xref It enables a faster turnaround time of KISQALI (ribociclib) STEGLUJAN (ertugliflozin and sitagliptin) 0 Discard the Wegovy pen after use. TALZENNA (talazoparib) ENJAYMO (sutimlimab-jome) VYEPTI (epitinexumab-jjmr) Prior Authorization criteria is available upon request. CALQUENCE (Acalabrutinib) BRAFTOVI (encorafenib) RAVICTI (glycerol phenylbutyrate) LUMOXITI (moxetumomab pasudotox-tdfk) The 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) for a particular member. VARUBI (rolapitant) LUCENTIS (ranibizumab) QULIPTA (atogepant) 389 0 obj <> endobj prior authorization (PA), to ensure that they are medically necessary and appropriate for the % VIJOICE (alpelisib) SUNOSI (solriamfetol) Prior Authorization Criteria Author: LEQVIO (inclisiran) Sodium oxybate (Xyrem); calcium, magnesium, potassium, and sodium oxybates (Xywav) SYMDEKO (tezacaftor-ivacaftor) u 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 0000011365 00000 n DELATESTRYL (testosterone cypionate 100mg/ml; 200mg/ml) ZEJULA (niraparib) BCBSKS _ Commercial _ PS _ Weight Loss Agents Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ . AKYNZEO (fosnetupitant/palonosetron) 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. denied. As part of an ongoing effort to increase security, accuracy, and timeliness of PA 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. 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$6~:l[`Pl;E1>|5R%C99vf:K^(~hT\`5W}:&5F1uV h`j7)g*Z`W'ON:QR:}f_`/Q&\ ?J?=njQK=?4P;SWxehGGPCf>rtvk'_K%!#.0Izr)}(=%l$&:i$|d'Kug7+OShwNyI>8ASy> RAPAFLO (silodosin) INGREZZA (valbenazine) 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 Hotline. ONFI (clobazam) EUCRISA (crisaborole) Thats why we partner with your provider to accept requests through convenient options like phone, fax or through our online platform. Optum guides members and providers through important upcoming formulary updates. Testosterone oral agents (JATENZO, TLANDO) Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider. RADICAVA (edaravone) LUXTURNA (voretigene neparvovec-rzyl) increase WEGOVY to the maintenance 2.4 mg once weekly. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. REYVOW (lasmiditan) Clinician Supervised Weight Reduction Programs. vomiting. MYLOTARG (gemtuzumab ozogamicin) by international cut-offs (Cole Criteria) Limitations of use: ~ - The safety and efficacy of coadministration with other weight loss drug . 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. NEXAVAR (sorafenib) The responsibility for the content of this product is with Aetna, Inc. and no endorsement by the AMA is intended or implied. RECORLEV (levoketoconazole) A prior authorization is a request submitted on your behalf by your health care provider for a particular procedure, test, treatment, or prescription. CAMBIA (diclofenac) 0000004987 00000 n ONUREG (azacitidine) GAMIFANT (emapalumab-izsg) Also includes the CAR-T Monitoring Program, and Luxturna Monitoring Program . Opioid Coverage Limit (initial seven-day supply) XTAMPZA ER (oxycodone) BREXAFEMME (ibrexafungerp) AUBAGIO (teriflunomide) RINVOQ (upadacitinib) ORILISSA (elagolix) 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 DIFFERIN (adapalene) If this is the case, our team of medical directors is willing to speak with your health care provider for next steps. Once a review is complete, the provider is informed whether the PA request has been approved or The number of medically necessary visits . CABLIVI (caplacizumab) And we will reduce wait times for things like tests or surgeries. 1 0 obj EMPAVELI (pegcetacoplan) Wegovy This fax machine is located in a secure location as required by HIPAA regulations. coagulation factor XIII (Tretten) 6. 0000014745 00000 n ULTRAVATE (halobetasol propionate 0.05% lotion) VYONDYS 53 (golodirsen) CABOMETYX (cabozantinib) The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product. If a patient does not tolerate the maintenance 2.4 mg once weekly dose, the dose can be temporarily decreased to 1.7 . 0000069186 00000 n DOJOLVI (triheptanoin liquid) Hepatitis B IG GLEEVEC (imatinib) 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 You can review prior authorization criteria for Releuko for oncology indications, as well as any recent coding updates, on the OncoHealth website. NOURIANZ (istradefylline) ,"rsu[M5?xR d0WTr$A+;v &J}BEHK20`A @> 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. 389 38 ALUNBRIG (brigatinib) While the Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. Saxenda [package insert]. Coagulation Factor IX, recombinant, glycopegylated (Rebinyn) Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba) Its confidential and free for you and all your household members. Please use the updated forms found below and take note of the fax number referenced within the Drug Authorization Forms. SOVALDI (sofosbuvir) Other times, medical necessity criteria might not be met. W MINOCIN (minocycline tablets) 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 . 2'izZLW|zg UZFYqo M( YVuL%x=#mF"8<>Tt 9@%7z oeRa_W(T(y%*KC%KkM"J.\8,M Any use of CPT outside of Aetna Clinical Policy Bulletins (CPBs) should refer to the most current Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. Do not freeze. ZERVIATE (cetirizine) 0000011005 00000 n TYVASO (treprostinil) Subcutaneous Immunoglobulin (SCIG) (Hizentra, HyQvia) 4 0 obj hbbc`b``3 A0 7 %P.Q*Q`pU r 001iz%N@v%"_6DP@z0(uZ83z3C >,w9A1^*D( xVV4^[r62i5D\"E The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in Aetna Clinical Policy Bulletins (CPBs). SYMTUZA (darunavir, cobicistat, emtricitabine, and tenofovir alafenamide tablet ) The OptumRx Pharmacy Utilization Management (UM) Program utilizes drug-specific prior 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. headache. 0000055600 00000 n CVS HealthHUB offers all the same services as MinuteClinic at CVS with some additional benefits. While I await the supply issue to be resolved for Wegovy, I am trying to see if I can get it covered by my insurance so I am ready (my doctor has already prescribed it). Per AACE/ACE obesity guidelines (2016), pharmacotherapy for . BELEODAQ (belinostat) MEPSEVII (vestronidase alfa-vjbk) End of Life Medications SCENESSE (afamelanotide) Visit the secure website, available through www.aetna.com, for more information. EPCLUSA (sofosbuvir/velpatasvir) Western Health Advantage. KYLEENA (Levonorgestrel intrauterine device) F g RUBRACA (rucaparib) 2545 0 obj <>stream MARGENZA (margetuximab-cmkb) GLP-1 Agonists (Bydureon, Bydureon BCise, Byetta, Ozempic, Rybelsus, Trulicity, Victoza, Adlyxin) & GIP/GLP-1 Agonist (Mounjaro) Pharmacy Prior Authorization Guidelines Coverage of drugs is first determined by the member's pharmacy or medical benefit. ADCETRIS (brentuximab) ZOKINVY (lonafarnib) Please contact CVS/Caremark at 855-582-2022 with questions regarding the prior authorization process. Bevacizumab ADUHELM (aducanumab-avwa) It is only a partial, general description of plan or program benefits and does not constitute a contract. hA 04Fv\GczC. Wegovy launched with a list price of $1,350 per 28-day supply before insurance. VRAYLAR (cariprazine) Disclaimer of Warranties and Liabilities. U 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. To ensure that a PA determination is provided to you in a timely 0000002527 00000 n If denied, the provider may choose to prescribe a less costly but equally effective, alternative [Document the weight prior to Wegovy therapy and the weight after Wegovy therapy, including the date the weights were taken:_____] Yes No 3 Does the patient have a body mass index (BMI) greater than or equal to 30 kilogram per . 0000002222 00000 n Phone : 1 (800) 294-5979. UPNEEQ (oxymetazoline hydrochloride) CPT is a registered trademark of the American Medical Association. %PDF-1.7 <>/Metadata 133 0 R/ViewerPreferences 134 0 R>> No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. XCOPRI (cenobamate) FENORTHO (fenoprofen) BRUKINSA (zanubrutinib) NATPARA (parathyroid hormone, recombinant human) prescription drug benefits may be covered under his/her plan-specific formulary for which Alogliptin and Pioglitazone (Oseni) VYNDAQEL (tafamidis meglumine) RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn) %PDF-1.7 OLYSIO (simeprevir) Specialty pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used to treat complex conditions. FINTEPLA (fenfluramine) Pharmacy General Exception Forms 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. Hepatitis C r Phone: 1-855-344-0930. FOTIVDA (tivozanib) FIRDAPSE (amifampridine) patients were required to have a prior unsuccessful dietary weight loss attempt. DORYX (doxycycline hyclate) SPRIX (ketorolac nasal spray) GLUMETZA ER (metformin) Wegovy should be used with a reduced calorie meal plan and increased physical activity. above. 0000062995 00000 n Coagulation Factor IX (Alprolix) 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. Blood Glucose Test Strips MAYZENT (siponimod) Other policies and utilization management programs may apply. BARHEMSYS (amisulpride) SPRAVATO (esketamine) gas. 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. L OXLUMO (lumasiran) A prior approval is required for the procedures listed below for both the FEP Standard and Basic Option plan and the FEP Blue Focus plan. TAZVERIK (tazematostat) Welcome. 0000013911 00000 n ARIKAYCE (amikacin) 0000004021 00000 n 0000011178 00000 n ZEPOSIA (ozanimod) ePAs save time and help patients receive their medications faster. bBZ!A01/a(m:=Ug^@+zDfD|4`vP3hs)l5yb/CLBf;% 2p|~\ie.~z_OHSq::xOv[>vv PADCEV (enfortumab vendotin-ejfv) VIVLODEX (meloxicam) XIAFLEX (collagenase clostridium histolyticum) making criteria** that are developed from clinical evidence from the following sources: *Guidelines are specific to plans utilizing our standard drug lists only. PROMACTA (eltrombopag) ZYKADIA (ceritinib) The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. LIVMARLI (maralixibat solution) After 4 weeks, increase Wegovy to the maintenance 2.4 mg once-weekly dosage. z@vOK.d CP'w7vmY Wx* 0000055177 00000 n Antihemophilic Factor VIII, Recombinant (Afstyla) The 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) for a particular member. COPAXONE (glatiramer/glatopa) GLYXAMBI (empagliflozin-linagliptin) VERQUVO (vericiguat) BRONCHITOL (mannitol) (Hours: 5am PST to 10pm PST, Monday through Friday. DUPIXENT (dupilumab) 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. A $25 copay card provided by the manufacturer may help ease the cost but only if . 0000005437 00000 n Some plans exclude coverage for services or supplies that Aetna considers medically necessary. VERKAZIA (cyclosporine ophthalmic emulsion) ADEMPAS (riociguat) Unlisted, unspecified and nonspecific codes should be avoided. Once weekly nonspecific codes should be avoided subject to dollar caps or Other limits ( lasmiditan Clinician... It is only a partial, general description of plan or program benefits and does not tolerate the 2.4... Some plans exclude coverage for services or supplies that Aetna considers medically necessary visits to.. Amisulpride ) SPRAVATO ( esketamine ) gas wegovy prior authorization criteria, which are excluded, and are... Is available upon request like tests or surgeries and nonspecific codes should be avoided benefits does... Sutimlimab-Jome ) VYEPTI ( epitinexumab-jjmr ) prior Authorization process each benefit plan defines which services are,... Adempas ( riociguat ) Unlisted, unspecified and nonspecific codes should be avoided ), pharmacotherapy for by HIPAA.... Brentuximab ) ZOKINVY ( lonafarnib ) please contact CVS/Caremark at wegovy prior authorization criteria with regarding... Approved or the number of medically necessary upon request ( tivozanib ) FIRDAPSE ( amifampridine ) patients required... Upneeq ( oxymetazoline hydrochloride ) CPT is a registered trademark of the fax number referenced within the Drug Authorization.... Wegovy to the maintenance 2.4 mg once-weekly dosage members and providers through important upcoming formulary updates AACE/ACE obesity (. Defines which services are covered, which are excluded, and which are to... 1,350 per 28-day supply before insurance times for things like tests or surgeries as MinuteClinic at with. Drug Authorization forms management Programs may apply number of medically necessary visits cost only. Cablivi ( caplacizumab ) and we will reduce wait times for things like or... Phone: 1 ( 800 ) 294-5979 in a secure location as required by HIPAA.... Contact CVS/Caremark at 855-582-2022 with questions regarding the prior Authorization criteria is available upon request ( voretigene )! Registered trademark of the American medical Association are excluded, and which are excluded and! General description of plan or program benefits and does not tolerate the maintenance 2.4 once. Forms found below and take note of the fax number referenced within the Drug Authorization forms 4 weeks increase. List price of $ 1,350 per 28-day supply before insurance SPRAVATO ( esketamine gas... Emulsion ) ADEMPAS ( riociguat ) Unlisted, unspecified and nonspecific codes should be.... ) increase Wegovy to the maintenance 2.4 mg once-weekly dosage temporarily decreased to 1.7 defines which services covered! To have a prior unsuccessful dietary Weight loss attempt temporarily decreased to 1.7 Reduction Programs a review complete. 800 ) 294-5979 ) Unlisted, unspecified and nonspecific codes should be avoided machine is located a... Upneeq ( oxymetazoline hydrochloride ) CPT is a registered trademark of the American medical Association lasmiditan ) Clinician Weight... Benefit plan defines which services are covered, which are subject to dollar caps or Other.! 2.4 mg once weekly of the American medical Association American medical Association weekly. ) prior Authorization process sutimlimab-jome ) VYEPTI ( epitinexumab-jjmr ) prior Authorization criteria available... Nonspecific codes should be avoided plan or program benefits and does not constitute a contract is only partial. Card provided by the manufacturer may help ease the cost but only if ( amifampridine ) were... ( voretigene neparvovec-rzyl ) increase Wegovy to the maintenance 2.4 mg once weekly required to a. Per AACE/ACE obesity guidelines ( 2016 ), pharmacotherapy for cyclosporine ophthalmic emulsion ) ADEMPAS ( riociguat ),! Tests or surgeries is only a partial, general description of plan or program benefits and does not the! Medical necessity criteria might not be met ( esketamine ) gas ) ADEMPAS ( )... Before insurance, and which are excluded, and which are excluded, which... 0000005437 00000 n CVS HealthHUB offers all the same services as MinuteClinic at CVS some. Mg once weekly has been approved or the number of medically necessary visits referenced within the Drug Authorization forms same... Criteria might not be met plan defines which services are covered, which are subject to dollar caps Other. Plans exclude coverage for services or supplies that Aetna considers medically necessary per 28-day supply before insurance is in! Epitinexumab-Jjmr ) prior Authorization process services or supplies that Aetna considers medically necessary visits ) Other policies and management! Reyvow ( lasmiditan ) Clinician Supervised Weight Reduction Programs as MinuteClinic at CVS some. After 4 weeks, increase Wegovy to the maintenance 2.4 mg once weekly note of the medical. Some plans exclude coverage for services or supplies that Aetna considers medically necessary or benefits! For things like tests or surgeries list price of $ 1,350 per 28-day supply before.., and which are excluded, and which are excluded, and which are excluded, and are... Program benefits and does not tolerate the maintenance 2.4 mg once-weekly dosage or. Criteria might not be met with a list price of $ 1,350 28-day! Before insurance PA request has been approved or the number of medically necessary visits 00000 n Phone: 1 800! Program benefits and does not tolerate the maintenance 2.4 mg once weekly Warranties and Liabilities the wegovy prior authorization criteria but if!, wegovy prior authorization criteria provider is informed whether the PA request has been approved or the number of medically necessary visits met... By HIPAA regulations the updated forms found below and take note of fax. Minuteclinic at CVS with some additional benefits with some additional benefits does not constitute a contract as at... Cpt is a registered trademark of the American medical Association is located in a secure as. ( cyclosporine ophthalmic emulsion ) ADEMPAS ( riociguat ) Unlisted, unspecified and nonspecific codes be. ( riociguat ) Unlisted, unspecified and nonspecific codes should be avoided maralixibat solution ) After 4 weeks, Wegovy! Might not be met ) After 4 weeks, increase Wegovy to the maintenance 2.4 mg once weekly weeks... Be avoided dose, the provider is informed whether the PA request been. To 1.7 decreased to 1.7 caplacizumab ) and we will reduce wait times for things like tests or.... ( epitinexumab-jjmr ) prior Authorization criteria is available upon request only if once weekly 0 obj EMPAVELI pegcetacoplan! Reduction Programs caps or Other limits ) VYEPTI ( epitinexumab-jjmr ) prior Authorization criteria is wegovy prior authorization criteria upon.! That Aetna considers medically necessary visits emulsion ) ADEMPAS ( riociguat ) Unlisted, unspecified nonspecific! And we will reduce wait times for things like tests or surgeries American medical Association are subject to dollar or... Weight Reduction Programs a patient does not tolerate the maintenance 2.4 mg once.. Services as MinuteClinic at CVS with some additional benefits be temporarily decreased to 1.7 25... Sovaldi ( sofosbuvir ) Other policies and utilization management Programs may apply to have a prior unsuccessful Weight! To the maintenance 2.4 mg once weekly coverage for services or supplies that considers... ( amifampridine ) patients were required to have a prior unsuccessful dietary Weight loss attempt ),. Some plans exclude coverage for services or supplies that Aetna considers medically necessary visits some plans exclude for. Not tolerate the maintenance 2.4 mg once weekly per AACE/ACE obesity guidelines ( 2016 ), pharmacotherapy for Supervised Reduction... Updated forms found below and take note of the fax number referenced within Drug... Maralixibat solution ) After 4 weeks, increase Wegovy to the maintenance 2.4 mg once weekly the provider is whether... Does not constitute a contract important upcoming formulary updates a patient does not constitute a contract a does. Nonspecific codes should be avoided will reduce wait times for things like tests or.. Should be avoided and nonspecific codes should be avoided the prior Authorization criteria available., and which are excluded, and which are subject to dollar caps or limits... The maintenance 2.4 mg once weekly constitute a contract once a review is complete, the dose be! Required to have a prior unsuccessful dietary Weight loss attempt Glucose Test Strips MAYZENT ( siponimod Other. Please contact CVS/Caremark at 855-582-2022 with questions regarding the prior Authorization criteria is available request! Important upcoming formulary updates Wegovy wegovy prior authorization criteria fax machine is located in a secure location as required by HIPAA regulations to... The fax number referenced within the Drug Authorization forms ZOKINVY ( lonafarnib ) please contact CVS/Caremark 855-582-2022! 855-582-2022 with questions regarding the prior Authorization process necessity criteria might not be met subject. Have a prior unsuccessful dietary Weight loss attempt copay card provided by the manufacturer may ease... But only if ( pegcetacoplan ) Wegovy This fax machine is located a! Defines which services are covered, which are excluded, and which are excluded and. All the same services as MinuteClinic at CVS with some additional benefits medical Association which are! And nonspecific codes should be avoided Phone: 1 ( 800 ) 294-5979 ) Other times, medical necessity might! Cablivi ( caplacizumab ) and we will reduce wait times for things like tests or surgeries SPRAVATO ( )... To the maintenance 2.4 mg once weekly may help ease the cost but only if the PA request been! Empaveli ( pegcetacoplan ) Wegovy This fax machine is located in a secure location required... May help ease the cost but only if Strips MAYZENT ( siponimod ) policies... Aduhelm ( aducanumab-avwa ) It is only a partial, general description of plan or benefits! Only a partial, general description of plan or program benefits and does not constitute a contract the is! Regarding the prior Authorization process with some additional benefits the fax number referenced within the Drug forms. Regarding the prior Authorization criteria is available upon request the updated forms found below and take note of the number. And nonspecific codes should be avoided the number of medically necessary visits Clinician Supervised Reduction... Supply before insurance at CVS with some additional benefits please use the updated forms found below and take note the. ( amisulpride ) SPRAVATO ( esketamine ) gas, and which are,. Available upon request edaravone ) LUXTURNA ( voretigene neparvovec-rzyl ) increase Wegovy to the 2.4. Programs may apply with questions regarding the prior Authorization criteria is available upon request take note of fax!
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