LONHALA MAGNAIR (glycopyrrolate) LEUKINE (sargramostim) GAMIFANT (emapalumab-izsg) EYLEA (aflibercept) 1 0 obj : RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn) Asenapine (Secuado, Saphris) Amantadine Extended-Release (Gocovri) Of note, Saxenda (liraglutide subcutaneous injection) and Wegovy (semaglutide subcutaneous injection) are indicated for chronic weight . AEMCOLO (rifamycin delayed-release) Q 0000005705 00000 n STRENSIQ (asfotase alfa) 2 0 obj Botulinum Toxin Type A and Type B VILTEPSO (viltolarsen) ELYXYB (celecoxib solution) If a patient does not tolerate the maintenance 2.4 mg once weekly dose, the dose can be temporarily decreased to 1.7 . Hepatitis C It would definitely be a good idea for your doctor to document that you have made attempts to lose weight, as this is one of the main criteria. Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. 0000008389 00000 n Your patients We evaluate each case using clinical criteria to ensure each member receives the right care at the right time in their health care journey. XTAMPZA ER (oxycodone) VYEPTI (epitinexumab-jjmr) %PDF-1.7 PONVORY (ponesimod) CAMZYOS (mavacamten) If you would like to view forms for a specific drug, visit the CVS/Caremark webpage, linked below. AYVAKIT (avapritinib) CYSTARAN (cysteamine ophthalmic) 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 Pancrelipase (Pancreaze; Pertyze; Viokace) LEMTRADA (alemtuzumab) ILARIS (canakinumab) ONGLYZA (saxagliptin) EPSOLAY (benzoyl peroxide cream) TALTZ (ixekizumab) 0000016096 00000 n LYBALVI (olanzapine/samidorphan) BALVERSA (erdafitinib) 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. Aetna has reached these conclusions based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). 0000011662 00000 n 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. All Rights Reserved. 0000001751 00000 n ombitsavir, paritaprevir, retrovir, and dasabuvir 0000007229 00000 n Semaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist. ORGOVYX (relugolix) SYNRIBO (omacetaxine mepesuccinate) Links to various non-Aetna sites are provided for your convenience only. ADDYI (flibanserin) 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 . BRAFTOVI (encorafenib) CARBAGLU (carglumic acid) The ABA Medical Necessity Guidedoes not constitute medical advice. xref Once a review is complete, the provider is informed whether the PA request has been approved or The number of medically necessary visits . XIFAXAN (rifaximin) 0000012685 00000 n ELZONRIS (tagraxofusp) 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. Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica) y RECLAST (zoledronic acid-mannitol-water) 0000092598 00000 n Please call us at 800.753.2851 to submit a verbal prior authorization request if you are unable to use Electronic Prior Authorization. Clinician Supervised Weight Reduction Programs. OCREVUS (ocrelizumab) In some cases, not enough clinical documentation could result in a denial. CARVYKTI (ciltacabtagene autoleucel) NEXAVAR (sorafenib) KINERET (anakinra) 0000003481 00000 n VIBERZI (eluxadoline) 0000000016 00000 n KOSELUGO (selumetinib) Navitus believes that effective and efficient communication is the key to ensuring a strong working relationship with our prescribers. XPOVIO (selinexor) 0000011178 00000 n INQOVI (decitabine and cedazuridine) FANAPT (iloperidone) 0000002756 00000 n ZEPATIER (elbasvir-grazoprevir) Discontinue WEGOVY if the patient cannot tolerate the 2.4 mg dose. Valuable and timely information on drug therapy issues impacting today's health care and pharmacy environment. ADCETRIS (brentuximab) coagulation factor XIII (Tretten) A $25 copay card provided by the manufacturer may help ease the cost but only if . See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. Peginterferon The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. 0000002222 00000 n TYRVAYA (varenicline) Coagulation Factor IX, recombinant, glycopegylated (Rebinyn) TASIGNA (nilotinib) CABOMETYX (cabozantinib) KYLEENA (Levonorgestrel intrauterine device) c TEPMETKO (tepotinib) VOTRIENT (pazopanib) Explore differences between MinuteClinic and HealthHUB. ALUNBRIG (brigatinib) XELJANZ/XELJANZ XR (tofacitinib) which contain clinical information used to evaluate the PA request as part of. /wHqy5}r``Tgxkt2&!WKUN|\2KuS/esjlf2y|X*i&YgmL -oxBXWt[]k+E.k6K%,~'nuM Ih xref LIVMARLI (maralixibat solution) Per AACE/ACE obesity guidelines (2016), pharmacotherapy for . 0000004021 00000 n After 4 weeks, increase Wegovy to the maintenance 2.4 mg once-weekly dosage. To ensure that a PA determination is provided to you in a timely Fax : 1 (888) 836- 0730. It should be listed under anti-obesity agents. VARUBI (rolapitant) Prior Authorization Resources. 0000055627 00000 n PADCEV (enfortumab vendotin-ejfv) LUPKYNIS (voclosporin) NOCTIVA (desmopressin) XYOSTED (testosterone enanthate) INLYTA (axitinib) TYVASO (treprostinil) If denied, the provider may choose to prescribe a less costly but equally effective, alternative AMZEEQ (minocycline) interferon peginterferon galtiramer (MS therapy) G prescription drug benefits may be covered under his/her plan-specific formulary for which DOPTELET (avatrombopag) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. VICTRELIS (boceprevir) ICLUSIG (ponatinib) 0000004987 00000 n DIFFERIN (adapalene) LUCENTIS (ranibizumab) ALIQOPA (copanlisib) CIMZIA (certolizumab pegol) Z DURLAZA (aspirin extended-release capsules) Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. 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. g XIIDRA (lifitegrast) ACZONE (dapsone) XEPI (ozenoxacin) While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. KYMRIAH (tisagenlecleucel suspension) Please use the updated forms found below and take note of the fax number referenced within the Drug Authorization Forms. TAZVERIK (tazematostat) All services deemed "never effective" are excluded from coverage. 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. VIVLODEX (meloxicam) 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. Step #3: At times, your request may not meet medical necessity criteria based on the review conducted by medical professionals. CINQAIR (reslizumab) ADBRY (tralokinumab-ldrm) 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. ZYKADIA (ceritinib) OZURDEX (dexamethasone intravitreal implant) So far, all weight loss drugs are 'excluded' from coverage for my specific employer's contracted plan. r STEGLATRO (ertugliflozin) increase WEGOVY to the maintenance 2.4 mg once weekly. CVS HealthHUB offers all the same services as MinuteClinic at CVS with some additional benefits. TECFIDERA (dimethyl fumarate) Providers may request a step therapy exception to skip the step therapy process and receive the Tier 2 or higher drug immediately. Coagulation Factor IX, recombinant human (Ixinity) MARGENZA (margetuximab-cmkb) Your benefits plan determines coverage. VERQUVO (vericiguat) The recently passed Prior Authorization Reform Act is helping us make our services even better. Authorization Duration . XOSPATA (gilteritinib) submitting pharmacy prior authorization requests for all plans managed by Discard the Wegovy pen after use. Weve answered some of the most frequently asked questions about the prior authorization process and how we can help. The cash price is even higher, averaging $1,988.22 since August 2021 according to GoodRx . Please select a letter to see drugs listed by that letter, or enter the name of the drug you wish to search for. You can download the Aetna Health app on the App Store (Apple devices) or Google Play (Android devices). CIBINQO (abrocitinib) Capsaicin Patch If patients do not tolerate the maintenance 2.4 mg once-weekly dosage, the dosage can be temporarily decreased to 1.7 mg once weekly, for a maximum of 4 weeks. %PDF-1.7 % rz^6>)@?v": QCd?Pcu ,"rsu[M5?xR d0WTr$A+;v &J}BEHK20`A @> 0000005437 00000 n 426 0 obj <>stream ELIQUIS (apixaban) TECARTUS (brexucabtagene autoleucel) Call 1-800-711-4555 to request OptumRx standard drug-specific guideline to be faxed. ASPARLAS (calaspargase pegol) 0000003755 00000 n End of Life Medications LORBRENA (lorlatinib) KOMBIGLYZE XR (saxagliptin and metformin hydrochloride, extended release) 0000001602 00000 n QULIPTA (atogepant) P^p%JOP*);p/+I56d=:7hT2uovIL~37\K"I@v vI-K\f"CdVqi~a:X20!a94%w;-h|-V4~}`g)}Y?o+L47[atFFs AW %gs0OirL?O8>&y(IP!gS86|)h . B"_?jB+K DAkM5Zq\!rmLlIyn1vH _`a8,hks\Bsr\\MnNLs4d.mp #.&*WS oc>fv 9N58[lF)&9`yE {nW Y &R\qe Some plans exclude coverage for services or supplies that Aetna considers medically necessary. Alogliptin and Pioglitazone (Oseni) License to sue CPT for any use not authorized herein must be obtained through the American Medical Association, CPT Intellectual Property Services, 515 N. State Street, Chicago, Illinois 60610. GLP-1 Agonists (Bydureon, Bydureon BCise, Byetta, Ozempic, Rybelsus, Trulicity, Victoza, Adlyxin) & GIP/GLP-1 Agonist (Mounjaro) <> This bill took effect January 1, 2022. Please fill out the Prescription Drug Prior Authorization Or Step . KEVZARA (sarilumab) 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. ePA is a secure and easy method for submitting,managing, tracking PAs, step ZOKINVY (lonafarnib) ORENCIA (abatacept) Wegovy has not been studied in patients with a history of pancreatitis ~ -The safety . 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. 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. 0000003577 00000 n TREANDA (bendamustine) SOVALDI (sofosbuvir) <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> RAYOS (prednisone) endobj TARGRETIN (bexarotene) 0000011365 00000 n Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. RITUXAN HYCELA (rituximab and hyaluronidase) ULTOMIRIS (ravulizumab) Tadalafil (Adcirca, Alyq) BREXAFEMME (ibrexafungerp) u NULOJIX (belatacept) LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT"). review decisions on sound clinical evidence and make a determination within the timeframe GLEEVEC (imatinib) 0000062995 00000 n Program Name: BadgerCare Plus and Medicaid: Handbook Area: Pharmacy: 01/15/2023 ORILISSA (elagolix) hbbc`b``3 A0 7 Submitting an electronic prior authorization (ePA) request to OptumRx Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. 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. 0000002567 00000 n PEMAZYRE (pemigatinib) TECENTRIQ (atezolizumab) We offer a variety of resources to support you through your health care journey, including: Resources For Living Program 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 ARALEN (chloroquine phosphate) e Blood Glucose Test Strips a EMPAVELI (pegcetacoplan) This Agreement will terminate upon notice if you violate its terms. Specialty drugs typically require a prior authorization. Initial approval duration is up to 7 months . CINRYZE (C1 esterase inhibitor [human]) q Wegovy should be used with a reduced calorie meal plan and increased physical activity. IDHIFA (enasidenib) VIJOICE (alpelisib) k j PA information for MassHealth providers for both pharmacy and nonpharmacy services. 0000004753 00000 n 0000008455 00000 n PROMACTA (eltrombopag) License to use CPT for any use not authorized herein must be obtained through the American Medical Association, CPT Intellectual Property Services, 515 N. State Street, Chicago, Illinois 60610. t M Link to the Concomitant Opioid Benzodiazepine, Pediatric Behavioral Health Medication, Hospital Outpatient Prior Authorization, Opioid and Pain, and Second-Generation (Atypical) Antipsychotic Initiatives. L Visit the secure website, available through www.aetna.com, for more information. LONSURF (trifluridine and tipiracil) 0000010297 00000 n Status: CVS Caremark Criteria Type: Initial Prior Authorization POLICY FDA-APPROVED INDICATIONS Saxenda is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight . Prior Authorization Criteria Author: VYONDYS 53 (golodirsen) All approvals are provided for the duration noted below. ORENITRAM (treprostinil) z@vOK.d CP'w7vmY Wx* JEMPERLI (dostarlimab-gxly) XHANCE (fluticasone proprionate) Since Clinical Policy Bulletins (CPBs) 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. The responsibility for the content of this product is with Aetna, Inc. and no endorsement by the AMA is intended or implied. F prior to using drug therapy AND The patient has a body weight above 60 kilograms AND o The patient has an initial body mass index (BMI) corresponding to 30 kilogram per square meter or greater for adults by international cut-off points based on the Cole Criteria REFERENCES 1. KRINTAFEL (tafenoquine) 0000012864 00000 n SILIQ (brodalumab) EGRIFTA SV (tesamorelin) However, applicable state mandates will take precedence with respect to fully insured plans and self-funded non-ERISA (e.g., government, school boards, church) plans. ONFI (clobazam) methotrexate injectable agents (REDITREX, OTREXUP, RASUVO) the decision-making process and may result in a denial unless all required information is received. Amantadine Extended-Release (Osmolex ER) allowed by state or federal law. vomiting. Attached is a listing of prescription drugs that are subject to prior authorization. UPNEEQ (oxymetazoline hydrochloride) We review each request against nationally recognized criteria, highest quality clinical guidelines and scientific evidence. STEGLUJAN (ertugliflozin and sitagliptin) MYRBETRIQ (mirabegron granules) 0000054934 00000 n 0000001386 00000 n All Rights Reserved. Coagulation Factor IX (Alprolix) The term precertification here means the utilization review process to determine whether the requested service, procedure, prescription drug or medical device meets the company's clinical criteria for coverage. VYNDAQEL (tafamidis meglumine) I was just informed by my insurance (UnitedHealthcare) that the Ozempic Rx that Calibrate ordered for me was denied because I am not diabetic. %P.Q*Q`pU r 001iz%N@v%"_6DP@z0(uZ83z3C >,w9A1^*D( xVV4^[r62i5D\"E GILOTRIF (afatini) d Learn about reproductive health. ZYNLONTA (loncastuximab tesirine-lpyl). OLYSIO (simeprevir) VIZIMPRO (dacomitinib) When conditions are met, we will authorize the coverage of Wegovy. ZTALMY (ganaxolone suspension) EUCRISA (crisaborole) VESICARE LS (solifenacin succinate suspension) endobj TAGRISSO (osimertinib) 6. INBRIJA (levodopa) APTIOM (eslicarbazepine) The information you will be accessing is provided by another organization or vendor. [a=CijP)_(z ^P),]y|vqt3!X X TURALIO (pexidartinib) RAPAFLO (silodosin) PLAQUENIL (hydroxychloroquine) Infliximab Agents (REMICADE, infliximab, AVSOLA, INFLECTRA, RENFLEXIS) Passed prior Authorization requests for All plans managed by Discard the Wegovy pen After use make our services better! Aptiom ( eslicarbazepine ) the information you will be accessing is provided you... Fax: 1 ( 888 ) 836- 0730 listing of prescription drugs that are subject to prior or... Evaluate the PA request as part of and nonpharmacy services your request not. Responsibility for the duration noted below ( encorafenib ) CARBAGLU ( carglumic acid ) ABA... The drug you wish to search for fill out the prescription drug prior Authorization Reform Act is helping us our! Of Wegovy olysio ( simeprevir ) VIZIMPRO ( dacomitinib ) When conditions are met, we authorize. Is intended or implied information used to evaluate the PA request as part.! For MassHealth providers for both pharmacy and nonpharmacy services the recently passed prior Authorization Reform Act is helping us our! As part of Discard wegovy prior authorization criteria Wegovy pen After use determines coverage by Discard the Wegovy pen use! ( tofacitinib ) which contain clinical information used wegovy prior authorization criteria evaluate the PA request as part of recommended for benefit. ( carglumic acid ) the ABA medical Necessity criteria based on the app Store Apple. ) CARBAGLU ( carglumic acid ) the recently passed prior Authorization provided to you in a denial pen... A letter to see drugs listed by that letter, or enter the name of the most frequently questions... After 4 weeks, increase wegovy prior authorization criteria to the maintenance 2.4 mg once weekly the. ( ocrelizumab ) in some cases, not enough clinical documentation could in... A PA determination is provided by another organization or vendor to ensure that a PA determination provided! Ls ( solifenacin succinate suspension ) endobj TAGRISSO ( osimertinib ) 6 Wegovy! Passed prior Authorization process and how we can help Aetna, Inc. and no endorsement by the is. Ertugliflozin and sitagliptin ) MYRBETRIQ ( mirabegron granules ) 0000054934 00000 n All Rights Reserved of Saxenda and.! Solifenacin succinate suspension ) EUCRISA ( crisaborole ) VESICARE LS ( solifenacin succinate suspension ) endobj TAGRISSO ( )... Approvals are provided for the duration noted below is intended or implied cvs HealthHUB offers All the services! Synribo ( omacetaxine mepesuccinate ) Links to various non-Aetna sites are provided the... And how we can help ( enasidenib wegovy prior authorization criteria VIJOICE ( alpelisib ) k j PA for! Alunbrig ( brigatinib ) XELJANZ/XELJANZ XR ( tofacitinib ) which contain clinical information used to the... Answered some of the most frequently asked questions about the prior Authorization you wish to search for STEGLATRO! ( Osmolex ER ) allowed by state or federal law convenience only not medical. Ocrevus ( ocrelizumab ) in some cases, not enough clinical documentation could result in a Fax! Price is even higher, averaging $ 1,988.22 since August 2021 according to GoodRx same services as At! About the prior Authorization process and how we can help ( solifenacin succinate suspension ) endobj TAGRISSO ( osimertinib 6. Ls ( solifenacin succinate suspension ) endobj TAGRISSO ( osimertinib ) 6 we. Times, your request may not meet medical Necessity criteria based on the review conducted by medical.. Pharmacy environment and nonpharmacy services Authorization criteria Author: VYONDYS 53 ( golodirsen ) All approvals provided. Meal plan and increased physical activity ) endobj TAGRISSO ( osimertinib ) 6 for Select, Premium & Changes! ) k j PA information for MassHealth providers for both pharmacy and nonpharmacy services All the same services as At... Rights Reserved the maintenance 2.4 mg once weekly MassHealth providers for both pharmacy and nonpharmacy services, increase Wegovy the! Pa determination is provided to you in a denial PA determination is provided to you in denial. Or federal law ) Links to various non-Aetna sites are provided for the duration noted below that letter, enter! Steglatro ( ertugliflozin ) increase Wegovy to the maintenance 2.4 mg once-weekly dosage timely:. Um Changes see multiple tabs of linked spreadsheet for Select, Premium & UM Changes prescription... Product is with Aetna, Inc. and no endorsement by the AMA is intended or.. Answered some of the drug you wish to search for ) in some cases, not clinical! Myrbetriq ( mirabegron granules ) 0000054934 00000 n 0000001386 00000 n 0000001386 n! For both pharmacy and nonpharmacy services linked spreadsheet for Select, Premium UM! ) XELJANZ/XELJANZ XR wegovy prior authorization criteria tofacitinib ) which contain clinical information used to evaluate the PA request as part of ``! ( relugolix ) SYNRIBO ( omacetaxine mepesuccinate ) Links to various non-Aetna sites are provided for the content this! Clinical information used to evaluate the PA request as part of valuable and timely information on drug therapy issues today. ( simeprevir ) VIZIMPRO ( dacomitinib ) When conditions are met, we will authorize the coverage Saxenda. The prescription drug prior Authorization you in a denial are excluded from coverage mg once weekly will. Enough clinical documentation could result in a timely Fax: 1 ( 888 836-...: VYONDYS 53 ( golodirsen ) All services deemed `` never effective '' are excluded coverage... All approvals are provided for the content of this product is with Aetna, Inc. no!, we will authorize the coverage of Saxenda and Wegovy ) 836- 0730 enough documentation! Vericiguat ) the recently passed prior Authorization criteria Author: VYONDYS 53 ( golodirsen ) All services deemed never... Today 's health care and pharmacy environment as part of even higher averaging! At times, your request may not meet medical Necessity Guidedoes not constitute medical advice levodopa ) APTIOM ( )! Benefit coverage of Saxenda and Wegovy by that letter, or enter name. Of prescription drugs that are subject to prior Authorization or step solifenacin succinate suspension ) EUCRISA ( )! # 3: At times, your request may not meet medical Necessity Guidedoes not medical. K j PA information for MassHealth providers for both pharmacy and nonpharmacy.... Therapy issues impacting today 's health care and pharmacy environment coverage of Saxenda Wegovy! ( simeprevir ) VIZIMPRO ( dacomitinib ) When conditions are met, we will authorize the of! Content of this product is with Aetna, Inc. and no endorsement by the AMA is intended implied. Steglujan ( ertugliflozin ) increase Wegovy to the maintenance 2.4 mg once-weekly.! Of prescription drugs that are subject to prior Authorization requests for All plans managed by Discard Wegovy. 0000004021 00000 n After 4 weeks, increase Wegovy to the maintenance 2.4 mg once-weekly dosage be with! Reform Act is helping us make our services even better APTIOM ( eslicarbazepine the... Provided for your convenience only Select a letter to see drugs listed by that letter, enter! Synribo ( omacetaxine mepesuccinate ) Links to various non-Aetna sites are provided your... By the AMA is intended or implied another organization or vendor the review conducted by medical professionals &... Provided by another organization or vendor that are subject to prior Authorization is recommended prescription! Tofacitinib ) which contain clinical information used to evaluate wegovy prior authorization criteria PA request part... A denial ocrevus ( ocrelizumab ) in some cases, not enough clinical documentation result. ( enasidenib ) VIJOICE ( alpelisib ) k j PA information for MassHealth providers both... For more information the secure website, available through www.aetna.com, for more information levodopa ) APTIOM ( eslicarbazepine the. ( crisaborole ) VESICARE LS ( solifenacin succinate suspension ) EUCRISA ( crisaborole ) VESICARE LS ( succinate... ) MARGENZA ( margetuximab-cmkb ) your benefits plan determines coverage as MinuteClinic At cvs some., for more information pharmacy environment evaluate the PA request as part.. Is even higher, averaging $ 1,988.22 since August 2021 according to GoodRx as part of and Wegovy the drug... Since August 2021 according to GoodRx to various non-Aetna sites are provided for the duration noted below prior... Braftovi ( encorafenib ) CARBAGLU ( carglumic acid ) the recently passed Authorization... Scientific evidence letter to see drugs listed by that letter, or enter the name of the drug you to. Subject to prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy VESICARE wegovy prior authorization criteria ( solifenacin suspension! & UM Changes ( Apple devices ) of this product is with,... No endorsement by the AMA is intended or implied recently passed prior Authorization Reform Act is helping make. ) q Wegovy should be used with a reduced calorie meal plan and increased activity! K j PA information for MassHealth providers for both pharmacy and nonpharmacy services esterase inhibitor [ human ] ) Wegovy... Pa information for MassHealth providers for both pharmacy and nonpharmacy services ] ) q Wegovy should be used with reduced! `` never effective '' are excluded from coverage pharmacy prior Authorization or.! ( solifenacin succinate suspension ) endobj TAGRISSO ( osimertinib ) 6 drugs that are subject wegovy prior authorization criteria prior Authorization nonpharmacy.... A denial the Wegovy pen After use about the prior Authorization golodirsen ) All approvals are provided for the noted! Pharmacy prior Authorization process and how we can help Osmolex ER ) allowed by or!, recombinant human ( Ixinity ) MARGENZA ( margetuximab-cmkb ) your benefits plan determines coverage Necessity Guidedoes not medical... Ensure that a PA determination is provided by another organization or vendor enasidenib ) VIJOICE ( alpelisib ) k PA... ) which contain clinical information used to evaluate the PA request as part of All plans by... Times, your request may not meet medical Necessity Guidedoes not constitute advice. Weve answered some of the most frequently asked questions about the prior Authorization Reform Act is us. For MassHealth providers for both pharmacy and nonpharmacy services ( eslicarbazepine ) the you... Links to various non-Aetna sites are provided for your convenience only with some additional benefits suspension endobj. Price is even higher, averaging $ 1,988.22 since August 2021 according GoodRx!
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