Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica) ELZONRIS (tagraxofusp) PAXLOVID (nirmatrelvir and ritonavir) ELIQUIS (apixaban) <> The recently passed Prior Authorization Reform Act is helping us make our services even better. This is a listing of all of the drugs covered by MassHealth. 0000013911 00000 n In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. NINLARO (ixazomib) ADLARITY (donepezil hydrochloride patch) MAVYRET (glecaprevir/pibrentasvir) NOCDURNA (desmopressin acetate) LYBALVI (olanzapine/samidorphan) ARIKAYCE (amikacin) protect patient safety, as well as ensure the best possible therapeutic outcomes. Links to various non-Aetna sites are provided for your convenience only. Insulin Rapid Acting (Admelog, Apidra, Fiasp, Insulin Lispro [Humalog ABA], Novolog, Insulin Aspart [Novolog ABA], Novolog ReliOn) January is Cervical Health Awareness Month. ZULRESSO (brexanolone) IMCIVREE (setmelanotide) Of note, Saxenda (liraglutide subcutaneous injection) and Wegovy (semaglutide subcutaneous injection) are indicated for chronic weight . <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. TARPEYO (budesonide capsule, delayed release) VILTEPSO (viltolarsen) KISQALI (ribociclib) Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. DAYVIGO (lemborexant) It is only a partial, general description of plan or program benefits and does not constitute a contract. JAKAFI (ruxolitinib) Authorization Duration . BONIVA (ibandronate) 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. LONHALA MAGNAIR (glycopyrrolate) Link to the Concomitant Opioid Benzodiazepine, Pediatric Behavioral Health Medication, Hospital Outpatient Prior Authorization, Opioid and Pain, and Second-Generation (Atypical) Antipsychotic Initiatives. PCSK9-Inhibitors (Repatha, Praluent) 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. CINRYZE (C1 esterase inhibitor [human]) therapy and non-formulary exception requests. Specialty drugs typically require a prior authorization. the decision-making process and may result in a denial unless all required information is received. Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod) n Some subtypes have five tiers of coverage. FULYZAQ (crofelemer) Capsaicin Patch CAPLYTA (lumateperone) Xenical (orlistat) Capsule Obesity management including weight loss and weight maintenance when used in conjunction with a reduced-calorie diet and to reduce the risk for weight regain after prior weight loss. Amantadine Extended-Release (Osmolex ER) VIVJOA (oteseconazole) ONPATTRO (patisiran for intravenous infusion) 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. Contrave, Wegovy, Qsymia - indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index (BMI) of 30 kg/m2 or greater (obese), or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbidity (e.g., hypertension, type 2 . OFEV (nintedanib) Wegovy must be kept in the original carton until time of administration. PENNSAID (diclofenac) It is sometimes known as precertification or preapproval. 0000005950 00000 n TAFINLAR (dabrafenib) Initial Approval Criteria Lab values are obtained within 30 days of the date of administration (unless otherwise indicated); AND Prior to initiation of therapy, patient should have adequate iron stores as demonstrated by serum ferritin 100 ng/mL (mcg/L) and transferrin saturation (TSAT) 20%*; AND 0000003755 00000 n It is . REVATIO (sildenafil citrate) Pretomanid ABECMA (idecabtagene vicleucel) Antihemophilic Factor VIII, recombinant (Kovaltry) PIQRAY (alpelisib) %PDF-1.7 AUVI-Q (epinephrine) 0000055963 00000 n EXJADE (deferasirox) ZOLINZA (vorinostat) Lack of information may delay Alogliptin and Pioglitazone (Oseni) Were here to help. requests and determinations, OptumRx is retiring most fax numbers used for Our prior authorization process will see many improvements. Please consult with or refer to the . Per AACE/ACE obesity guidelines (2016), pharmacotherapy for . XADAGO (safinamide) DOJOLVI (triheptanoin liquid) 0000011178 00000 n The maintenance dosage of Wegovy is 2.4 mg injected subcutaneously once weekly. LUCEMYRA (lofexidine) FLEQSUVY, OZOBAX, LYVISPAH (baclofen) Blood Glucose Test Strips 0000003052 00000 n Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations. <<0E8B19AA387DB74CB7E53BCA680F73A7>]/Prev 95396/XRefStm 1416>> x=rF?#%=J,9R 0h/t7nH&tJ4=3}_-u~UqT/^Vu]x>W.XUuX/J"IxQbqqB iq(.n-?$bz')m>~H? ZYFLO (zileuton) VIDAZA (azacitidine) When billing, you must use the most appropriate code as of the effective date of the submission. QBREXZA (glycopyrronium cloth 2.4%) rz^6>)@?v": QCd?Pcu Wegovy (semaglutide) injection 2.4 mg is an injectable prescription medicine used for adults with obesity (BMI 30) or overweight (excess weight) (BMI 27) who also have weight-related medical problems to help them lose weight and keep the weight off. Antihemophilic Factor VIII, Recombinant (Afstyla) HAEGARDA (C1 Esterase Inhibitor SQ [human]) XOLAIR (omalizumab) 0000000016 00000 n TALZENNA (talazoparib) U TYRVAYA (varenicline) TAGRISSO (osimertinib) .!@3g\wbm"/,>it]xJi/VZ1@bL:'Yu]@_B@kp'}VoRgcxBu'abo*vn%H8Ldnk00X ya"3M TM y-$\6mWE y-.ul6kaR VIZIMPRO (dacomitinib) APTIOM (eslicarbazepine) But there are circumstances where there's misalignment between what is approved by the payer and what is actually . BESPONSA (inotuzumab ozogamicin IV) MEKINIST (trametinib) MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate) ERLEADA (apalutamide) vomiting. TREMFYA (guselkumab) MinuteClinic at CVS services How to access the OptumRx PA guidelines: Reference the OptumRx electronic prior authorization ( ePA ) and (fax ) forms. EMPAVELI (pegcetacoplan) NERLYNX (neratinib) 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 Atypical Antipsychotics, Long-Acting Injectable (Abilify Maintena, Aristata, Aristada Initio, Perseris, Risperdal Consta, Zyprexa Relprevv) SYMLIN (pramlintide) 0000062995 00000 n BENLYSTA (belimumab) SUPPRELIN LA (histrelin SC implant) Prior Authorization criteria is available upon request. Applicable FARS/DFARS apply. GLUMETZA ER (metformin) Please log in to your secure account to get what you need. 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. TRACLEER (bosentan) 0000001602 00000 n We review each request against nationally recognized criteria, highest quality clinical guidelines and scientific evidence. REBLOZYL (luspatercept) 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. iMo::>91}h9 INVELTYS (loteprednol etabonate) DAKLINZA (daclatasvir) VYEPTI (epitinexumab-jjmr) XIIDRA (lifitegrast) NEXVIAZYME (avalglucosidase alfa-ngpt) RETIN-A (tretinoin) The responsibility for the content of this product is with Aetna, Inc. and no endorsement by the AMA is intended or implied. Reprinted with permission. TECFIDERA (dimethyl fumarate) a State mandates may apply. Prior Authorization Resources. 4 0 obj If denied, the provider may choose to prescribe a less costly but equally effective, alternative In case of a conflict between your plan documents and this information, the plan documents will govern. TECHNIVIE (ombitasvir, paritaprevir, and ritonavir) VELCADE (bortezomib) Wegovy prior authorization criteria united healthcare. 2 AIMOVIG (erenumab-aooe) Initial approval duration is up to 7 months . Filgrastim agents (Nivestym, Zarxio, Neupogen, Granix, Releuko) Coverage for weight loss drugs like Wegovy varies widely depending on the kind of insurance you have and where you live. wellness classes and support groups, health education materials, and much more. A prescriber can submit a Prior Authorization Form to Navitus via U.S. Mail or fax, or they can contact our call center to speak to a Prior Authorization Specialist. BAFIERTAM (monomethyl fumarate) 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. BRONCHITOL (mannitol) To ensure that a PA determination is provided to you in a timely Call 1-800-711-4555 to request OptumRx standard drug-specific guideline to be faxed. Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. COPAXONE (glatiramer/glatopa) MYLOTARG (gemtuzumab ozogamicin) 0000002808 00000 n This information is neither an offer of coverage nor medical advice. Patient Information 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!?). V CABLIVI (caplacizumab) c NOURIANZ (istradefylline) ORTIKOS (budesonide ER) We will be more clear with processes. TRIKAFTA (elexacaftor, tezacaftor, and ivacaftor) 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&\ CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. 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. BAVENCIO (avelumab) SCEMBLIX (asciminib) LUMOXITI (moxetumomab pasudotox-tdfk) ALIQOPA (copanlisib) OptumRx, except for the following states: MA, RI, SC, and TX. FENORTHO (fenoprofen) N VIVITROL (naltrexone) BRINEURA (cerliponase alfa IV) hbbc`b``3 A0 7 ADHD Stimulants, Extended-Release (ER) Y Pre-authorization is a routine process. AMEVIVE (alefacept) %PDF-1.7 % It will show you whether a drug is covered or not covered, but the tier information may not be the same as it is for your specific plan. LIBTAYO (cemiplimab-rwlc) which contain clinical information used to evaluate the PA request as part of. The number of medically necessary visits . 0000012685 00000 n * For more information about this side effect . CARVYKTI (ciltacabtagene autoleucel) paliperidone palmitate (Invega Hafyera, Invega Trinza, Invega Sustenna) 0000004987 00000 n trailer Wegovy This fax machine is located in a secure location as required by HIPAA regulations. Submitting a PA request to OptumRx via phone or fax. PAs help manage costs, control misuse, and LONSURF (trifluridine and tipiracil) GLYXAMBI (empagliflozin-linagliptin) 0000011005 00000 n 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. VOXZOGO (vosoritide) 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. SUBLOCADE (buprenorphine ER) It enables a faster turnaround time of 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. ", The five character codes included in the Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology (CPT. If you have questions, you can reach out to your health care provider. Phone: 1-855-344-0930. Long-Acting Muscarinic Antagonists (LAMA) (Tudorza, Seebri, Incruse Ellipta) 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. OLYSIO (simeprevir) Step #1: Your health care provider submits a request on your behalf. FANAPT (iloperidone) It should be listed under anti-obesity agents. 0000002571 00000 n STRENSIQ (asfotase alfa) ZORVOLEX (diclofenac) AJOVY (fremanezumab-vfrm) - 30 kg/m (obesity), or. SUSVIMO (ranibizumab) In doing so, CVS/Caremark will be able to decide whether or not the requested prescription is included in the patient's insurance plan. <>/Metadata 133 0 R/ViewerPreferences 134 0 R>> End of Life Medications We evaluate each case using clinical criteria to ensure each member receives the right care at the right time in their health care journey. ROZLYTREK (entrectinib) Wegovy should be used with a reduced calorie meal plan and increased physical activity. Tadalafil (Adcirca, Alyq) The member's benefit plan determines coverage. K AYVAKIT (avapritinib) Antihemophilic factor VIII (Eloctate) AEMCOLO (rifamycin delayed-release) RAVICTI (glycerol phenylbutyrate) VRAYLAR (cariprazine) XPOVIO (selinexor) hb```b``{k @16=v1?Q_# tY H LEUKINE (sargramostim) Please . 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. ONZETRA XSAIL (sumatriptan nasal) Navitus believes that effective and efficient communication is the key to ensuring a strong working relationship with our prescribers. PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp) ULTOMIRIS (ravulizumab) The most efficient way to initiate a prior authorization is to ask your physician to contact Express Scripts' prior authorization hotline at 1-800-753-2851. ONGLYZA (saxagliptin) CRESEMBA (isavuconazonium) Interferon beta-1b (Betaseron, Extavia) BCBSKS _ Commercial _ PS _ Weight Loss Agents Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ . J PALYNZIQ (pegvaliase-pqpz) FOTIVDA (tivozanib) 0000016096 00000 n ombitsavir, paritaprevir, retrovir, and dasabuvir v VYVGART (efgartigimod alfa-fcab) SCENESSE (afamelanotide) Part D drug list for Medicare plans. We offer a variety of resources to support you through your health care journey, including: Resources For Living Program RECORLEV (levoketoconazole) 0000003577 00000 n %PDF-1.7 % Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn) allowed by state or federal law. 0000014745 00000 n New and revised codes are added to the CPBs as they are updated. 0000003724 00000 n The request processes as quickly as possible once all required information is together. Angiotensin Receptor Blockers (e.g., Atacand, Atacand HCT, Tribenzor, Edarbi, Edarbyclor, Teveten) CARBAGLU (carglumic acid) 0000004700 00000 n STEGLATRO (ertugliflozin) Blue Shield Medicare plans follow Medicare guidelines for risk allocation and Medicare national and local coverage guideline. authorization (PA) guidelines* to encompass assessment of drug indications, set guideline DELATESTRYL (testosterone cypionate 100mg/ml; 200mg/ml) Please be sure to add a 1 before your mobile number, ex: 19876543210, Guidelines from nationally recognized health care organizations such as the Centers for Medicare and Medicaid Services (CMS), Peer-reviewed, published medical journals, A review of available studies on a particular topic, Expert opinions of health care professionals. 0000003227 00000 n Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. VIJOICE (alpelisib) Discontinue WEGOVY if the patient cannot tolerate the 2.4 mg dose. 0000007133 00000 n TURALIO (pexidartinib) 0 Submitting an electronic prior authorization (ePA) request to OptumRx Any federal regulatory requirements and the member specific benefit plan coverage may also impact coverage criteria. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. 0000002376 00000 n Welcome. SUTENT (sunitinib) AMONDYS 45 (casimersen) The cash price is even higher, averaging $1,988.22 since August 2021 according to GoodRx . ZOMETA (zoledronic acid) 0000009958 00000 n
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