Please fill out the Prescription Drug Prior Authorization Or Step . KADCYLA (Ado-trastuzumab emtansine)
EMPAVELI (pegcetacoplan)
. Fluoxetine Tablets (Prozac, Sarafem)
When conditions are met, we will authorize the coverage of Wegovy.
AUVI-Q (epinephrine)
If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits.
ZOLINZA (vorinostat)
ANNOVERA (segesterone acetate/ethinyl estradiol)
Your benefits plan determines coverage.
ZOSTAVAX (zoster vaccine live)
Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. 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).
0000002704 00000 n
0000010297 00000 n
ELZONRIS (tagraxofusp)
So far, all weight loss drugs are 'excluded' from coverage for my specific employer's contracted plan. Criteria for a step therapy exception can be found in OHCA rules 317:30-5-77.4. RETEVMO (selpercatinib)
See multiple tabs of linked spreadsheet for Select, Premium & UM Changes.
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. The number of medically necessary visits .
KRINTAFEL (tafenoquine)
You can take advantage of a wide range of services across a variety of categories, including: CVS HealthHUBservices RYPLAZIM (plasminogen, human-tvmh)
XEPI (ozenoxacin)
NUEDEXTA (dextromethorphan and quinidine)
ENTYVIO (vedolizumab)
ENDARI (l-glutamine oral powder)
CPT is a registered trademark of the American Medical Association. And we will reduce wait times for things like tests or surgeries. Indication and Usage. Some plans exclude coverage for services or supplies that Aetna considers medically necessary.
Its confidential and free for you and all your household members. 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. ZERVIATE (cetirizine)
GILOTRIF (afatini)
HWn8}7#Y 0MCFME"R+$Yrp
yN.oHC Dhx4iE$D;NP&+Xi:!WB>|\_ Step #1: Your health care provider submits a request on your behalf. 6\
!D"'"PN~#
yV)GH"4LGAK`h9c&3yzGX/EN5~jx6g"nk!{`=(`\MNUokEfOnJ "1 Attached is a listing of prescription drugs that are subject to prior authorization. How to access the OptumRx PA guidelines: Reference the OptumRx electronic prior authorization ( ePA ) and (fax ) forms. Wegovy will be used concomitantly with behavioral modification and a reduced-calorie diet .
But the disease is preventable.
LYNPARZA (olaparib)
RITUXAN (rituximab)
ZINPLAVA (bezlotoxumab)
Growth Hormone (Norditropin; Nutropin; Genotropin; Humatrope; Omnitrope; Saizen; Sogroya; Skytrofa; Zomacton; Serostim; Zorbtive)
5JB7P@i`xHKMBueX7{
Lm!vpp
;BfP,(&!lQo;!oDx3 vKC$Uq/.^F`EK!v?f\g b/R8;v
dPVmB8z?F'_+,8=;J #)3g;VYv_Rjb$6~:l[`Pl;E1>|5R%C99vf:K^(~hT\`5W}:&5F1uV h`j7)g*Z`W'ON:QR:}f_`/Q&\ Off-label and Administrative Criteria
ZOMETA (zoledronic acid)
which contain clinical information used to evaluate the PA request as part of. 0000003755 00000 n
TREANDA (bendamustine)
Hyaluronic Acid derivatives (Synvisc, Hyalgan, Orthovisc, Euflexxa, Supartz)
Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. If you would like to view forms for a specific drug, visit the CVS/Caremark webpage, linked below. VIVLODEX (meloxicam)
TEGSEDI (inotersen)
wellness assessment,
SYLVANT (siltuximab)
ORIAHNN (elagolix, estradiol, norethindrone)
0000003724 00000 n
Please . LONHALA MAGNAIR (glycopyrrolate)
I was just informed by my insurance (UnitedHealthcare) that the Ozempic Rx that Calibrate ordered for me was denied because I am not diabetic. 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. 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). VIDAZA (azacitidine)
2493 53
SILIQ (brodalumab)
0000000016 00000 n
NUPLAZID (pimavanserin)
Propranolol (Inderal XL, InnoPran XL)
0000003936 00000 n
Of note, this policy targets Saxenda and Wegovy; other glucagon-like peptide-1 agonists which.
RECARBRIO (imipenem, cilastin and relebactam)
ACTHAR (corticotropin)
CRESEMBA (isavuconazonium)
UPNEEQ (oxymetazoline hydrochloride)
While the Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. 0000008635 00000 n
by international cut-offs (Cole Criteria) Limitations of use: ~ - The safety and efficacy of coadministration with other weight loss drug . F
VABYSMO (faricimab)
NAYZILAM (midazolam nasal spray)
VOSEVI (sofosbuvir/velpatasvir/voxilaprevir)
0000011365 00000 n
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.
Allergen Immunotherapy Agents (Grastek, Odactra, Oralair, Ragwitek)
REVATIO (sildenafil citrate)
ZOLGENSMA (onasemnogene abeparvovec-xioi)
NEXLETOL (bempedoic acid)
In the event that a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision. 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 . b
ZURAMPIC (lesinurad)
Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. LUCENTIS (ranibizumab)
nausea *. KERENDIA (finerenone)
<>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>>
ZOKINVY (lonafarnib)
Get Pre-Authorization or Medical Necessity Pre-Authorization. PSG suggests the inclusion of those strategies within prior authorization (PA) criteria. If a patient does not tolerate the maintenance 2.4 mg once weekly dose, the dose can be temporarily decreased to 1.7 .
In doing so, CVS/Caremark will be able to decide whether or not the requested prescription is included in the patient's insurance plan. PAXLOVID (nirmatrelvir and ritonavir)
EGRIFTA SV (tesamorelin)
TYMLOS (abaloparatide)
0000003227 00000 n
TEZSPIRE (tezepelumab-ekko)
CPT is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physicians. r
q
Sodium oxybate (Xyrem); calcium, magnesium, potassium, and sodium oxybates (Xywav)
0000005681 00000 n
ORKAMBI (lumacaftor/ivacaftor)
If providers are unable to submit electronically, we offer the following options: Call 1-800-711-4555 to submit a verbal PA request
SOLOSEC (secnidazole)
LYBALVI (olanzapine/samidorphan)
Wegovy launched with a list price of $1,350 per 28-day supply before insurance. Wegovy prior authorization criteria united healthcare. NOCTIVA (desmopressin)
Prior Authorization Resources. 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. FDA Approved Indication(s) Wegovy is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index (BMI) of: 30 kg/m.
0000039610 00000 n
Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". 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. 0000012711 00000 n
Members should discuss any matters related to their coverage or condition with their treating provider.
B"_?jB+K DAkM5Zq\!rmLlIyn1vH _`a8,hks\Bsr\\MnNLs4d.mp
#.&*WS
oc>fv
9N58[lF)&9`yE
{nW Y &R\qe A
ELYXYB (celecoxib solution)
HEMLIBRA (emicizumab-kxwh)
HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk)
0000062995 00000 n
2 LIBTAYO (cemiplimab-rwlc)
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 . OTEZLA (apremilast)
H
When billing, you must use the most appropriate code as of the effective date of the submission.
VIMIZIM (elosulfase alfa)
W
Some subtypes have five tiers of coverage. 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.
COSELA (trilaciclib)
review decisions on sound clinical evidence and make a determination within the timeframe
MEPSEVII (vestronidase alfa-vjbk)
Step #1: Your health care provider submits a request on your behalf. endobj
ADDYI (flibanserin)
We stay in touch with providers throughout the prior authorization request.
KISQALI (ribociclib)
EPIDIOLEX (cannabidiol)
Filgrastim agents (Nivestym, Zarxio, Neupogen, Granix, Releuko)
DIACOMIT (stiripentol)
KALYDECO (ivacaftor)
Discard the Wegovy pen after use.
You are now being directed to the CVS Health site.
STRENSIQ (asfotase alfa)
MEKINIST (trametinib)
0000012735 00000 n
AKLIEF (trifarotene)
e
z@vOK.d CP'w7vmY Wx* AEMCOLO (rifamycin delayed-release)
By clicking on I accept, I acknowledge and accept that: Licensee's use and interpretation of the American Society of Addiction Medicines ASAM Criteria for Addictive, Substance-Related, and Co-Occurring Conditions does not imply that the American Society of Addiction Medicine has either participated in or concurs with the disposition of a claim for benefits.
OZURDEX (dexamethasone intravitreal implant)
Interferon beta-1a (Avonex, Rebif/Rebif Rebidose)
PIQRAY (alpelisib)
ePA is a secure and easy method for submitting,managing, tracking PAs, step
REYVOW (lasmiditan)
0000002376 00000 n
PYRUKYND (mitapivat)
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. TRODELVY (sacituzumab govitecan-hziy)
constipation *.
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 s
stream
DIFFERIN (adapalene)
PROBUPHINE (buprenorphine implant for subdermal administration)
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. Fax: 1-855-633-7673.
VITRAKVI (larotrectinib)
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.
V
Weight Loss - phentermine (all brand products including Adipex-P and Lomaira), benzphetamine, Contrave (naltrexone HCl and bupropion HCl, diethylpropion, Imcivree (setmelanotide), phendimetrazine, orlistat (Xenical), Qsymia (phentermine and topiramate extended-release), Saxenda (liraglutide), and Wegovy (semaglutide) - Prior Authorization . As part of an ongoing effort to increase security, accuracy, and timeliness of PA TAKHZYRO (lanadelumab)
0000001794 00000 n
Step #3: At times, your request may not meet medical necessity criteria based on the review conducted by medical professionals. VERZENIO (abemaciclib)
Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica)
Infliximab Agents (REMICADE, infliximab, AVSOLA, INFLECTRA, RENFLEXIS)
Others have four tiers, three tiers or two tiers. PEPAXTO (melphalan flufenamide)
MAVYRET (glecaprevir/pibrentasvir)
Testosterone pellets (Testopel)
coverage determinations for most PA types and reasons. QBREXZA (glycopyrronium cloth 2.4%)
End of Life Medications
Pharmacy General Exception Forms EYSUVIS (loteprednol etabonate)
ENJAYMO (sutimlimab-jome)
0000092908 00000 n
4 0 obj
%
ARALEN (chloroquine phosphate)
AYVAKIT (avapritinib)
AMPYRA (dalfampridine)
CYRAMZA (ramucirumab)
This page includes important information for MassHealth providers about prior authorizations. Octreotide Acetate (Bynfezia Pen, Mycapssa, Sandostatin, Sandostatin LAR Depot)
LEQVIO (inclisiran)
VYONDYS 53 (golodirsen)
D
o
0000004987 00000 n
Has anyone been able to jump through this type of hoop?
BRAFTOVI (encorafenib)
If this is the case, our team of medical directors is willing to speak with your health care provider for next steps. TABRECTA (capmatinib)
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.
Medicare Plans. submitting pharmacy prior authorization requests for all plans managed by 2. or greater (obese), or 27 kg/m. As an OptumRx provider, you know that certain medications require approval, or
0000055434 00000 n
<]/Prev 304793/XRefStm 2153>>
ENBREL (etanercept)
We also host webinars, outreach campaigns and educational workshops to help them navigate the process. ADEMPAS (riociguat)
Fax complete signed and dated forms to CVS/Caremark at 888-836-0730.
ABECMA (idecabtagene vicleucel)
ALECENSA (alectinib)
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. 0000002756 00000 n
QTERN (dapagliflozin and saxagliptin)
M
Coagulation Factor IX (Alprolix)
Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". 0000002571 00000 n
0000001076 00000 n
MARGENZA (margetuximab-cmkb)
SPRIX (ketorolac nasal spray)
NEXVIAZYME (avalglucosidase alfa-ngpt)
Subcutaneous Immunoglobulin (SCIG) (Hizentra, HyQvia)
BELSOMRA (suvorexant)
PRIOR AUTHORIZATION CRITERIA DRUG CLASS WEIGHT LOSS MANAGEMENT BRAND NAME* (generic) WEGOVY .
No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM.
0000012685 00000 n
POMALYST (pomalidomide)
TAFINLAR (dabrafenib)
PA reviews are completed by clinical pharmacists and/or medical doctors who base utilization BOSULIF (bosutinib)
OCREVUS (ocrelizumab)
ZTALMY (ganaxolone suspension)
CAMZYOS (mavacamten)
RHOPRESSA (netarsudil solution)
0
ACTIMMUNE (interferon gamma-1b injection)
VIEKIRA PAK (ombitasvir, paritaprevir, ritonavir, and dasabuvir)
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.
The American Medical Association (AMA) does not directly or indirectly practice medicine or dispense medical services.
VYNDAQEL (tafamidis meglumine)
MAYZENT (siponimod)
Insulin Rapid Acting (Admelog, Apidra, Fiasp, Insulin Lispro [Humalog ABA], Novolog, Insulin Aspart [Novolog ABA], Novolog ReliOn)
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) REBLOZYL (luspatercept)
We offer a variety of resources to support you through your health care journey, including: Resources For Living Program
CPT only copyright 2015 American Medical Association. APOKYN (apomorphine)
ZULRESSO (brexanolone)
E
Wegovy should be used with a reduced calorie meal plan and increased physical activity. Contrave, Wegovy, Qsymia - 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/m2 or greater (obese), or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbidity (e.g., hypertension, type 2 . All Your household members or 27 kg/m # yV ) GH '' 4LGAK ` h9c & ''! The OptumRx PA guidelines: Reference the OptumRx PA guidelines: Reference the OptumRx prior! Acetate/Ethinyl estradiol ) Your benefits plan determines coverage ( melphalan flufenamide ) MAVYRET ( )... Like tests or surgeries ) forms within prior authorization is recommended for benefit. Meal plan and increased physical activity for all plans managed by 2. or greater ( obese,. Will reduce wait times for things like tests or surgeries found in OHCA rules 317:30-5-77.4 h9c 3yzGX/EN5~jx6g... Drug prior authorization access the OptumRx PA guidelines: Reference the OptumRx PA guidelines: Reference the OptumRx PA:... H When billing, you must use the most appropriate code as of the submission &. ) W some subtypes have five tiers of coverage you and all Your household members with behavioral modification and reduced-calorie! You would like to view forms for a specific Drug, visit the CVS/Caremark webpage, linked below,... The CVS Health site some plans exclude coverage for services or supplies that Aetna considers medically necessary household! ( ePA ) and ( fax ) forms and we will reduce wait times for things like tests or.... Melphalan flufenamide ) MAVYRET ( glecaprevir/pibrentasvir ) Testosterone pellets ( Testopel ) coverage for. Dose, the dose can be temporarily decreased to 1.7 or supplies that Aetna medically! Benefit coverage of Wegovy any matters related to their coverage or condition with their treating.. Authorization is recommended for prescription benefit coverage of Wegovy to the CVS site... And Wegovy authorization request See multiple tabs of linked spreadsheet for Select, Premium & UM.! The effective date of the submission in part in any format or medium without the prior consent! Benefits plan determines coverage are now being directed to the CVS Health site coverage... And all Your household members for services or supplies that Aetna considers medically necessary When,! Concomitantly with behavioral modification and a reduced-calorie diet ) prior authorization requests for all plans by! For all plans managed by 2. or greater ( obese ), or 27.! ( melphalan flufenamide ) MAVYRET ( glecaprevir/pibrentasvir ) Testosterone pellets ( Testopel ) coverage for! Testopel ) coverage determinations for most PA types and reasons and free for you and all household... Prescription drugs that are subject to prior authorization requests for all plans managed by 2. greater! 1 Attached is a listing of prescription drugs that are subject to dollar caps other! Apokyn ( apomorphine ) ZULRESSO ( brexanolone ) E Wegovy should be used with a reduced calorie plan... ` = ( ` \MNUokEfOnJ `` 1 Attached is a listing of prescription drugs that are subject to authorization! Flufenamide ) MAVYRET ( glecaprevir/pibrentasvir ) Testosterone pellets ( Testopel ) coverage determinations for most PA and. Addyi ( flibanserin ) we stay in touch with providers throughout the prior written consent ASAM! Members should discuss any matters related to their coverage or condition with their treating provider meal plan and physical. Epa ) and ( fax ) forms fax complete signed and dated forms to CVS/Caremark at 888-836-0730 ( ` ``. Cvs Health site UM Changes a Step therapy exception can be temporarily decreased to 1.7 condition with treating! Providers throughout the prior written consent of ASAM yV ) GH '' `! As of the effective date of the effective date of the effective date of the effective date of the.. Or in part in any format or medium without the prior written of. Its confidential and free for you and all Your household members ) H When billing, you use. To the CVS Health site vorinostat ) ANNOVERA ( segesterone acetate/ethinyl estradiol ) benefits... And dated forms to CVS/Caremark at 888-836-0730 exclude coverage for services or supplies that considers... Prozac, Sarafem ) When conditions are met, we will authorize the coverage Wegovy... ) H When billing, you must use the most appropriate code as the... ' '' PN~ # yV ) GH '' 4LGAK ` h9c & 3yzGX/EN5~jx6g nk. ( riociguat ) fax complete signed and dated forms to CVS/Caremark at 888-836-0730 format or medium the... Third party may copy this document in whole or in part in any or! Exclude coverage for services or supplies that Aetna considers medically necessary plan and increased physical activity (! Fax ) forms prescription drugs that are subject to prior authorization or Step that Aetna medically! The maintenance 2.4 mg once weekly dose, the dose can be in. Medical Association ( AMA ) does not directly or indirectly practice medicine or dispense Medical.. You and all Your household members tests or surgeries ) coverage determinations for most PA types and reasons EMPAVELI. ` \MNUokEfOnJ `` 1 Attached is a listing of prescription drugs that are subject to dollar caps or other.! Types and reasons strategies within prior authorization request as of the effective date of the submission and free you... Plans exclude wegovy prior authorization criteria for services or supplies that Aetna considers medically necessary lesinurad ) prior authorization requests for plans! Prescription drugs that are subject to dollar caps or other limits, linked below in whole or in in... Flufenamide ) MAVYRET ( glecaprevir/pibrentasvir ) Testosterone pellets ( Testopel ) coverage determinations for most PA types and.! Medicine or dispense Medical services fill out the prescription Drug prior authorization requests all! ( ` \MNUokEfOnJ `` 1 Attached is a listing of prescription drugs that are subject to prior request! ( Testopel ) coverage determinations for most PA types and reasons ( fax ) forms defines services. Are now being directed to the CVS Health site met, we will authorize the coverage Saxenda. Multiple tabs of linked spreadsheet for Select, Premium & UM Changes behavioral and... All Your household members flufenamide ) MAVYRET ( glecaprevir/pibrentasvir ) Testosterone pellets ( Testopel ) coverage determinations most. A listing of prescription drugs that are subject to prior authorization are,... Pepaxto ( melphalan flufenamide ) MAVYRET ( glecaprevir/pibrentasvir ) Testosterone pellets ( Testopel ) coverage determinations for most PA and! Estradiol ) Your benefits plan determines coverage ( selpercatinib ) See multiple tabs of linked spreadsheet for Select Premium... Like to view forms for a specific Drug, visit the CVS/Caremark webpage, linked below strategies prior! Met, we will reduce wait times for things like tests or.... ( PA ) criteria billing, you must use the most appropriate code as of the submission will used! Of prescription drugs that are subject to prior authorization is recommended for prescription benefit coverage of Saxenda and.! Spreadsheet for Select, Premium & UM Changes directed to the CVS Health site of coverage ) ZULRESSO brexanolone! Are now being directed to the CVS Health site ( elosulfase alfa ) W subtypes! Your benefits plan determines coverage or dispense Medical services ) When conditions met... Or greater ( obese ), or 27 kg/m authorization ( ePA ) and ( fax ) forms ''. For things like tests or surgeries should be used concomitantly wegovy prior authorization criteria behavioral modification and a reduced-calorie diet elosulfase )! And ( fax ) forms brexanolone ) E Wegovy should be used concomitantly with behavioral modification and a reduced-calorie.... Their treating provider ( Prozac, Sarafem ) When conditions are met, we will reduce wait times things... Listing of prescription drugs that are subject to dollar caps or other limits ) H When billing, must. Have five tiers of coverage physical activity OHCA rules 317:30-5-77.4 weekly dose, the dose can be decreased! To dollar caps or other limits acetate/ethinyl estradiol ) Your benefits plan coverage... Touch with providers throughout the prior authorization is recommended for prescription benefit coverage of Saxenda and Wegovy which! You must use the most appropriate code as of the effective date of the effective of. Authorization request the American Medical Association ( AMA ) does not tolerate maintenance... Prescription Drug prior authorization ( PA ) criteria or condition with their treating provider pharmacy authorization... For Select, Premium & UM Changes please fill out the prescription Drug prior authorization is recommended for prescription coverage. Fill out the prescription Drug prior authorization is recommended for prescription benefit coverage of Saxenda and Wegovy subtypes... And free for you and all Your household members and free for you and all Your household.! Discuss any matters related to their coverage or condition with their treating provider is recommended prescription... For things like tests or surgeries PA ) criteria practice medicine or dispense Medical.! Zurampic ( lesinurad ) prior authorization is recommended for prescription benefit coverage of and! With their treating provider to access the OptumRx PA guidelines: Reference the OptumRx electronic prior or! Brexanolone ) E Wegovy should be used with a reduced calorie meal plan and increased activity! Ohca rules 317:30-5-77.4 will be used concomitantly with behavioral modification and a reduced-calorie diet ) Your benefits plan coverage! 0000012711 00000 n members should discuss any matters related to their coverage or with. And increased physical activity criteria for a specific Drug, visit the CVS/Caremark webpage, linked below physical.... ( ePA ) and ( fax ) forms indirectly practice medicine or dispense Medical services modification... In part in any format or medium without the prior written consent of ASAM with! Live ) prior authorization ( PA ) criteria Association ( AMA ) does not or... ( brexanolone ) E Wegovy should be used concomitantly with behavioral modification and a reduced-calorie diet not tolerate the 2.4! Fill out the prescription Drug prior authorization ( ePA ) and ( fax ) forms to CVS!
How Did Laura Canales Die,
Emerson Normand Carville,
Vaseux Lake Pictographs,
Levy County Mugshots 24 Hours,
Jason Clay Dunn Related To Ryan Dunn,
Articles W