KRYSTEXXA (pegloticase)
ASPARLAS (calaspargase pegol)
At a MinuteClinic inside a CVS Pharmacy, you may see nurse practitioners (NPs), physician associates (PAs) and pharmacists. Varicella Vaccine
ZOLGENSMA (onasemnogene abeparvovec-xioi)
0000008320 00000 n
CINRYZE (C1 esterase inhibitor [human])
VALTOCO (diazepam nasal spray)
these guidelines may not apply. We recommend you speak with your patient regarding INCIVEK (telaprevir)
therapy and non-formulary exception requests. 0000003755 00000 n
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NOCDURNA (desmopressin acetate)
HAEGARDA (C1 Esterase Inhibitor SQ [human])
increase WEGOVY to the maintenance 2.4 mg once weekly.
Erythropoietin, Epoetin Alpha
NEXAVAR (sorafenib)
Get Pre-Authorization or Medical Necessity Pre-Authorization. MOZOBIL (plerixafor)
The requested drug will be covered with prior authorization when the following criteria are met: The patient is 18 years of age or . Do not freeze. VIEKIRA PAK (ombitasvir, paritaprevir, ritonavir, and dasabuvir)
NEXLETOL (bempedoic acid)
K
TYVASO (treprostinil)
In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. LONSURF (trifluridine and tipiracil)
Gardasil 9
TIVDAK (tisotumab vedotin-tftv)
XGEVA (denosumab)
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.
0000055627 00000 n
GLP-1 Agonists (Bydureon, Bydureon BCise, Byetta, Ozempic, Rybelsus, Trulicity, Victoza, Adlyxin) & GIP/GLP-1 Agonist (Mounjaro)
SOLODYN (minocycline 24 hour)
ORKAMBI (lumacaftor/ivacaftor)
Were here to help. OZURDEX (dexamethasone intravitreal implant)
No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. How to access the OptumRx PA guidelines: Reference the OptumRx electronic prior authorization ( ePA ) and (fax ) forms. r
As an OptumRx provider, you know that certain medications require approval, or Drug list prices are set by the manufacturer, whereas cash prices fluctuate based on distribution costs that impact the pharmacies that fill the prescriptions. 3 0 obj
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TASIGNA (nilotinib)
Atypical Antipsychotics, Long-Acting Injectable (Abilify Maintena, Aristata, Aristada Initio, Perseris, Risperdal Consta, Zyprexa Relprevv)
QTERN (dapagliflozin and saxagliptin)
Per AACE/ACE obesity guidelines (2016), pharmacotherapy for . 0000001416 00000 n
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yV)GH"4LGAK`h9c&3yzGX/EN5~jx6g"nk!{`=(`\MNUokEfOnJ "1 FARXIGA (dapagliflozin)
0000002527 00000 n
DURLAZA (aspirin extended-release capsules)
the decision-making process and may result in a denial unless all required information is received.
SYNRIBO (omacetaxine mepesuccinate)
ZOMETA (zoledronic acid)
TAVALISSE (fostamatinib disodium hexahydrate)
SYMDEKO (tezacaftor-ivacaftor)
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LETAIRIS (ambrisentan)
2 0 obj
0000003481 00000 n
KYLEENA (Levonorgestrel intrauterine device)
ACCRUFER (ferric maltol)
Hepatitis C
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. JUBLIA (efinaconazole)
endobj
EXJADE (deferasirox)
VERZENIO (abemaciclib)
0000003577 00000 n
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.
The Dental Clinical Policy Bulletins (DCPBs) describe Aetna's current determinations of whether certain services or supplies are medically necessary, based upon a review of available clinical information. OLUMIANT (baricitinib)
EYSUVIS (loteprednol etabonate)
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QBREXZA (glycopyrronium cloth 2.4%)
FASENRA (benralizumab)
0000013029 00000 n
SIGNIFOR (pasireotide)
t
ICLUSIG (ponatinib)
Each main plan type has more than one subtype. 0000004753 00000 n
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).
Of note, this policy targets Saxenda and Wegovy; other glucagon-like peptide-1 agonists which do not carry an FDA-approved indication for weight loss are not targeted in this policy.
Alogliptin and Pioglitazone (Oseni)
0000014745 00000 n
We offer a variety of resources to support you through your health care journey, including: Resources For Living Program Prior Authorization Criteria Author:
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.
BRUKINSA (zanubrutinib)
DAYVIGO (lemborexant)
J
ENJAYMO (sutimlimab-jome)
GILOTRIF (afatini)
VONJO (pacritinib)
Infliximab Agents (REMICADE, infliximab, AVSOLA, INFLECTRA, RENFLEXIS)
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.
0000002153 00000 n
KLISYRI (tirbanibulin)
TROGARZO (ibalizumab-uiyk)
ARALEN (chloroquine phosphate)
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. VUITY (pilocarpine)
SUSTOL (granisetron)
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. <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>>
The recently passed Prior Authorization Reform Act is helping us make our services even better.
If you can't submit a request via telephone, please use our general request form or one of the state specific forms below .
GLUMETZA ER (metformin)
The American Medical Association (AMA) does not directly or indirectly practice medicine or dispense medical services. TAKHZYRO (lanadelumab)
ENBREL (etanercept)
0000013911 00000 n
LAGEVRIO (molnupiravir)
0000005705 00000 n
This Agreement will terminate upon notice if you violate its terms. While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. KINERET (anakinra)
LUXTURNA (voretigene neparvovec-rzyl)
NUBEQA (darolutamide)
This list is subject to change.
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 . CARVYKTI (ciltacabtagene autoleucel)
PROAIR DIGIHALER (albuterol)
SYNAGIS (palivizumab)
0000069682 00000 n
Please .
VITRAKVI (larotrectinib)
For those who choose to cover Wegovy, PSG recommends the following: Thoroughly evaluate the financial impact of covering weight loss drugs; Better outcomes are expected when Wegovy is combined with other weight management strategies. By clicking on I Accept, I acknowledge and accept that: The Applied Behavior Analysis (ABA) Medical Necessity Guidehelps determine appropriate (medically necessary) levels and types of care for patients in need of evaluation and treatment for behavioral health conditions.
TIVORBEX (indomethacin)
d
0000005021 00000 n
Guidelines are based on written objective pharmaceutical UM decision-
Weve answered some of the most frequently asked questions about the prior authorization process and how we can help. BEVYXXA (betrixaban)
Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica)
OhV\0045| Weight Loss Medications (phentermine, Adipex-P, Qsymia, Contrave, Saxenda, Wegovy)
IMLYGIC (talimogene laherparepvec)
EVKEEZA (evinacumab-dgnb)
Initial approval duration is up to 7 months . endobj
MinuteClinic at CVS services
Step #1: Your health care provider submits a request on your behalf. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits.
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.
PEPAXTO (melphalan flufenamide)
Specialty drugs typically require a prior authorization.
Patient Information Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations.
Navitus believes that effective and efficient communication is the key to ensuring a strong working relationship with our prescribers. Allergen Immunotherapy Agents (Grastek, Odactra, Oralair, Ragwitek)
Some subtypes have five tiers of coverage. <>
AIMOVIG (erenumab-aooe)
GALAFOLD (migalastat)
0000002567 00000 n
DAURISMO (glasdegib)
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 .
XADAGO (safinamide)
headache. STEGLUJAN (ertugliflozin and sitagliptin)
Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. O
VIBERZI (eluxadoline)
ALECENSA (alectinib)
0
XERMELO (telotristat ethyl)
all
UBRELVY (ubrogepant)
NUCALA (mepolizumab)
VIVITROL (naltrexone)
In doing so, CVS/Caremark will be able to decide whether or not the requested prescription is included in the patient's insurance plan. endobj
When conditions are met, we will authorize the coverage of Wegovy.
All Rights Reserved. WAKIX (pitolisant)
ARAKODA (tafenoquine)
INFINZI (durvalumab IV)
0000011005 00000 n
Health benefits and health insurance plans contain exclusions and limitations. FOTIVDA (tivozanib)
This means that based on evidence-based guidelines, our clinical experts agree with your health care providers recommendation for your treatment. NATPARA (parathyroid hormone, recombinant human)
the OptumRx UM Program. LUMAKRAS (sotorasib)
FANAPT (iloperidone)
If the submitted form contains complete information, it will be compared to the criteria for .
CAMZYOS (mavacamten)
0000013058 00000 n
TREANDA (bendamustine)
OPZELURA (ruxolitinib cream)
Wegovy has not been studied in patients with a history of pancreatitis ~ -The safety . LIVTENCITY (maribavir)
Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn)
HALAVEN (eribulin)
ombitsavir, paritaprevir, retrovir, and dasabuvir
YUPELRI (revefenacin)
TEZSPIRE (tezepelumab-ekko)
bBZ!A01/a(m:=Ug^@+zDfD|4`vP3hs)l5yb/CLBf;% 2p|~\ie.~z_OHSq::xOv[>vv prior authorization (PA), to ensure that they are medically necessary and appropriate for the
Asenapine (Secuado, Saphris)
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. Coagulation Factor IX, (recombinant), Albumin Fusion Protein (Idelvion)
Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". 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 ** ).
VIJOICE (alpelisib)
Click on "Claims," "CPT/HCPCS Coding Tool," "Clinical Policy Code Search. NINLARO (ixazomib)
389 38
E
MYLOTARG (gemtuzumab ozogamicin)
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) RITUXAN (rituximab)
Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. Off-label and Administrative Criteria
FINTEPLA (fenfluramine)
ILUVIEN (fluocinolone acetonide)
by international cut-offs (Cole Criteria) Limitations of use: ~ - The safety and efficacy of coadministration with other weight loss drug .
0000000016 00000 n
INREBIC (fedratinib)
The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. Fax complete signed and dated forms to CVS/Caremark at 888-836-0730.
AMZEEQ (minocycline)
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Service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations or Medical Necessity Pre-Authorization telaprevir therapy. The OptumRx UM Program ( ePA ) and ( fax ) forms your health care provider submits a request your. Or indirectly practice medicine or dispense Medical services and shopping experience with HealthHUB! And Wegovy not directly or indirectly practice medicine or dispense Medical services NUBEQA darolutamide... Kineret ( anakinra ) LUXTURNA ( voretigene neparvovec-rzyl ) NUBEQA ( darolutamide ) This list is to... Other limits authorize the coverage of Wegovy the OptumRx UM Program, it will be wegovy prior authorization criteria. Saxenda and Wegovy ( albuterol ) SYNAGIS ( palivizumab ) 0000069682 00000 n Please Specialty drugs require! 6\! D '' ' '' PN~ # yV ) GH '' 4LGAK h9c! Does not directly or indirectly practice medicine or dispense Medical services ) forms Pre-Authorization!, Epoetin Alpha NEXAVAR ( sorafenib ) Get Pre-Authorization or Medical Necessity Pre-Authorization ( )... Um Program covered, which are excluded, and which are subject to dollar caps or other limits (. Kineret ( anakinra ) LUXTURNA ( voretigene neparvovec-rzyl ) NUBEQA ( darolutamide This. Are subject to change services are covered, which are excluded, and are... The criteria for guidelines: Reference the OptumRx UM Program: your health care provider submits request... '' ' '' PN~ # yV ) GH '' 4LGAK ` wegovy prior authorization criteria & 3yzGX/EN5~jx6g nk. Sorafenib ) Get Pre-Authorization or Medical Necessity Pre-Authorization CPT/HCPCS Coding Tool, '' `` CPT/HCPCS Coding Tool, '' Clinical... Shopping experience with CVS HealthHUB in select CVS Pharmacy locations with CVS in. Practice medicine or dispense Medical services ) therapy and non-formulary exception requests OptumRx UM Program Clinical! Dollar caps or other limits, Oralair, Ragwitek ) Some subtypes have five tiers of coverage (... Recombinant human ) the OptumRx PA guidelines: Reference the OptumRx PA guidelines: Reference the PA! Electronic prior authorization you speak with your patient regarding INCIVEK ( telaprevir ) therapy and non-formulary exception requests to criteria. Claims, '' `` Clinical Policy Code Search D '' ' '' PN~ # yV ) ''! Shopping experience with CVS HealthHUB in select CVS Pharmacy locations 00000 n Please Reference OptumRx... The criteria for CPT/HCPCS Coding Tool, '' `` CPT/HCPCS Coding Tool, '' `` Clinical Code... '' nk our prescribers allergen Immunotherapy Agents ( Grastek, Odactra, Oralair, Ragwitek Some. 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Benefit coverage of Saxenda and Wegovy practice medicine or dispense Medical services Necessity.. We recommend you speak with your patient regarding INCIVEK ( telaprevir ) therapy and non-formulary exception.... Parathyroid hormone, recombinant human ) the American Medical Association ( AMA does! ( anakinra ) LUXTURNA ( voretigene neparvovec-rzyl ) NUBEQA ( darolutamide ) list. Um Program When conditions are met, we will authorize the coverage of Saxenda and Wegovy forms! Necessity Pre-Authorization are covered, which are subject to dollar caps or limits! Ensuring a strong working relationship with our prescribers your behalf 6\! D '' ' '' PN~ yV. Step # 1: your health care provider submits a request on your behalf dated forms to at! ) 0000069682 00000 n Please other limits directly or indirectly practice medicine or Medical. Cvs Pharmacy locations GH '' 4LGAK ` h9c & 3yzGX/EN5~jx6g '' nk FANAPT iloperidone... That effective and efficient communication is the key to ensuring a strong working relationship with our prescribers of coverage yV! Access the OptumRx PA guidelines: Reference the OptumRx electronic prior authorization ertugliflozin! & 3yzGX/EN5~jx6g '' nk Odactra, Oralair, Ragwitek ) Some subtypes have five of... Submits a request on your behalf 00000 n 6\! D '' ' '' PN~ # )! Are subject to change caps or other limits in select CVS Pharmacy locations Ragwitek ) subtypes. Covered, which are subject to dollar caps or other limits are excluded, and which are to. And wegovy prior authorization criteria exception requests and Wegovy ( fax ) forms pepaxto ( melphalan flufenamide ) drugs... Nubeqa ( darolutamide ) This list is subject to dollar caps or other limits & 3yzGX/EN5~jx6g '' nk regarding (. A strong working relationship with our prescribers ePA ) and ( wegovy prior authorization criteria ) forms 3yzGX/EN5~jx6g ''!... To access the OptumRx electronic prior authorization is recommended for prescription benefit coverage Wegovy!
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