ZILXI (minocycline 1.5% foam) NEXLIZET (bempedoic acid and ezetimibe) Other policies and utilization management programs may apply. GILENYA (fingolimod) INLYTA (axitinib) TAVALISSE (fostamatinib disodium hexahydrate) XEMBIFY (immune globulin subcutaneous, human klhw) Growth Hormone (Norditropin; Nutropin; Genotropin; Humatrope; Omnitrope; Saizen; Sogroya; Skytrofa; Zomacton; Serostim; Zorbtive) VRAYLAR (cariprazine) 0000002376 00000 n ZEPOSIA (ozanimod) REVATIO (sildenafil citrate) XERMELO (telotristat ethyl) endobj 0000004700 00000 n Wegovy prior authorization criteria united healthcare. 0000054864 00000 n STELARA (ustekinumab) SPRIX (ketorolac nasal spray) C VUITY (pilocarpine) 0000007229 00000 n SOVALDI (sofosbuvir) HALAVEN (eribulin) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. ONZETRA XSAIL (sumatriptan nasal) Antihemophilic Factor [recombinant] pegylated-aucl (Jivi) TECFIDERA (dimethyl fumarate) Please be sure to add a 1 before your mobile number, ex: 19876543210, Guidelines from nationally recognized health care organizations such as the Centers for Medicare and Medicaid Services (CMS), Peer-reviewed, published medical journals, A review of available studies on a particular topic, Expert opinions of health care professionals. Links to various non-Aetna sites are provided for your convenience only. Welcome. Drug Prior Authorization Request Forms Vabysmo (faricimab-svoa) Open a PDF Viscosupplementation with Hyaluronic Acid - For Osteoarthritis of the Knee (Durolane, Gel-One, Gelsyn-3, Genvisc 850, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz FX, Synojoynt, Triluron, TriVisc, Visco-3) Open a PDF N SOTYKTU (deucravacitinib) 0000011178 00000 n LIBTAYO (cemiplimab-rwlc) ODOMZO (sonidegib) ombitsavir, paritaprevir, retrovir, and dasabuvir RYPLAZIM (plasminogen, human-tvmh) Hyaluronic Acid derivatives (Synvisc, Hyalgan, Orthovisc, Euflexxa, Supartz) Under certain plans, if more than one service can be used to treat a covered person's dental condition, Aetna may decide to authorize coverage only for a less costly covered service provided that certain terms are met. TIVORBEX (indomethacin) Loginto your preferred web-based portal account and select New Requestwithin headache. VILTEPSO (viltolarsen) Visit the secure website, available through www.aetna.com, for more information. AUVI-Q (epinephrine) The responsibility for the content of Aetna Precertification Code Search Tool is with Aetna and no endorsement by the AMA is intended or should be implied. 0000005021 00000 n 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. Please consult with or refer to the Evidence of Coverage or Certificate of Insurance document for a list of exclusions and limitations. ALUNBRIG (brigatinib) 0000002756 00000 n x=ko?,pHE^rEQ q4'MN89dYuj[%'G_^KRi{qD\p8o7lMv;_,N_Wogv>|{G/foM=?J~{(K3eUrc %,4eRUZJtzN7b5~$%1?s?&MMs&\byQl!x@eYZF`'"N(L6FDX Alogliptin and Pioglitazone (Oseni) 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. TRIPTODUR (triptorelin extended-release) TUKYSA (tucatinib) 0000003046 00000 n Please use the updated forms found below and take note of the fax number referenced within the Drug Authorization Forms. STEGLATRO (ertugliflozin) upQz:G Cs }%u\%"4}OWDw 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. EVKEEZA (evinacumab-dgnb) Authorization Duration . FLECTOR (diclofenac) Discard the Wegovy pen after use. covered medication, and/or OptumRx will offer information on the process to appeal the adverse decision. Please select a letter to see drugs listed by that letter, or enter the name of the drug you wish to search for. Please call us at 800.753.2851 to submit a verbal prior authorization request if you are unable to use Electronic Prior Authorization. Pharmacy Prior Authorization Guidelines. Filgrastim agents (Nivestym, Zarxio, Neupogen, Granix, Releuko) MEPSEVII (vestronidase alfa-vjbk) MOZOBIL (plerixafor) 0000039610 00000 n 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. JYNARQUE (tolvaptan) FABRAZYME (agalsidase beta) Per AACE/ACE obesity guidelines (2016), pharmacotherapy for . j The prior authorization process helps ensure that the test, treatment, and/or procedure your provider requests is effective, safe, and medically appropriate. endstream endobj 390 0 obj <>/Metadata 19 0 R/Pages 18 0 R/StructTreeRoot 21 0 R/Type/Catalog/ViewerPreferences 391 0 R>> endobj 391 0 obj <> endobj 392 0 obj <>/MediaBox[0 0 612 792]/Parent 18 0 R/Resources<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI]/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 393 0 obj <> endobj 394 0 obj <> endobj 395 0 obj <> endobj 396 0 obj <> endobj 397 0 obj <> endobj 398 0 obj <> endobj 399 0 obj [352 0 0 0 0 1076 0 0 454 454 636 0 364 454 364 454 636 636 636 636 636 636 636 636 636 636 454 0 0 0 0 0 0 684 686 698 771 632 575 775 751 421 0 0 557 843 748 787 603 787 695 684 616 0 0 989 685 615 0 0 0 0 818 636 0 601 623 521 623 596 352 623 633 272 0 592 272 973 633 607 623 623 427 521 394 633 592 818 592 592 525 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1000] endobj 400 0 obj <> endobj 401 0 obj [342 0 0 0 0 0 0 0 543 543 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 402 0 0 0 0 0 0 776 762 724 830 683 650 811 837 546 0 0 637 948 847 850 733 850 782 710 682 812 764 1128 0 0 692 0 0 0 0 0 0 668 0 588 699 664 422 699 712 342 0 0 342 1058 712 687 699 0 497 593 456 712 650 980 0 651 597] endobj 402 0 obj <>stream requests and determinations, OptumRx is retiring most fax numbers used for 2>7_0ns]+hVaP{}A QULIPTA (atogepant) all TAFINLAR (dabrafenib) SOLARAZE (diclofenac) These clinical guidelines are frequently reviewed and updated to reflect best practices. SUSVIMO (ranibizumab) POLIVY (polatuzumab vedotin-piiq) endstream endobj 2544 0 obj <>/Filter/FlateDecode/Index[84 2409]/Length 69/Size 2493/Type/XRef/W[1 1 1]>>stream VIVJOA (oteseconazole) VOXZOGO (vosoritide) 0000069682 00000 n 0000001751 00000 n 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. At a MinuteClinic inside a CVS Pharmacy, you may see nurse practitioners (NPs), physician associates (PAs) and pharmacists. Please log in to your secure account to get what you need. CPT only copyright 2015 American Medical Association. Therefore, Arizona residents, members, employers and brokers must contact Aetna directly or their employers for information regarding Aetna products and services. RUCONEST (recombinant C1 esterase inhibitor) PADCEV (enfortumab vendotin-ejfv) STROMECTOL (ivermectin) PALYNZIQ (pegvaliase-pqpz) This means that based on evidence-based guidelines, our clinical experts agree with your health care providers recommendation for your treatment. SUNOSI (solriamfetol) You may also view the prior approval information in the Service Benefit Plan Brochures. 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. SYMDEKO (tezacaftor-ivacaftor) 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 POMALYST (pomalidomide) KEVZARA (sarilumab) Please note also that the ABA Medical Necessity Guidemay be updated and are, therefore, subject to change. A 0000005705 00000 n ZOLINZA (vorinostat) XGEVA (denosumab) K GALAFOLD (migalastat) ILARIS (canakinumab) AMEVIVE (alefacept) MEKINIST (trametinib) 1 0 obj Of note, Saxenda (liraglutide subcutaneous injection) and Wegovy (semaglutide subcutaneous injection) are indicated for chronic weight . ELIQUIS (apixaban) XTANDI (enzalutamide) NINLARO (ixazomib) Propranolol (Inderal XL, InnoPran XL) Coagulation Factor IX, recombinant, glycopegylated (Rebinyn) coagulation factor XIII (Tretten) Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod) CONTRAVE (bupropion and naltrexone) m In doing so, CVS/Caremark will be able to decide whether or not the requested prescription is included in the patient's insurance plan. BCBSKS _ Commercial _ PS _ Weight Loss Agents Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ . TAZVERIK (tazematostat) LEUKINE (sargramostim) h The Prescriber Portal offers 24/7 access to plan specifications, formulary and prior authorization forms, everything you need to manage your business and provide your patients the best possible care. 0000013356 00000 n HUMIRA (adalimumab) ZIPSOR (diclofenac) RAVICTI (glycerol phenylbutyrate) DUPIXENT (dupilumab) 0000003755 00000 n Opioid Coverage Limit (initial seven-day supply) If you can't submit a request via telephone, please use our general request form or one of the state specific forms below . FASENRA (benralizumab) 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.. Wegovy should be used with a reduced calorie meal plan and increased physical activity. GLUMETZA ER (metformin) <>/Metadata 497 0 R/ViewerPreferences 498 0 R>> 0000007133 00000 n Treating providers are solely responsible for medical advice and treatment of members. u startxref AKYNZEO (fosnetupitant/palonosetron) 0000002222 00000 n paliperidone palmitate (Invega Hafyera, Invega Trinza, Invega Sustenna) Initial approval duration is up to 7 months . Antihemophilic Factor VIII, recombinant (Kovaltry) NULIBRY (fosdenopterin) 0000017217 00000 n EXJADE (deferasirox) 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. You can download the Aetna Health app on the App Store (Apple devices) or Google Play (Android devices). ARALEN (chloroquine phosphate) GLP-1 Agonists (Bydureon, Bydureon BCise, Byetta, Ozempic, Rybelsus, Trulicity, Victoza, Adlyxin) & GIP/GLP-1 Agonist (Mounjaro) When conditions are met, we will authorize the coverage of Wegovy. TYVASO (treprostinil) FENORTHO (fenoprofen) Sodium oxybate (Xyrem); calcium, magnesium, potassium, and sodium oxybates (Xywav) If you do not intend to leave our site, close this message. 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. J TAGRISSO (osimertinib) The member's benefit plan determines coverage. AIMOVIG (erenumab-aooe) UPNEEQ (oxymetazoline hydrochloride) WHA members have access to a wealth of resources including a Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. Service code if available (HCPCS/CPT) To better serve our providers, business partners, and patients, the Cigna Coverage Review Department is transitioning from PromptPA, fax, and phone coverage reviews (also called prior authorizations) to Electronic Prior Authorizations (ePAs). SYMTUZA (darunavir, cobicistat, emtricitabine, and tenofovir alafenamide tablet ) XIIDRA (lifitegrast) 0000055434 00000 n 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. Copyright 2015 by the American Society of Addiction Medicine. ARAKODA (tafenoquine) q[#rveQ:7cntFHb)?&\FmBmF[l~7NizfdUc\q (^"_>{s^kIi&=s oqQ^Ne[* h$h~^h2:YYWO8"Si5c@9tUh1)4 KADCYLA (Ado-trastuzumab emtansine) MYRBETRIQ (mirabegron granules) Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. 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Guidelines ( 2016 ), pharmacotherapy for app on the app Store ( Apple devices ) or Google (! List of exclusions and limitations the Evidence of Coverage or Certificate of Insurance document for a list of and... Contact Aetna directly or their employers for information regarding Aetna products and services that,. Determines Coverage get what you need in the Service Benefit Plan determines Coverage app Store ( devices. Can download the Aetna Health app on the app Store ( Apple devices or. To your secure account to get what you need to the Evidence of or.
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