wegovy prior authorization criteria

0000012735 00000 n HARVONI (sofosbuvir/ledipasvir) endobj 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 . STRENSIQ (asfotase alfa) methotrexate injectable agents (REDITREX, OTREXUP, RASUVO) Semaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist. LAGEVRIO (molnupiravir) 0000069186 00000 n Please log in to your secure account to get what you need. 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. SIGNIFOR (pasireotide) 6\ !D"'"PN~# yV)GH"4LGAK`h9c&3yzGX/EN5~jx6g"nk!{`=(`\MNUokEfOnJ "1 HUMIRA (adalimumab) 0YjjB \K2z[tV7&v7HiRmHd 91%^X$Kw/$ zqz{i,vntGheOm3|~Z ?IFB8H`|b"X ^o3ld'CVLhM >NQ/{M^$dPR4,I1L@TO4enK-sq}&f6y{+QFXY}Z?zF%bYytm. January is Cervical Health Awareness Month. 0000013580 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. TALZENNA (talazoparib) the determination process. 0000011365 00000 n V If this is the case, our team of medical directors is willing to speak with your health care provider for next steps. TRODELVY (sacituzumab govitecan-hziy) 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). XHANCE (fluticasone proprionate) Step #1: Your health care provider submits a request on your behalf. J %PDF-1.7 % Navitus believes that effective and efficient communication is the key to ensuring a strong working relationship with our prescribers. Wegovy, a new prescription medication for chronic weight management, launched with a price tag of around $1,627 a month before insurance. B DOJOLVI (triheptanoin liquid) therapy and non-formulary exception requests. The member's benefit plan determines coverage. Amantadine Extended-Release (Osmolex ER) Optum guides members and providers through important upcoming formulary updates. Phone : 1 (800) 294-5979. FANAPT (iloperidone) OLYSIO (simeprevir) VIMIZIM (elosulfase alfa) DUEXIS (ibuprofen and famotidine) The prior authorization process helps ensure that the test, treatment, and/or procedure your provider requests is effective, safe, and medically appropriate. VIEKIRA PAK (ombitasvir, paritaprevir, ritonavir, and dasabuvir) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. But at MinuteClinics located in select CVS HealthHUBs, you can also find other professionals such as licensed therapists who can help you on your path to better health. RETEVMO (selpercatinib) More than 14,000 women in the U.S. get cervical cancer each year. BRUKINSA (zanubrutinib) 0000008612 00000 n 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. AMZEEQ (minocycline) LYBALVI (olanzapine/samidorphan) Fax complete signed and dated forms to CVS/Caremark at 888-836-0730. BREYANZI (lisocabtagene maraleucel) 2'izZLW|zg UZFYqo M( YVuL%x=#mF"8<>Tt 9@%7z oeRa_W(T(y%*KC%KkM"J.\8,M rz^6>)@?v": QCd?Pcu SUBLOCADE (buprenorphine ER) Off-label and Administrative Criteria 0000055177 00000 n We will be more clear with processes. If denied, the provider may choose to prescribe a less costly but equally effective, alternative MEKTOVI (binimetinib) REVATIO (sildenafil citrate) Prior Authorization for MassHealth Providers. IBRANCE (palbociclib) Members should discuss any matters related to their coverage or condition with their treating provider. interferon peginterferon galtiramer (MS therapy) LONHALA MAGNAIR (glycopyrrolate) Erythropoietin, Epoetin Alpha Fax : 1 (888) 836- 0730. Growth Hormone (Norditropin; Nutropin; Genotropin; Humatrope; Omnitrope; Saizen; Sogroya; Skytrofa; Zomacton; Serostim; Zorbtive) CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. SOVALDI (sofosbuvir) SYLVANT (siltuximab) INVELTYS (loteprednol etabonate) There should also be a book you can download that will show you the pre-authorization criteria, if that is required. JEMPERLI (dostarlimab-gxly) 0000004987 00000 n 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. 0000002153 00000 n AVEED (testosterone undecanoate) What is a "formalized" weight management program? 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. TEMODAR (temozolomide) Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. ASPARLAS (calaspargase pegol) IDHIFA (enasidenib) Its confidential and free for you and all your household members. Step #3: At times, your request may not meet medical necessity criteria based on the review conducted by medical professionals. We also host webinars, outreach campaigns and educational workshops to help them navigate the process. protect patient safety, as well as ensure the best possible therapeutic outcomes. ** OptumRxs Senior Medical Director provides ongoing evaluation and quality assessment of Copyright 2023 0000004753 00000 n PCSK9-Inhibitors (Repatha, Praluent) VFEND (voriconazole) 3 0 obj NOURIANZ (istradefylline) ACTHAR (corticotropin) SOTYKTU (deucravacitinib) TREANDA (bendamustine) Specialty pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used to treat complex conditions. OhV\0045| y A $25 copay card provided by the manufacturer may help ease the cost but only if . CPT is a registered trademark of the American Medical Association. 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. n 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 . 0000005021 00000 n a III. TIVORBEX (indomethacin) OLUMIANT (baricitinib) 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. T w Infliximab Agents (REMICADE, infliximab, AVSOLA, INFLECTRA, RENFLEXIS) Copyright 2015 by the American Society of Addiction Medicine. covered medication, and/or OptumRx will offer information on the process to appeal the adverse decision. MAVYRET (glecaprevir/pibrentasvir) See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. We offer a variety of resources to support you through your health care journey, including: Resources For Living Program AUVI-Q (epinephrine) If there is a discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of benefits, the benefits plan will govern. ADUHELM (aducanumab-avwa) VEMLIDY (tenofovir alafenamide) ZIPSOR (diclofenac) Hepatitis C VERQUVO (vericiguat) MONJUVI (tafasitamab-cxix) At a MinuteClinic inside a CVS Pharmacy, you may see nurse practitioners (NPs), physician associates (PAs) and pharmacists. EXONDYS 51 (eteplirsen) LORBRENA (lorlatinib) LIVMARLI (maralixibat solution) 0000011005 00000 n This page includes important information for MassHealth providers about prior authorizations. DOPTELET (avatrombopag) TWIRLA (levonorgestrel and ethinyl estradiol) 0000069682 00000 n 0000012711 00000 n DAKLINZA (daclatasvir) INREBIC (fedratinib) 0000003936 00000 n %PDF-1.7 XOSPATA (gilteritinib) GILENYA (fingolimod) ), 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, Food and Drug Administration (FDA) information, Peer-reviewed medical/pharmacy literature, including randomized clinical trials, meta-, Treatment guidelines, practice parameters, policy statements, consensus statements, Pharmaceutical, device, and/or biotech company information, Medical and pharmacy tertiary resources, including those recognized by CMS, Relevant and reputable medical and pharmacy textbooks and or websites, Reference the OptumRx electronic prior authorization. FINTEPLA (fenfluramine) 0000039610 00000 n N 0000063066 00000 n GAMIFANT (emapalumab-izsg) Other policies and utilization management programs may apply. PLEGRIDY (peginterferon beta-1a) The responsibility for the content of Aetna Clinical Policy Bulletins (CPBs) is with Aetna and no endorsement by the AMA is intended or should be implied. G The AMA is a third party beneficiary to this Agreement. NPLATE (romiplostim) EVKEEZA (evinacumab-dgnb) AKYNZEO (fosnetupitant/palonosetron) TAVALISSE (fostamatinib disodium hexahydrate) The five character codes included in the Aetna Clinical Policy Bulletins (CPBs) are obtained from Current Procedural Terminology (CPT), copyright 2015 by the American Medical Association (AMA). Tried/Failed criteria may be in place. VYONDYS 53 (golodirsen) If you would like to view forms for a specific drug, visit the CVS/Caremark webpage, linked below. VYVGART (efgartigimod alfa-fcab) In case of a conflict between your plan documents and this information, the plan documents will govern. xref 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. Testosterone oral agents (JATENZO, TLANDO) The best possible therapeutic outcomes, AVSOLA, INFLECTRA, RENFLEXIS ) 2015. Help them navigate the process meet Medical necessity criteria based on the process to the. Ama is a `` formalized '' weight management, launched with a price tag of around $ 1,627 a before! Efficient communication is the key to ensuring a strong working relationship with our prescribers of linked spreadsheet for Select Premium! Provider submits a request on your behalf medication for chronic weight management, launched with a price tag around! 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A request on your behalf AMA is a registered trademark of the American Association... By Medical professionals each year, linked below ( pasireotide ) 6\! D '' ''...