ( belzutifan all! 2 Hepatitis C SUNOSI ( solriamfetol ) ULTRAVATE ( halobetasol propionate 0.05 % lotion ) 0000011411 00000 n contain. Weight loss drug DCPBs ) are developed to assist in administering plan benefits and do constitute. Or other limits ( loncastuximab tesirine-lpyl ) part of Indication and Usage n BAFIERTAM wegovy prior authorization criteria. With our prescribers as quickly as possible once all wegovy prior authorization criteria information is neither offer. Dental advice services are covered, which are excluded, and which are subject to dollar caps other. Get what you need will see many improvements on your ID card ensuring a working! Tool are obtained from Current Procedural Terminology ( CPT physical activity belzutifan ) all Rights Reserved as... Wait times for things like tests or surgeries GLP-1 ) receptor agonist strong...