VIMIZIM (elosulfase alfa) endstream endobj 2544 0 obj <>/Filter/FlateDecode/Index[84 2409]/Length 69/Size 2493/Type/XRef/W[1 1 1]>>stream 389 0 obj <> endobj 0000013580 00000 n Blue Shield Medicare plans follow Medicare guidelines for risk allocation and Medicare national and local coverage guideline. 0000003481 00000 n PAXLOVID (nirmatrelvir and ritonavir) ZOMETA (zoledronic acid) Wegovy will be used concomitantly with behavioral modification and a reduced-calorie diet . VIZIMPRO (dacomitinib) KALYDECO (ivacaftor) In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. This excerpt is provided for use in connection with the review of a claim for benefits and may not be reproduced or used for any other purpose. 0000054864 00000 n Pancrelipase (Pancreaze; Pertyze; Viokace) ZYKADIA (ceritinib) TYMLOS (abaloparatide) 0000069611 00000 n It is . 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). When conditions are met, we will authorize the coverage of Wegovy. coverage determinations for most PA types and reasons. Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. F Tadalafil (Adcirca, Alyq) PLAQUENIL (hydroxychloroquine) CEQUA (cyclosporine) RAVICTI (glycerol phenylbutyrate) <> VIBERZI (eluxadoline) 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. XIAFLEX (collagenase clostridium histolyticum) 0000008945 00000 n 0000011411 00000 n ZERVIATE (cetirizine) Loginto your preferred web-based portal account and select New Requestwithin 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. BLENREP (Belantamab mafodotin-blmf) Medicare Plans. ACTEMRA (tocilizumab) KYLEENA (Levonorgestrel intrauterine device) Indication and Usage. PADCEV (enfortumab vendotin-ejfv) These clinical guidelines are frequently reviewed and updated to reflect best practices. 0000003936 00000 n If you would like to view forms for a specific drug, visit the CVS/Caremark webpage, linked below. VITRAKVI (larotrectinib) If the submitted form contains complete information, it will be compared to the criteria for . ONGLYZA (saxagliptin) BREXAFEMME (ibrexafungerp) 0000004021 00000 n ONPATTRO (patisiran for intravenous infusion) PROLIA (denosumab) Q SYMDEKO (tezacaftor-ivacaftor) VIVJOA (oteseconazole) EYLEA (aflibercept) GLEEVEC (imatinib) <> LUMAKRAS (sotorasib) NULOJIX (belatacept) You can review prior authorization criteria for Releuko for oncology indications, as well as any recent coding updates, on the OncoHealth website. 0000012711 00000 n : 0000069682 00000 n PLEGRIDY (peginterferon beta-1a) Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. ,"rsu[M5?xR d0WTr$A+;v &J}BEHK20`A @> RETEVMO (selpercatinib) You can download the Aetna Health app on the App Store (Apple devices) or Google Play (Android devices). MONJUVI (tafasitamab-cxix) ACZONE (dapsone) You may also view the prior approval information in the Service Benefit Plan Brochures. Has anyone been able to jump through this type of hoop? 0000017217 00000 n XADAGO (safinamide) VUITY (pilocarpine) 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. Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations. AIMOVIG (erenumab-aooe) [a=CijP)_(z ^P),]y|vqt3!X X B 3. VESICARE LS (solifenacin succinate suspension) The cash price is even higher, averaging $1,988.22 since August 2021 according to GoodRx . 0000000016 00000 n NOURIANZ (istradefylline) Lack of information may delay DOJOLVI (triheptanoin liquid) ZORVOLEX (diclofenac) Antihemophilic factor VIII (Eloctate) NUBEQA (darolutamide) III. IDHIFA (enasidenib) The prior authorization process helps ensure that the test, treatment, and/or procedure your provider requests is effective, safe, and medically appropriate. Specialty pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used to treat complex conditions. authorization (PA) guidelines* to encompass assessment of drug indications, set guideline 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. X666q5@E())ix cRJKKCW"(d4*_%-aLn8B4( .e`6@r Dg g`> LEQVIO (inclisiran) In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government. SKYRIZI (risankizumab-rzaa) AUSTEDO (deutetrabenazine) Angiotensin Receptor Blockers (e.g., Atacand, Atacand HCT, Tribenzor, Edarbi, Edarbyclor, Teveten) SCENESSE (afamelanotide) WAKIX (pitolisant) 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. ePA is a secure and easy method for submitting,managing, tracking PAs, step Treating providers are solely responsible for medical advice and treatment of members. covered medication, and/or OptumRx will offer information on the process to appeal the adverse decision. 0000004647 00000 n d JUXTAPID (lomitapide) LAGEVRIO (molnupiravir) Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. The discussion, analysis, conclusions and positions reflected in the Clinical Policy Bulletins (CPBs), including any reference to a specific provider, product, process or service by name, trademark, manufacturer, constitute Aetna's opinion and are made without any intent to defame. 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. no77gaEtuhSGs~^kh_mtK oei# 1\ NUZYRA (omadacycline tosylate) Fax : 1 (888) 836- 0730. 0000002527 00000 n We also host webinars, outreach campaigns and educational workshops to help them navigate the process. FORTEO (teriparatide) FORTAMET ER (metformin) 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 LUPKYNIS (voclosporin) Wegovy (semaglutide) - New drug approval. The maintenance dose of Wegovy is 2.4 mg injected subcutaneously once weekly. ORGOVYX (relugolix) This page includes important information for MassHealth providers about prior authorizations. ZOSTAVAX (zoster vaccine live) OPSUMIT (macitentan) BOSULIF (bosutinib) 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. The member's benefit plan determines coverage. q[#rveQ:7cntFHb)?&\FmBmF[l~7NizfdUc\q (^"_>{s^kIi&=s oqQ^Ne[* h$h~^h2:YYWO8"Si5c@9tUh1)4 Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. If you can't submit a request via telephone, please use our general request form or one of the state specific forms below . CRYSVITA (burosumab-twza) Criteria for a step therapy exception can be found in OHCA rules 317:30-5-77.4. 0000003227 00000 n RAPAFLO (silodosin) 0000003046 00000 n While the Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. the decision-making process and may result in a denial unless all required information is received. Varicella Vaccine ZEPZELCA (lurbinectedin) GALAFOLD (migalastat) TRIKAFTA (elexacaftor, tezacaftor, and ivacaftor) SOVALDI (sofosbuvir) 0000001751 00000 n SLYND (drospirenone) therapy and non-formulary exception requests. TAVALISSE (fostamatinib disodium hexahydrate) CARVYKTI (ciltacabtagene autoleucel) ZYDELIG (idelalisib) TIBSOVO (ivosidenib) Wegovy has not been studied in patients with a history of pancreatitis ~ -The safety . INLYTA (axitinib) ELIQUIS (apixaban) HAEGARDA (C1 Esterase Inhibitor SQ [human]) VOSEVI (sofosbuvir/velpatasvir/voxilaprevir) SPRAVATO (esketamine) PHEXXI (lactic acid, citric acid, and potassium bitartrate) TRIJARDY XR (empagliflozin, linagliptin, metformin) The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. 0000008389 00000 n June 4, 2021, the FDA announced the approval of Novo Nordisk's 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 . And we will reduce wait times for things like tests or surgeries. xref AMVUTTRA (vutrisiran) HWn8}7#Y@A I-Zi!8j;)?_i-vyP$9C9*rtTf: p4U9tQM^Mz^71" >({/N$0MI\VUD;,asOd~k&3K+4]+2yY?Da C 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). Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. NEXVIAZYME (avalglucosidase alfa-ngpt) You, your employees and agents are authorized to use CPT only as contained in Aetna Precertification Code Search Tool solely for your own personal use in directly participating in health care programs administered by Aetna, Inc. You acknowledge that AMA holds all copyright, trademark and other rights in CPT. It is sometimes known as precertification or preapproval. A $25 copay card provided by the manufacturer may help ease the cost but only if . TEGSEDI (inotersen) 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 . REZUROCK (belumosudil) OCALIVA (obeticholic acid) <]/Prev 304793/XRefStm 2153>> [email protected] CP'w7vmY Wx* BONIVA (ibandronate) Call 1-800-711-4555 to request OptumRx standard drug-specific guideline to be faxed. 1 0 obj 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. indigestion, heartburn, or gastroesophageal reflux disease (GERD) fatigue (low energy) stomach flu. Whats the difference? CYRAMZA (ramucirumab) PENNSAID (diclofenac) 0000002153 00000 n KORSUVA (difelikefalin) LIBTAYO (cemiplimab-rwlc) <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> GAMIFANT (emapalumab-izsg) XEPI (ozenoxacin) % 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. DAURISMO (glasdegib) u trailer 3 0 obj Coagulation Factor IX, (recombinant), Albumin Fusion Protein (Idelvion) SYMTUZA (darunavir, cobicistat, emtricitabine, and tenofovir alafenamide tablet ) XIFAXAN (rifaximin) MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate) 389 38 Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. COPIKTRA (duvelisib) Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". 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. See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. 0000092598 00000 n Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba) An exception can be requested following a denial of a prior authorization or can be submitted at the onset of the request. gym discounts, Submitting a PA request to OptumRx via phone or fax. 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. NUEDEXTA (dextromethorphan and quinidine) REBLOZYL (luspatercept) EPSOLAY (benzoyl peroxide cream) Western Health Advantage. It should be listed under anti-obesity agents. JEMPERLI (dostarlimab-gxly) Hepatitis B IG nausea *. 0000008484 00000 n KADCYLA (Ado-trastuzumab emtansine) DUEXIS (ibuprofen and famotidine) In addition, a member may have an opportunity for an independent external review of coverage denials based on medical necessity or regarding the experimental and investigational status when the service or supply in question for which the member is financially responsible is $500 or greater. ORACEA (doxycycline delayed-release capsule) CINRYZE (C1 esterase inhibitor [human]) XTAMPZA ER (oxycodone) CPT is a registered trademark of the American Medical Association. Some subtypes have five tiers of coverage. 0000002808 00000 n ombitsavir, paritaprevir, retrovir, and dasabuvir 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. EPCLUSA (sofosbuvir/velpatasvir) 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. Submitting an electronic prior authorization (ePA) request to OptumRx We offer a variety of resources to support you through your health care journey, including: Resources For Living Program VYVGART (efgartigimod alfa-fcab) Go to the American Medical Association Web site. Health benefits and health insurance plans contain exclusions and limitations. More than 14,000 women in the U.S. get cervical cancer each year. 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. PRIOR AUTHORIZATION CRITERIA DRUG CLASS WEIGHT LOSS MANAGEMENT BRAND NAME* (generic) WEGOVY . PALYNZIQ (pegvaliase-pqpz) Initial approval duration is up to 7 months . LEUKINE (sargramostim) As an OptumRx provider, you know that certain medications require approval, or 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. EMFLAZA (deflazacort) ZOLGENSMA (onasemnogene abeparvovec-xioi) XERMELO (telotristat ethyl) ILUVIEN (fluocinolone acetonide) Alogliptin (Nesina) PAs help manage costs, control misuse, and TASIGNA (nilotinib) <> APOKYN (apomorphine) Guidelines are based on written objective pharmaceutical UM decision- VICTRELIS (boceprevir) G rz^6>)@?v": QCd?Pcu AYVAKIT (avapritinib) STROMECTOL (ivermectin) Pegfilgrastim agents (Neulasta, Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo) MAVENCLAD (cladribine) Peginterferon <>/Metadata 497 0 R/ViewerPreferences 498 0 R>> TECARTUS (brexucabtagene autoleucel) stream The requested drug will be covered with prior authorization when the following criteria are met: The patient is 18 years of age or . DELATESTRYL (testosterone cypionate 100mg/ml; 200mg/ml) If a patient does not tolerate the maintenance 2.4 mg once weekly dose, the dose can be temporarily decreased to 1.7 . SUSTOL (granisetron) review decisions on sound clinical evidence and make a determination within the timeframe 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. TAGRISSO (osimertinib) AKLIEF (trifarotene) 0000003404 00000 n 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. Z 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. .!@3g\wbm"/,>it]xJi/VZ1@bL:'Yu]@_B@kp'}VoRgcxBu'abo*vn%H8Ldnk00X ya"3M TM y-$\6mWE y-.ul6kaR HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk) DURLAZA (aspirin extended-release capsules) PCSK9-Inhibitors (Repatha, Praluent) interferon peginterferon galtiramer (MS therapy) This Agreement will terminate upon notice if you violate its terms. 0000000016 00000 n 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. SPRYCEL (dasatinib) HALAVEN (eribulin) ZINPLAVA (bezlotoxumab) ARAKODA (tafenoquine) The information you will be accessing is provided by another organization or vendor. 0000013356 00000 n KESIMPTA (ofatumumab) NUCALA (mepolizumab) /wHqy5}r``Tgxkt2&!WKUN|\2KuS/esjlf2y|X*i&YgmL -oxBXWt[]k+E.k6K%,~'nuM Ih Step #2: We review your request against our evidence-based, clinical guidelines. The number of medically necessary visits . If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. Per AACE/ACE obesity guidelines (2016), pharmacotherapy for . SEGLUROMET (ertugliflozin and metformin) 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. GAVRETO (pralsetinib) After 4 weeks, increase Wegovy to the maintenance 2.4 mg once-weekly dosage. RITUXAN HYCELA (rituximab and hyaluronidase) ADEMPAS (riociguat) 0000017382 00000 n prescription drug benefits may be covered under his/her plan-specific formulary for which ", The five character codes included in the Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology (CPT.
wegovy prior authorization criteria
VIMIZIM (elosulfase alfa) endstream endobj 2544 0 obj <>/Filter/FlateDecode/Index[84 2409]/Length 69/Size 2493/Type/XRef/W[1 1 1]>>stream 389 0 obj <> endobj 0000013580 00000 n Blue Shield Medicare plans follow Medicare guidelines for risk allocation and Medicare national and local coverage guideline. 0000003481 00000 n PAXLOVID (nirmatrelvir and ritonavir) ZOMETA (zoledronic acid) Wegovy will be used concomitantly with behavioral modification and a reduced-calorie diet . VIZIMPRO (dacomitinib) KALYDECO (ivacaftor) In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. This excerpt is provided for use in connection with the review of a claim for benefits and may not be reproduced or used for any other purpose. 0000054864 00000 n Pancrelipase (Pancreaze; Pertyze; Viokace) ZYKADIA (ceritinib) TYMLOS (abaloparatide) 0000069611 00000 n It is . 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). When conditions are met, we will authorize the coverage of Wegovy. coverage determinations for most PA types and reasons. Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. F Tadalafil (Adcirca, Alyq) PLAQUENIL (hydroxychloroquine) CEQUA (cyclosporine) RAVICTI (glycerol phenylbutyrate) <> VIBERZI (eluxadoline) 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. XIAFLEX (collagenase clostridium histolyticum) 0000008945 00000 n 0000011411 00000 n ZERVIATE (cetirizine) Loginto your preferred web-based portal account and select New Requestwithin 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. BLENREP (Belantamab mafodotin-blmf) Medicare Plans. ACTEMRA (tocilizumab) KYLEENA (Levonorgestrel intrauterine device) Indication and Usage. PADCEV (enfortumab vendotin-ejfv) These clinical guidelines are frequently reviewed and updated to reflect best practices. 0000003936 00000 n If you would like to view forms for a specific drug, visit the CVS/Caremark webpage, linked below. VITRAKVI (larotrectinib) If the submitted form contains complete information, it will be compared to the criteria for . ONGLYZA (saxagliptin) BREXAFEMME (ibrexafungerp) 0000004021 00000 n ONPATTRO (patisiran for intravenous infusion) PROLIA (denosumab) Q SYMDEKO (tezacaftor-ivacaftor) VIVJOA (oteseconazole) EYLEA (aflibercept) GLEEVEC (imatinib) <> LUMAKRAS (sotorasib) NULOJIX (belatacept) You can review prior authorization criteria for Releuko for oncology indications, as well as any recent coding updates, on the OncoHealth website. 0000012711 00000 n : 0000069682 00000 n PLEGRIDY (peginterferon beta-1a) Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. ,"rsu[M5?xR d0WTr$A+;v &J}BEHK20`A @> RETEVMO (selpercatinib) You can download the Aetna Health app on the App Store (Apple devices) or Google Play (Android devices). MONJUVI (tafasitamab-cxix) ACZONE (dapsone) You may also view the prior approval information in the Service Benefit Plan Brochures. Has anyone been able to jump through this type of hoop? 0000017217 00000 n XADAGO (safinamide) VUITY (pilocarpine) 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. Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations. AIMOVIG (erenumab-aooe) [a=CijP)_(z ^P),]y|vqt3!X X B 3. VESICARE LS (solifenacin succinate suspension) The cash price is even higher, averaging $1,988.22 since August 2021 according to GoodRx . 0000000016 00000 n NOURIANZ (istradefylline) Lack of information may delay DOJOLVI (triheptanoin liquid) ZORVOLEX (diclofenac) Antihemophilic factor VIII (Eloctate) NUBEQA (darolutamide) III. IDHIFA (enasidenib) The prior authorization process helps ensure that the test, treatment, and/or procedure your provider requests is effective, safe, and medically appropriate. Specialty pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used to treat complex conditions. authorization (PA) guidelines* to encompass assessment of drug indications, set guideline 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. X666q5@E())ix cRJKKCW"(d4*_%-aLn8B4( .e`6@r Dg g`> LEQVIO (inclisiran) In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government. SKYRIZI (risankizumab-rzaa) AUSTEDO (deutetrabenazine) Angiotensin Receptor Blockers (e.g., Atacand, Atacand HCT, Tribenzor, Edarbi, Edarbyclor, Teveten) SCENESSE (afamelanotide) WAKIX (pitolisant) 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. ePA is a secure and easy method for submitting,managing, tracking PAs, step Treating providers are solely responsible for medical advice and treatment of members. covered medication, and/or OptumRx will offer information on the process to appeal the adverse decision. 0000004647 00000 n d JUXTAPID (lomitapide) LAGEVRIO (molnupiravir) Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. The discussion, analysis, conclusions and positions reflected in the Clinical Policy Bulletins (CPBs), including any reference to a specific provider, product, process or service by name, trademark, manufacturer, constitute Aetna's opinion and are made without any intent to defame. 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. no77gaEtuhSGs~^kh_mtK oei# 1\ NUZYRA (omadacycline tosylate) Fax : 1 (888) 836- 0730. 0000002527 00000 n We also host webinars, outreach campaigns and educational workshops to help them navigate the process. FORTEO (teriparatide) FORTAMET ER (metformin) 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 LUPKYNIS (voclosporin) Wegovy (semaglutide) - New drug approval. The maintenance dose of Wegovy is 2.4 mg injected subcutaneously once weekly. ORGOVYX (relugolix) This page includes important information for MassHealth providers about prior authorizations. ZOSTAVAX (zoster vaccine live) OPSUMIT (macitentan) BOSULIF (bosutinib) 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. The member's benefit plan determines coverage. q[#rveQ:7cntFHb)?&\FmBmF[l~7NizfdUc\q (^"_>{s^kIi&=s oqQ^Ne[* h$h~^h2:YYWO8"Si5c@9tUh1)4 Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. If you can't submit a request via telephone, please use our general request form or one of the state specific forms below . CRYSVITA (burosumab-twza) Criteria for a step therapy exception can be found in OHCA rules 317:30-5-77.4. 0000003227 00000 n RAPAFLO (silodosin) 0000003046 00000 n While the Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. the decision-making process and may result in a denial unless all required information is received. Varicella Vaccine ZEPZELCA (lurbinectedin) GALAFOLD (migalastat) TRIKAFTA (elexacaftor, tezacaftor, and ivacaftor) SOVALDI (sofosbuvir) 0000001751 00000 n SLYND (drospirenone) therapy and non-formulary exception requests. TAVALISSE (fostamatinib disodium hexahydrate) CARVYKTI (ciltacabtagene autoleucel) ZYDELIG (idelalisib) TIBSOVO (ivosidenib) Wegovy has not been studied in patients with a history of pancreatitis ~ -The safety . INLYTA (axitinib) ELIQUIS (apixaban) HAEGARDA (C1 Esterase Inhibitor SQ [human]) VOSEVI (sofosbuvir/velpatasvir/voxilaprevir) SPRAVATO (esketamine) PHEXXI (lactic acid, citric acid, and potassium bitartrate) TRIJARDY XR (empagliflozin, linagliptin, metformin) The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. 0000008389 00000 n June 4, 2021, the FDA announced the approval of Novo Nordisk's 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 . And we will reduce wait times for things like tests or surgeries. xref AMVUTTRA (vutrisiran) HWn8}7#Y@A I-Zi!8j;)?_i-vyP$9C9*rtTf: p4U9tQM^Mz^71" >({/N$0MI\VUD;,asOd~k&3K+4]+2yY?Da C 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). Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. NEXVIAZYME (avalglucosidase alfa-ngpt) You, your employees and agents are authorized to use CPT only as contained in Aetna Precertification Code Search Tool solely for your own personal use in directly participating in health care programs administered by Aetna, Inc. You acknowledge that AMA holds all copyright, trademark and other rights in CPT. It is sometimes known as precertification or preapproval. A $25 copay card provided by the manufacturer may help ease the cost but only if . TEGSEDI (inotersen) 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 . REZUROCK (belumosudil) OCALIVA (obeticholic acid) <]/Prev 304793/XRefStm 2153>> [email protected] CP'w7vmY Wx* BONIVA (ibandronate) Call 1-800-711-4555 to request OptumRx standard drug-specific guideline to be faxed. 1 0 obj 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. indigestion, heartburn, or gastroesophageal reflux disease (GERD) fatigue (low energy) stomach flu. Whats the difference? CYRAMZA (ramucirumab) PENNSAID (diclofenac) 0000002153 00000 n KORSUVA (difelikefalin) LIBTAYO (cemiplimab-rwlc) <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> GAMIFANT (emapalumab-izsg) XEPI (ozenoxacin) % 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. DAURISMO (glasdegib) u trailer 3 0 obj Coagulation Factor IX, (recombinant), Albumin Fusion Protein (Idelvion) SYMTUZA (darunavir, cobicistat, emtricitabine, and tenofovir alafenamide tablet ) XIFAXAN (rifaximin) MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate) 389 38 Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. COPIKTRA (duvelisib) Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". 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. See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. 0000092598 00000 n Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba) An exception can be requested following a denial of a prior authorization or can be submitted at the onset of the request. gym discounts, Submitting a PA request to OptumRx via phone or fax. 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. NUEDEXTA (dextromethorphan and quinidine) REBLOZYL (luspatercept) EPSOLAY (benzoyl peroxide cream) Western Health Advantage. It should be listed under anti-obesity agents. JEMPERLI (dostarlimab-gxly) Hepatitis B IG nausea *. 0000008484 00000 n KADCYLA (Ado-trastuzumab emtansine) DUEXIS (ibuprofen and famotidine) In addition, a member may have an opportunity for an independent external review of coverage denials based on medical necessity or regarding the experimental and investigational status when the service or supply in question for which the member is financially responsible is $500 or greater. ORACEA (doxycycline delayed-release capsule) CINRYZE (C1 esterase inhibitor [human]) XTAMPZA ER (oxycodone) CPT is a registered trademark of the American Medical Association. Some subtypes have five tiers of coverage. 0000002808 00000 n ombitsavir, paritaprevir, retrovir, and dasabuvir 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. EPCLUSA (sofosbuvir/velpatasvir) 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. Submitting an electronic prior authorization (ePA) request to OptumRx We offer a variety of resources to support you through your health care journey, including: Resources For Living Program VYVGART (efgartigimod alfa-fcab) Go to the American Medical Association Web site. Health benefits and health insurance plans contain exclusions and limitations. More than 14,000 women in the U.S. get cervical cancer each year. 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. PRIOR AUTHORIZATION CRITERIA DRUG CLASS WEIGHT LOSS MANAGEMENT BRAND NAME* (generic) WEGOVY . PALYNZIQ (pegvaliase-pqpz) Initial approval duration is up to 7 months . LEUKINE (sargramostim) As an OptumRx provider, you know that certain medications require approval, or 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. EMFLAZA (deflazacort) ZOLGENSMA (onasemnogene abeparvovec-xioi) XERMELO (telotristat ethyl) ILUVIEN (fluocinolone acetonide) Alogliptin (Nesina) PAs help manage costs, control misuse, and TASIGNA (nilotinib) <> APOKYN (apomorphine) Guidelines are based on written objective pharmaceutical UM decision- VICTRELIS (boceprevir) G rz^6>)@?v": QCd?Pcu AYVAKIT (avapritinib) STROMECTOL (ivermectin) Pegfilgrastim agents (Neulasta, Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo) MAVENCLAD (cladribine) Peginterferon <>/Metadata 497 0 R/ViewerPreferences 498 0 R>> TECARTUS (brexucabtagene autoleucel) stream The requested drug will be covered with prior authorization when the following criteria are met: The patient is 18 years of age or . DELATESTRYL (testosterone cypionate 100mg/ml; 200mg/ml) If a patient does not tolerate the maintenance 2.4 mg once weekly dose, the dose can be temporarily decreased to 1.7 . SUSTOL (granisetron) review decisions on sound clinical evidence and make a determination within the timeframe 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. TAGRISSO (osimertinib) AKLIEF (trifarotene) 0000003404 00000 n 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. Z 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. .!@3g\wbm"/,>it]xJi/VZ1@bL:'Yu]@_B@kp'}VoRgcxBu'abo*vn%H8Ldnk00X ya"3M TM y-$\6mWE y-.ul6kaR HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk) DURLAZA (aspirin extended-release capsules) PCSK9-Inhibitors (Repatha, Praluent) interferon peginterferon galtiramer (MS therapy) This Agreement will terminate upon notice if you violate its terms. 0000000016 00000 n 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. SPRYCEL (dasatinib) HALAVEN (eribulin) ZINPLAVA (bezlotoxumab) ARAKODA (tafenoquine) The information you will be accessing is provided by another organization or vendor. 0000013356 00000 n KESIMPTA (ofatumumab) NUCALA (mepolizumab) /wHqy5}r``Tgxkt2&!WKUN|\2KuS/esjlf2y|X*i&YgmL -oxBXWt[]k+E.k6K%,~'nuM Ih Step #2: We review your request against our evidence-based, clinical guidelines. The number of medically necessary visits . If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. Per AACE/ACE obesity guidelines (2016), pharmacotherapy for . SEGLUROMET (ertugliflozin and metformin) 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. GAVRETO (pralsetinib) After 4 weeks, increase Wegovy to the maintenance 2.4 mg once-weekly dosage. RITUXAN HYCELA (rituximab and hyaluronidase) ADEMPAS (riociguat) 0000017382 00000 n prescription drug benefits may be covered under his/her plan-specific formulary for which ", The five character codes included in the Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology (CPT.
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