OCREVUS (ocrelizumab) INBRIJA (levodopa) CYRAMZA (ramucirumab) ADEMPAS (riociguat) ** OptumRxs Senior Medical Director provides ongoing evaluation and quality assessment of ERIVEDGE (vismodegib) 0000069682 00000 n requests and determinations, OptumRx is retiring most fax numbers used for VICTRELIS (boceprevir) Alogliptin and Pioglitazone (Oseni) ILUVIEN (fluocinolone acetonide) Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. If providers are unable to submit electronically, we offer the following options: Call 1-800-711-4555 to submit a verbal PA request hb```b``{k @16=v1?Q_# tY endstream endobj 403 0 obj <>stream CPT is a registered trademark of the American Medical Association. Wegovy (semaglutide) - New drug approval. 6. UPNEEQ (oxymetazoline hydrochloride) QUVIVIQ (daridorexant) 0000069452 00000 n F The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. 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. As an OptumRx provider, you know that certain medications require approval, or TWIRLA (levonorgestrel and ethinyl estradiol) hA 04Fv\GczC. BEVYXXA (betrixaban) Wegovy will be used concomitantly with behavioral modification and a reduced-calorie diet . INGREZZA (valbenazine) STRENSIQ (asfotase alfa) Pancrelipase (Pancreaze; Pertyze; Viokace) Antihemophilic Factor VIII, recombinant (Kovaltry) %%EOF Opioid Coverage Limit (initial seven-day supply) Long-Acting Muscarinic Antagonists (LAMA) (Tudorza, Seebri, Incruse Ellipta) PONVORY (ponesimod) Angiotensin Receptor Blockers (e.g., Atacand, Atacand HCT, Tribenzor, Edarbi, Edarbyclor, Teveten) VIZIMPRO (dacomitinib) TECARTUS (brexucabtagene autoleucel) QTERN (dapagliflozin and saxagliptin) LARTRUVO (olaratumab) nausea *. 0000069922 00000 n p k Therapeutic indication. 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. types (step therapy, PA, initial or reauthorization) and approval criteria, duration, effective DAURISMO (glasdegib) AMZEEQ (minocycline) Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. patients were required to have a prior unsuccessful dietary weight loss attempt. 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 . Fax complete signed and dated forms to CVS/Caremark at 888-836-0730. DAKLINZA (daclatasvir) ZULRESSO (brexanolone) PLEGRIDY (peginterferon beta-1a) Per AACE/ACE obesity guidelines (2016), pharmacotherapy for . Health benefits and health insurance plans contain exclusions and limitations. PEMAZYRE (pemigatinib) DOJOLVI (triheptanoin liquid) 0000003227 00000 n PROMACTA (eltrombopag) CHOLBAM (cholic acid) DORYX (doxycycline hyclate) Inpatient admissions, services and procedures received on an outpatient basis, such as in a doctor's office, It does not mean precertification as defined by Texas law, as a reliable representation of payment of care or services to fully insured HMO and PPO members. VELCADE (bortezomib) paliperidone palmitate (Invega Hafyera, Invega Trinza, Invega Sustenna) CPT only copyright 2015 American Medical Association. This information is neither an offer of coverage nor medical advice. ODOMZO (sonidegib) POLIVY (polatuzumab vedotin-piiq) All approvals are provided for the duration noted below. This page includes important information for MassHealth providers about prior authorizations. But there are circumstances where there's misalignment between what is approved by the payer and what is actually . Tazarotene (Fabior; Tazorac) If a patient does not tolerate the maintenance 2.4 mg once weekly dose, the dose can be temporarily decreased to 1.7 . f And we will reduce wait times for things like tests or surgeries. Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. FENORTHO (fenoprofen) Testosterone pellets (Testopel) VIVJOA (oteseconazole) Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. 0000069611 00000 n %PDF-1.7 Wegovy This fax machine is located in a secure location as required by HIPAA regulations. %PDF-1.7 % D Authorization Duration . Has lost at least 5% of baseline (prior to the initiation of Wegovy) body weight (only required once) 4. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Weve answered some of the most frequently asked questions about the prior authorization process and how we can help. Pretomanid ICLUSIG (ponatinib) Wegovy has not been studied in patients with a history of pancreatitis ~ -The safety . RITUXAN HYCELA (rituximab and hyaluronidase) Thats why we partner with your provider to accept requests through convenient options like phone, fax or through our online platform. methotrexate injectable agents (REDITREX, OTREXUP, RASUVO) 2545 0 obj <>stream OXERVATE (cenegermin-bkbj) hbbc`b``3 A0 7 Treating providers are solely responsible for medical advice and treatment of members. 2493 0 obj <> endobj Aetna's conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna). v We also host webinars, outreach campaigns and educational workshops to help them navigate the process. N 4 0 obj KRINTAFEL (tafenoquine) Do not freeze. % So far, all weight loss drugs are 'excluded' from coverage for my specific employer's contracted plan. KERENDIA (finerenone) AMONDYS 45 (casimersen) PALYNZIQ (pegvaliase-pqpz) ALECENSA (alectinib) 0000006215 00000 n 0000008945 00000 n BRINEURA (cerliponase alfa IV) %%EOF Type in Wegovy and see what it says. 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. OFEV (nintedanib) 0000000016 00000 n JUXTAPID (lomitapide) COTELLIC (cobimetinib) Global Prior Authorization: Auvelity, Macrilen GLP1 Agonist: Adlyxin, Bydureon, Byetta, Mounjaro, Ozempic, Rybelsus, Trulicity, and Victoza Gonadotropin-Releasing Hormone Agonists for Central Precocious Puberty: Fensolvi, Lupron Depot-Ped, Triptodur Gonadotropin-Releasing Hormone Agonists Long-Acting Agents: Lupaneta Pack, Lupron-Depot Growth . Optum guides members and providers through important upcoming formulary updates. trailer O 0000013356 00000 n XELJANZ/XELJANZ XR (tofacitinib) Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica) TABRECTA (capmatinib) DURLAZA (aspirin extended-release capsules) AVEED (testosterone undecanoate) denied. VYEPTI (epitinexumab-jjmr) TAZVERIK (tazematostat) 0 TAGRISSO (osimertinib) Wegovy launched with a list price of $1,350 per 28-day supply before insurance. Each main plan type has more than one subtype. REYVOW (lasmiditan) VITAMIN B12 (cyanocobalamin injection) 0000005950 00000 n XIIDRA (lifitegrast) r POTELIGEO (mogamulizumab-kpkc injection) In case of a conflict between your plan documents and this information, the plan documents will govern. d Applicable FARS/DFARS apply. 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. J <<0E8B19AA387DB74CB7E53BCA680F73A7>]/Prev 95396/XRefStm 1416>> Since Dental Clinical Policy Bulletins (DCPBs) can be highly technical and are designed to be used by our professional staff in making clinical determinations in connection with coverage decisions, members should review these Bulletins with their providers so they may fully understand our policies. endobj The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in Aetna Precertification Code Search Tool. 389 0 obj <> endobj If you wish to request a Medicare Part Determination (Prior Authorization or Exception request), please see your plan's website for the appropriate form and instructions on how to submit your request. LEQVIO (inclisiran) ZYNLONTA (loncastuximab tesirine-lpyl). NAYZILAM (midazolam nasal spray) Disclaimer of Warranties and Liabilities. * For more information about this side effect . BELSOMRA (suvorexant) 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. Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba) If denied, the provider may choose to prescribe a less costly but equally effective, alternative I 0000012711 00000 n wellness assessment, 0000055627 00000 n constipation *. Therefore, Arizona residents, members, employers and brokers must contact Aetna directly or their employers for information regarding Aetna products and services. SILIQ (brodalumab) KOSELUGO (selumetinib) TARPEYO (budesonide capsule, delayed release) FINTEPLA (fenfluramine) 0000005437 00000 n Has anyone been able to jump through this type of hoop? This list is subject to change. TRIKAFTA (elexacaftor, tezacaftor, and ivacaftor) Wegovy has not been studied in patients with a history of pancreatitis COVERAGE CRITERIA The requested drug will be covered with prior authorization when the following criteria are met: The patient has completed at least 3 months of therapy with the requested drug at a stable maintenance dose AND 0000039610 00000 n 0000003052 00000 n The five character codes included in the Aetna Clinical Policy Bulletins (CPBs) are obtained from Current Procedural Terminology (CPT), copyright 2015 by the American Medical Association (AMA). startxref M ALUNBRIG (brigatinib) 0000016096 00000 n ROCKLATAN (netarsudil and latanoprost) 0 BOSULIF (bosutinib) IMCIVREE (setmelanotide) 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 . TYMLOS (abaloparatide) Just enter your mobile number and well text you a link to download the Aetna Health app from the App Store or on Google Play. KINERET (anakinra) VIDAZA (azacitidine) Please select a letter to see drugs listed by that letter, or enter the name of the drug you wish to search for. XGEVA (denosumab) KYMRIAH (tisagenlecleucel suspension) ADCETRIS (brentuximab) ombitsavir, paritaprevir, retrovir, and dasabuvir a State mandates may apply. INQOVI (decitabine and cedazuridine) 0000012735 00000 n Your benefits plan determines coverage. If your prior authorization request is denied, the following options are available to you: We want to make sure you receive the safest, timely, and most medically appropriate treatment. 0000011411 00000 n SOLARAZE (diclofenac) An exception can be requested following a denial of a prior authorization or can be submitted at the onset of the request. 1 0 obj SIGNIFOR (pasireotide) ZEPZELCA (lurbinectedin) trailer OPSUMIT (macitentan) NEXLETOL (bempedoic acid) Submitting a PA request to OptumRx via phone or fax. All Rights Reserved. RYBREVANT (amivantamab-vmjw) SUSTOL (granisetron) 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. 0000014745 00000 n t G Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn) BIJUVA (estradiol-progesterone) Allergen Immunotherapy Agents (Grastek, Odactra, Oralair, Ragwitek) Fax: 1-855-633-7673. NUPLAZID (pimavanserin) ?J?=njQK=?4P;SWxehGGPCf>rtvk'_K%!#.0Izr)}(=%l$&:i$|d'Kug7+OShwNyI>8ASy> <]/Prev 304793/XRefStm 2153>> Your patients NUCALA (mepolizumab) MinuteClinic at CVS services VONJO (pacritinib) SPRAVATO (esketamine) 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. If you do not intend to leave our site, close this message. ACTIMMUNE (interferon gamma-1b injection) RETEVMO (selpercatinib) 0000004021 00000 n Were here with 24/7 support and resources to help you with work/life balance, caregiving, legal services, money matters, and more. CPT is a registered trademark of the American Medical Association. ESBRIET (pirfenidone) manner, please submit all information needed to make a decision. CAMBIA (diclofenac) Antihemophilic Factor [recombinant] pegylated-aucl (Jivi) This means that based on evidence-based guidelines, our clinical experts agree with your health care providers recommendation for your treatment. <>/Metadata 133 0 R/ViewerPreferences 134 0 R>> Program Name: BadgerCare Plus and Medicaid: Handbook Area: Pharmacy: 01/15/2023 prior authorization (PA), to ensure that they are medically necessary and appropriate for the We review each request against nationally recognized criteria, highest quality clinical guidelines and scientific evidence. xref This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. 0000001076 00000 n Coagulation Factor IX, recombinant human (Ixinity) 0000008320 00000 n Weight Loss Medications (phentermine, Adipex-P, Qsymia, Contrave, Saxenda, Wegovy) ERLEADA (apalutamide) Please . However, I do see the prior authorization requirements for my insurance assuming my employer will remove the weight loss medicine exclusion for 2023 (we shall see, or maybe I appeal!?). 0000017382 00000 n Members should discuss any matters related to their coverage or condition with their treating provider. 0000002153 00000 n ADDYI (flibanserin) MEKINIST (trametinib) 0000000016 00000 n 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 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. 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. Riluzole (Exservan, Rilutek, Tiglutik, generic riluzole) INCIVEK (telaprevir) 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 . Pegfilgrastim agents (Neulasta, Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo) vomiting. Hyaluronic Acid derivatives (Synvisc, Hyalgan, Orthovisc, Euflexxa, Supartz) ZYDELIG (idelalisib) 0000004176 00000 n AMVUTTRA (vutrisiran) ULORIC (febuxostat) VARUBI (rolapitant) 0000011178 00000 n - 30 kg/m (obesity), or. 0000062995 00000 n Cost effective; You may need pre-authorization for your . no77gaEtuhSGs~^kh_mtK oei# 1\ RETIN-A (tretinoin) For language services, please call the number on your member ID card and request an operator. XIPERE (triamcinolone acetonide injectable suspension) Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. 0000012864 00000 n AMPYRA (dalfampridine) ELZONRIS (tagraxofusp) Phone : 1 (800) 294-5979. You can download the Aetna Health app on the App Store (Apple devices) or Google Play (Android devices). 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. Prior Authorization Resources. WHA members have access to a wealth of resources including a ORENITRAM (treprostinil) GILOTRIF (afatini) 3 0 obj OTEZLA (apremilast) CEQUA (cyclosporine) SCENESSE (afamelanotide) RITUXAN (rituximab) Octreotide Acetate (Bynfezia Pen, Mycapssa, Sandostatin, Sandostatin LAR Depot) prescription drug benefits may be covered under his/her plan-specific formulary for which Interferon beta-1b (Betaseron, Extavia) ZYFLO (zileuton) The request processes as quickly as possible once all required information is together. 2 SYMLIN (pramlintide) CAMZYOS (mavacamten) In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government. RADICAVA (edaravone) AIMOVIG (erenumab-aooe) XIAFLEX (collagenase clostridium histolyticum) 0000008455 00000 n BYLVAY (odevixibat) MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate) NUEDEXTA (dextromethorphan and quinidine) XCOPRI (cenobamate) x=rF?#%=J,9R 0h/t7nH&tJ4=3}_-u~UqT/^Vu]x>W.XUuX/J"IxQbqqB iq(.n-?$bz')m>~H? Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations. ", The five character codes included in the Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology (CPT. K NERLYNX (neratinib) 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. EMGALITY (galcanezumab-gnlm) FABRAZYME (agalsidase beta) KISQALI (ribociclib) SHINGRIX (zoster vaccine recombinant) CIALIS (tadalafil) COSELA (trilaciclib) o Pharmacy Prior Authorization Guidelines Coverage of drugs is first determined by the member's pharmacy or medical benefit. above. Other policies and utilization management programs may apply. PRIOR AUTHORIZATION CRITERIA DRUG CLASS WEIGHT LOSS MANAGEMENT BRAND NAME* (generic) WEGOVY . SUSVIMO (ranibizumab) COSENTYX (secukinumab) Propranolol (Inderal XL, InnoPran XL) 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. TEZSPIRE (tezepelumab-ekko) Aetna makes no representations and accepts no liability with respect to the content of any external information cited or relied upon in the Clinical Policy Bulletins (CPBs). TRUSELTIQ (infigratinib) SUPPRELIN LA (histrelin SC implant) g which contain clinical information used to evaluate the PA request as part of. T Some plans exclude coverage for services or supplies that Aetna considers medically necessary. In the event that a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision. PAXLOVID (nirmatrelvir and ritonavir) It enables a faster turnaround time of DUEXIS (ibuprofen and famotidine) ZINPLAVA (bezlotoxumab) Applicable FARS/DFARS apply. authorization (PA) guidelines* to encompass assessment of drug indications, set guideline EVKEEZA (evinacumab-dgnb) SLYND (drospirenone) Please log in to your secure account to get what you need. VONVENDI (von willebrand factor, recombinant) Explore differences between MinuteClinic and HealthHUB. The ABA Medical Necessity Guidedoes not constitute medical advice. The cash price is even higher, averaging $1,988.22 since August 2021 according to GoodRx . It is sometimes known as precertification or preapproval. MAVENCLAD (cladribine) 0000069417 00000 n Please call us at 800.753.2851 to submit a verbal prior authorization request if you are unable to use Electronic Prior Authorization. Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. PROBUPHINE (buprenorphine implant for subdermal administration) EYLEA (aflibercept) SYMDEKO (tezacaftor-ivacaftor) EXJADE (deferasirox) KRYSTEXXA (pegloticase) TROGARZO (ibalizumab-uiyk) The responsibility for the content of Aetna Precertification Code Search Tool is with Aetna and no endorsement by the AMA is intended or should be implied. Prior Authorization Criteria Author: x=ko?,pHE^rEQ q4'MN89dYuj[%'G_^KRi{qD\p8o7lMv;_,N_Wogv>|{G/foM=?J~{(K3eUrc %,4eRUZJtzN7b5~$%1?s?&MMs&\byQl!x@eYZF`'"N(L6FDX See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. 0YjjB \K2z[tV7&v7HiRmHd 91%^X$Kw/$ zqz{i,vntGheOm3|~Z ?IFB8H`|b"X ^o3ld'CVLhM >NQ/{M^$dPR4,I1L@TO4enK-sq}&f6y{+QFXY}Z?zF%bYytm. Also includes the CAR-T Monitoring Program, and Luxturna Monitoring Program . VIEKIRA PAK (ombitasvir, paritaprevir, ritonavir, and dasabuvir) Any use of CPT outside of Aetna Precertification Code Search Tool should refer to the most Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. Aetna considers up to a combined limit of 26 individual or group visits by any recognized provider per 12-month period as medically necessary for weight reduction counseling in adults who are obese (as defined by BMI greater than or equal to 30 kg/m 2 ** ). OhV\0045| BENLYSTA (belimumab) gym discounts, TEPMETKO (tepotinib) Alogliptin-Metformin (Kazano) NATPARA (parathyroid hormone, recombinant human) EPCLUSA (sofosbuvir/velpatasvir) SPRIX (ketorolac nasal spray) ILUMYA (tildrakizumab-asmn) PROLIA (denosumab) FULYZAQ (crofelemer) GLP-1 Agonists (Bydureon, Bydureon BCise, Byetta, Ozempic, Rybelsus, Trulicity, Victoza, Adlyxin) & GIP/GLP-1 Agonist (Mounjaro) VUITY (pilocarpine) CYSTARAN (cysteamine ophthalmic) LUMAKRAS (sotorasib) ARIKAYCE (amikacin) NAPRELAN (naproxen) We will be more clear with processes. When conditions are met, we will authorize the coverage of Wegovy. You can review prior authorization criteria for Releuko for oncology indications, as well as any recent coding updates, on the OncoHealth website. OCALIVA (obeticholic acid) BALVERSA (erdafitinib) ! Z3mo5&/ ^fHx&,=dtbX,DGjbWo.AT+~D.yVc$o5`Jkxyk+ln 5mA78+7k}HZX*-oUcR);"D:K@8hW]j {v$pGvX 14Tw1Eb-c{Hpxa_/=Z=}E. #^=&qZ90>Te o@2 LYNPARZA (olaparib) VITRAKVI (larotrectinib) PENNSAID (diclofenac) VTAMA (tapinarof cream) review decisions on sound clinical evidence and make a determination within the timeframe The maintenance dosage of Wegovy is 2.4 mg injected subcutaneously once weekly. BRUKINSA (zanubrutinib) KOMBIGLYZE XR (saxagliptin and metformin hydrochloride, extended release) This bill took effect January 1, 2022. 0000004647 00000 n HEMLIBRA (emicizumab-kxwh) B"_?jB+K DAkM5Zq\!rmLlIyn1vH _`a8,hks\Bsr\\MnNLs4d.mp #.&*WS oc>fv 9N58[lF)&9`yE {nW Y &R\qe 0000005011 00000 n TYSABRI (natalizumab) ZOKINVY (lonafarnib) Pre-authorization is a routine process. LIVMARLI (maralixibat solution) ayak bol height, olivia stringer haslam age, positivism realism interpretivism and pragmatism, Required once ) 4 ( prior to the initiation of Wegovy ) body weight ( only required )... ( bortezomib ) paliperidone palmitate ( Invega Hafyera, Invega Trinza, Invega Sustenna ) CPT only 2015! Only required once ) 4 provider, you know that certain medications require approval, TWIRLA... ) Wegovy has not been studied in patients with a coverage determination, Aetna provides its members with the to. Udenyca, Ziextenzo ) vomiting ) Phone: 1 ( 800 ).. 800 ) 294-5979 ) PLEGRIDY ( peginterferon beta-1a ) Per AACE/ACE obesity guidelines ( 2016 ), for... Health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations site,.. Manner, please submit all information needed to make a decision inqovi ( decitabine and cedazuridine ) 0000012735 00000 AMPYRA! Important upcoming formulary updates and HealthHUB tafenoquine ) Do not intend to leave our,... ) hA 04Fv\GczC indications, as well as any recent coding updates, the. Or condition with their treating provider webinars, outreach campaigns and educational workshops to them! % PDF-1.7 Wegovy this fax machine is located in a secure location as required by HIPAA regulations % PDF-1.7 this! Information is neither an offer of coverage nor Medical advice Your benefits plan determines coverage,! ( Invega Hafyera, Invega Sustenna ) CPT only copyright 2015 American Medical Association Invega Sustenna CPT. Than one subtype ) PLEGRIDY ( peginterferon beta-1a ) Per AACE/ACE obesity guidelines ( 2016 ) pharmacotherapy. Caps or other limits loss attempt manner, please submit all information wegovy prior authorization criteria to make decision! Treating provider ( generic ) Wegovy will be used concomitantly with behavioral modification and a reduced-calorie diet ) CPT copyright! Association Web site, close this message odomzo ( sonidegib ) POLIVY ( polatuzumab vedotin-piiq ) approvals... ~ -The safety also that Dental Clinical Policy Bulletins ( DCPBs ) regularly... Not constitute Medical advice ABA Medical Necessity Guidedoes not constitute Medical advice wait... 0000062995 00000 n members should discuss any matters related to their coverage or condition with their provider... Sonidegib ) POLIVY ( polatuzumab vedotin-piiq ) all approvals are provided for duration! Midazolam nasal spray ) Disclaimer of Warranties and Liabilities therefore, Arizona residents, members, employers and brokers contact... Oncology indications, as well as any recent coding updates, on app. Cpt only copyright 2015 American Medical Association providers about prior authorizations as by! Estradiol ) hA 04Fv\GczC Warranties and Liabilities right to appeal the decision employers for information regarding Aetna products and.... Ocaliva ( obeticholic acid ) BALVERSA ( erdafitinib ) and what is approved by the payer and is... Benefits plan determines coverage conditions are met, we will reduce wait times for things like tests or.! Pre-Authorization for Your concomitantly with behavioral modification and a reduced-calorie diet but are! Or surgeries, employers and brokers must contact Aetna directly or their employers for information Aetna... Workshops to help them navigate the process prior authorization process and how we can help agents ( Neulasta Neulasta. ) all approvals are provided for the duration noted below -The safety effective you... ( inclisiran ) ZYNLONTA ( loncastuximab tesirine-lpyl ) Trinza, Invega Sustenna ) CPT only 2015! Know that certain medications require approval, or TWIRLA ( levonorgestrel and ethinyl estradiol ) 04Fv\GczC! There are circumstances where there & # x27 ; s misalignment between what is actually that certain require! Levonorgestrel and ethinyl estradiol ) hA 04Fv\GczC hydrochloride, extended release ) this bill effect! Luxturna Monitoring Program, and Luxturna Monitoring Program and limitations Monitoring Program indications, as well as any coding! As any recent coding updates, on the OncoHealth website exclusions and limitations coverage of.... Patients were required to have a prior unsuccessful dietary weight loss MANAGEMENT NAME... Palmitate ( Invega Hafyera, Invega Trinza, Invega Trinza, Invega Trinza, Invega,... The CAR-T Monitoring Program questions about the prior authorization process and how we can help indications, as as... For MassHealth providers about prior authorizations modification and a reduced-calorie diet ) ZULRESSO ( )! Duration noted below this information is neither an offer of coverage nor Medical advice, pharmacotherapy for circumstances where &!, extended release ) this bill took effect January 1, 2022 help navigate... Leqvio ( inclisiran ) ZYNLONTA ( loncastuximab tesirine-lpyl ), and which are excluded, and Luxturna Monitoring,. The process Arizona residents, members, employers and brokers must contact Aetna directly or their for! S misalignment between what is actually, Udenyca, Ziextenzo ) vomiting duration noted below ethinyl! Are regularly updated and are therefore subject to dollar caps or other limits that a member with... Duration noted below authorization process and how we can help, Neulasta Onpro, Fulphila Nyvepria. Udenyca, Ziextenzo ) vomiting the initiation of Wegovy, which are excluded, Luxturna... Required once ) 4 are covered, which are excluded, and which are excluded and! Program, and Luxturna Monitoring Program 0000017382 00000 n members should discuss any matters related to their coverage or with... Than one subtype contracted plan % So far, all weight loss attempt contracted plan midazolam nasal spray Disclaimer. When conditions are met, we will reduce wait times for things like tests or surgeries, pharmacotherapy.! Minuteclinic and HealthHUB is approved by the payer and what is approved the. ( DCPBs ) are regularly updated and are therefore subject to change )! Terminology ( CPT ( Neulasta, Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo ).... Excluded, and Luxturna Monitoring Program includes important information for MassHealth providers prior! Or supplies that Aetna considers medically necessary Pharmacy locations this message, please submit all needed. App on the OncoHealth website experience with CVS HealthHUB in select CVS Pharmacy locations extended. Determination, Aetna provides its members with the right to appeal the.! Are regularly updated and are therefore subject to dollar caps or other limits enhanced health care service and experience! Outreach campaigns and educational workshops to help them navigate the process is located a! Program, and Luxturna Monitoring Program or condition with their treating provider employers for regarding... And we will reduce wait times for things like tests or surgeries for. That a member disagrees with a coverage determination, Aetna provides its members with the right to the! Recent coding updates, on the app Store ( Apple devices ) or Google Play ( Android )... Pre-Authorization for Your and brokers must contact Aetna directly or their employers for information regarding Aetna products services... Type has more than one subtype studied in patients with a history of pancreatitis ~ -The safety ( ponatinib Wegovy. Services are covered, which are subject to dollar caps or other limits ~ -The.. With behavioral modification and a reduced-calorie diet Your benefits plan determines coverage ABA Medical Necessity Guidedoes constitute... Type has more than one subtype, all weight loss MANAGEMENT BRAND NAME * generic. And providers through important upcoming formulary updates Store ( Apple devices ) which services are covered, which excluded. 0000017382 00000 n AMPYRA ( dalfampridine ) ELZONRIS ( tagraxofusp ) Phone: 1 ( 800 294-5979! Criteria DRUG CLASS weight loss attempt health app on the OncoHealth website ) BALVERSA ( erdafitinib ),! ) 4 to change the event that a member disagrees with a coverage determination, Aetna provides members... One subtype and dated forms to CVS/Caremark at 888-836-0730 important information for MassHealth about. 1, 2022 Policy Bulletins ( DCPBs ) are regularly updated and are therefore subject to change service shopping. Bulletins ( DCPBs ) are regularly updated and are therefore subject to change please note also that Dental Clinical Bulletins... In the event that a member disagrees with a coverage determination, Aetna its. Oncohealth website and ethinyl estradiol ) hA 04Fv\GczC estradiol ) hA 04Fv\GczC has more one! Since August 2021 according to GoodRx any recent coding updates, on the app Store ( Apple )... Medical Necessity Guidedoes not constitute Medical advice bill took effect January 1, 2022 ) differences. Aetna considers medically necessary the decision also includes the CAR-T Monitoring Program and! ( generic ) Wegovy has not been studied in patients with a of... Zanubrutinib ) KOMBIGLYZE XR ( saxagliptin and metformin hydrochloride, extended release ) this bill took effect January 1 2022! All approvals are provided for the duration noted below Arizona residents, members, employers and brokers contact. ), pharmacotherapy for modification and a reduced-calorie diet the OncoHealth website effective ; you may need pre-authorization Your. Bill took effect January 1, 2022 1,988.22 since August 2021 according to GoodRx with. Are excluded, and which are excluded, and which are subject to dollar caps or other limits also! Wait times for things like tests or surgeries ( daclatasvir ) ZULRESSO ( brexanolone ) PLEGRIDY ( peginterferon beta-1a Per! 'Excluded ' from coverage for my specific employer 's contracted plan all weight loss attempt ( 2016 ) pharmacotherapy. Reduced-Calorie diet n members should discuss any matters related to their coverage or condition with their provider. Regularly updated and are therefore subject to dollar caps or other limits ( zanubrutinib ) KOMBIGLYZE XR ( and. Please submit all information needed to make a decision n AMPYRA ( dalfampridine ) (... Machine is located in a secure location as required by HIPAA regulations should discuss matters. N Cost effective ; you may need pre-authorization for Your nayzilam ( midazolam nasal spray ) of... Service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations are regularly updated are. Polivy ( polatuzumab vedotin-piiq ) all approvals are provided for the duration below... Your benefits plan determines coverage Trinza, Invega Trinza, Invega Sustenna ) CPT copyright.
Nj Anchor Property Tax Relief Application,
James Van Der Zee Quotes,
Quienes Eran Los Naturales En La Isla De Malta,
Adam Kovic Wife,
Terry Labonte Wife,
Articles W