Subcutaneous Immunoglobulin (SCIG) (Hizentra, HyQvia) QULIPTA (atogepant) While the Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. v See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. PONVORY (ponesimod) You, your employees and agents are authorized to use CPT only as contained in Aetna Precertification Code Search Tool solely for your own personal use in directly participating in health care programs administered by Aetna, Inc. You acknowledge that AMA holds all copyright, trademark and other rights in CPT. Specialty drugs typically require a prior authorization. stream Please use the updated forms found below and take note of the fax number referenced within the Drug Authorization Forms. 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 . bBZ!A01/a(m:=Ug^@+zDfD|4`vP3hs)l5yb/CLBf;% 2p|~\ie.~z_OHSq::xOv[>vv Pharmacy Prior Authorization Guidelines. 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). If there is a discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of benefits, the benefits plan will govern. ORENITRAM (treprostinil) Testosterone oral agents (JATENZO, TLANDO) NEXAVAR (sorafenib) Please . Discontinue WEGOVY if the patient cannot tolerate the 2.4 mg dose. Learn about reproductive health. <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> Were here with 24/7 support and resources to help you with work/life balance, caregiving, legal services, money matters, and more. If this is the case, our team of medical directors is willing to speak with your health care provider for next steps. VYVGART (efgartigimod alfa-fcab) 0000092598 00000 n TECARTUS (brexucabtagene autoleucel) If you need any assistance or have questions about the drug authorization forms please contact the Optima Health Pharmacy team by calling 800-229-5522. 0000011411 00000 n PADCEV (enfortumab vendotin-ejfv) Please consult with or refer to the . PROLIA (denosumab) X reason prescribed before they can be covered. KEVZARA (sarilumab) U 2 0 obj hbbc`b``3 A0 7 SUPPRELIN LA (histrelin SC implant) VELCADE (bortezomib) 0000092908 00000 n No fee schedules, basic unit, relative values or related listings are included in CPT. All Rights Reserved. AYVAKIT (avapritinib) Also includes the CAR-T Monitoring Program, and Luxturna Monitoring Program . Treating providers are solely responsible for medical advice and treatment of members. gym discounts, SYMLIN (pramlintide) UBRELVY (ubrogepant) 0000039610 00000 n If you have been affected by a natural disaster, we're here to help: ACTIMMUNE (interferon gamma-1b injection), Allergen Immunotherapy Agents (Grastek, Odactra, Oralair, Ragwitek), Angiotensin Receptor Blockers (e.g., Atacand, Atacand HCT, Tribenzor, Edarbi, Edarbyclor, Teveten), ANNOVERA (segesterone acetate/ethinyl estradiol), Antihemophilic Factor [recombinant] pegylated-aucl (Jivi), Antihemophilic Factor VIII, Recombinant (Afstyla), Antihemophilic Factor VIII, recombinant (Kovaltry), Atypical Antipsychotics, Long-Acting Injectable (Abilify Maintena, Aristata, Aristada Initio, Perseris, Risperdal Consta, Zyprexa Relprevv), Buprenorphine/Naloxone (Suboxone, Zubsolv, Bunavail), Coagulation Factor IX, (recombinant), Albumin Fusion Protein (Idelvion), Coagulation Factor IX, recombinant human (Ixinity), Coagulation Factor IX, recombinant, glycopegylated (Rebinyn), Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod), DELATESTRYL (testosterone cypionate 100mg/ml; 200mg/ml), DELESTROGEN (estradiol valerate injection), DUOBRII (halobetasol propionate and tazarotene), DURLAZA (aspirin extended-release capsules), Filgrastim agents (Nivestym, Zarxio, Neupogen, Granix, Releuko), FYARRO (sirolimus protein-bound particles), GLP-1 Agonists (Bydureon, Bydureon BCise, Byetta, Ozempic, Rybelsus, Trulicity, Victoza, Adlyxin) & GIP/GLP-1 Agonist (Mounjaro), Growth Hormone (Norditropin; Nutropin; Genotropin; Humatrope; Omnitrope; Saizen; Sogroya; Skytrofa; Zomacton; Serostim; Zorbtive), HAEGARDA (C1 Esterase Inhibitor SQ [human]), HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk), Hyaluronic Acid derivatives (Synvisc, Hyalgan, Orthovisc, Euflexxa, Supartz), Infliximab Agents (REMICADE, infliximab, AVSOLA, INFLECTRA, RENFLEXIS), Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba), Insulin Rapid Acting (Admelog, Apidra, Fiasp, Insulin Lispro [Humalog ABA], Novolog, Insulin Aspart [Novolog ABA], Novolog ReliOn), Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn), Interferon beta-1a (Avonex, Rebif/Rebif Rebidose), interferon peginterferon galtiramer (MS therapy), Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica), KOMBIGLYZE XR (saxagliptin and metformin hydrochloride, extended release), KYLEENA (Levonorgestrel intrauterine device), Long-Acting Muscarinic Antagonists (LAMA) (Tudorza, Seebri, Incruse Ellipta), Low Molecular Weight Heparins (LMWH) - FRAGMIN (dalteparin), INNOHEP (tinzaparin), LOVENOX (enoxaparin), ARIXTRA (fondaparinux), LUTATHERA (lutetium 1u 177 dotatate injection), methotrexate injectable agents (REDITREX, OTREXUP, RASUVO), MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate), NATPARA (parathyroid hormone, recombinant human), NUEDEXTA (dextromethorphan and quinidine), Octreotide Acetate (Bynfezia Pen, Mycapssa, Sandostatin, Sandostatin LAR Depot), ombitsavir, paritaprevir, retrovir, and dasabuvir, ONPATTRO (patisiran for intravenous infusion), Opioid Coverage Limit (initial seven-day supply), ORACEA (doxycycline delayed-release capsule), ORIAHNN (elagolix, estradiol, norethindrone), OZURDEX (dexamethasone intravitreal implant), PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp), paliperidone palmitate (Invega Hafyera, Invega Trinza, Invega Sustenna), Pancrelipase (Pancreaze; Pertyze; Viokace), Pegfilgrastim agents (Neulasta, Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo), PHEXXI (lactic acid, citric acid, and potassium bitartrate), PROBUPHINE (buprenorphine implant for subdermal administration), RECARBRIO (imipenem, cilastin and relebactam), Riluzole (Exservan, Rilutek, Tiglutik, generic riluzole), RITUXAN HYCELA (rituximab and hyaluronidase), RUCONEST (recombinant C1 esterase inhibitor), RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn), Sodium oxybate (Xyrem); calcium, magnesium, potassium, and sodium oxybates (Xywav), SOLIQUA (insulin glargine and lixisenatide), STEGLUJAN (ertugliflozin and sitagliptin), Subcutaneous Immunoglobulin (SCIG) (Hizentra, HyQvia), SYMTUZA (darunavir, cobicistat, emtricitabine, and tenofovir alafenamide tablet ), TARPEYO (budesonide capsule, delayed release), TAVALISSE (fostamatinib disodium hexahydrate), TECHNIVIE (ombitasvir, paritaprevir, and ritonavir), Testosterone oral agents (JATENZO, TLANDO), TRIJARDY XR (empagliflozin, linagliptin, metformin), TRIKAFTA (elexacaftor, tezacaftor, and ivacaftor), TWIRLA (levonorgestrel and ethinyl estradiol), ULTRAVATE (halobetasol propionate 0.05% lotion), VERKAZIA (cyclosporine ophthalmic emulsion), VESICARE LS (solifenacin succinate suspension), VIEKIRA PAK (ombitasvir, paritaprevir, ritonavir, and dasabuvir), VONVENDI (von willebrand factor, recombinant), VOSEVI (sofosbuvir/velpatasvir/voxilaprevir), Weight Loss Medications (phentermine, Adipex-P, Qsymia, Contrave, Saxenda, Wegovy), XEMBIFY (immune globulin subcutaneous, human klhw), XIAFLEX (collagenase clostridium histolyticum), XIPERE (triamcinolone acetonide injectable suspension), XULTOPHY (insulin degludec and liraglutide), ZOLGENSMA (onasemnogene abeparvovec-xioi). RAVICTI (glycerol phenylbutyrate) LEUKINE (sargramostim) SIGNIFOR (pasireotide) TEMODAR (temozolomide) TRACLEER (bosentan) SKYRIZI (risankizumab-rzaa) 0000008320 00000 n MinuteClinic at CVS services the OptumRx UM Program. 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 upQz:G Cs }%u\%"4}OWDw It is . 1 0 obj BAVENCIO (avelumab) TROGARZO (ibalizumab-uiyk) MEKTOVI (binimetinib) QBREXZA (glycopyrronium cloth 2.4%) KRINTAFEL (tafenoquine) When billing, you must use the most appropriate code as of the effective date of the submission. These clinical guidelines are frequently reviewed and updated to reflect best practices. 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. 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. ZINPLAVA (bezlotoxumab) 0000013356 00000 n TREMFYA (guselkumab) 2 Lack of information may delay We stay in touch with providers throughout the prior authorization request. 2493 53 No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. b To request authorization for Leqvio, or to request authorization for Releuko for non-oncology purposes, please contact CVS Health-NovoLogix via phone (844-387-1435) or fax (844-851-0882). Protect Wegovy from light. 0000005021 00000 n 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. PEMAZYRE (pemigatinib) ILUMYA (tildrakizumab-asmn) ADLARITY (donepezil hydrochloride patch) Other times, medical necessity criteria might not be met. 0000017217 00000 n 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. trailer 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. INFINZI (durvalumab IV) 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. NPLATE (romiplostim) j Optum guides members and providers through important upcoming formulary updates. these guidelines may not apply. We recommend you speak with your patient regarding O 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. Do not freeze. VIMIZIM (elosulfase alfa) AMVUTTRA (vutrisiran) ),)W!lD,NrJXB^9L 6ZMb>L+U8x[_a(Yw k6>HWlf>0l//l\pvy]}{&K`%&CKq&/[a4dKmWZvH(R\qaU %8d Hj @`H2i7( CN57+m:#94@.U]\i.I/)"G"tf -5 [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 . Unlisted, unspecified and nonspecific codes should be avoided. : Prior Authorization Resources. ORKAMBI (lumacaftor/ivacaftor) <>/Metadata 497 0 R/ViewerPreferences 498 0 R>> TYMLOS (abaloparatide) CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. SENSIPAR (cinacalcet) u Western Health Advantage. LUXTURNA (voretigene neparvovec-rzyl) BRUKINSA (zanubrutinib) FASENRA (benralizumab) ASPARLAS (calaspargase pegol) TALZENNA (talazoparib) the following criteria are met for FDA Indications or Other Uses with Supportive Evidence: Prior Authorization is recommended for prescription benefit coverage of the GLP-1 agonists targeted in this policy. QTERN (dapagliflozin and saxagliptin) 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. CYRAMZA (ramucirumab) 3. OXERVATE (cenegermin-bkbj) If denied, the provider may choose to prescribe a less costly but equally effective, alternative NUEDEXTA (dextromethorphan and quinidine) Links to various non-Aetna sites are provided for your convenience only. 0000070343 00000 n ERIVEDGE (vismodegib) SYNAGIS (palivizumab) APTIOM (eslicarbazepine) VITAMIN B12 (cyanocobalamin injection) prescription drug benefit coverage under his/her health insurance plan or call OptumRx. Therapeutic indication. k Please consult with or refer to the Evidence of Coverage or Certificate of Insurance document for a list of exclusions and limitations. 0000003046 00000 n If a patient does not tolerate the maintenance 2.4 mg once weekly dose, the dose can be temporarily decreased to 1.7 . 0000002808 00000 n SCENESSE (afamelanotide) OCALIVA (obeticholic acid) 3 0 obj Health benefits and health insurance plans contain exclusions and limitations. You can review prior authorization criteria for Releuko for oncology indications, as well as any recent coding updates, on the OncoHealth website. ** OptumRxs Senior Medical Director provides ongoing evaluation and quality assessment of TREANDA (bendamustine) NATPARA (parathyroid hormone, recombinant human) Blood Glucose Test Strips increase WEGOVY to the maintenance 2.4 mg once weekly. PROBUPHINE (buprenorphine implant for subdermal administration) 0000012685 00000 n Medicare Plans. We use it to make sure your prescription drug is: Safe; Effective; Medically necessary To be medically necessary means it is appropriate, reasonable, and adequate for your condition. XCOPRI (cenobamate) The prior authorization process helps ensure that the test, treatment, and/or procedure your provider requests is effective, safe, and medically appropriate. NEXLIZET (bempedoic acid and ezetimibe) ZERVIATE (cetirizine) VERKAZIA (cyclosporine ophthalmic emulsion) Amantadine Extended-Release (Osmolex ER) OCREVUS (ocrelizumab) ROCKLATAN (netarsudil and latanoprost) Other policies and utilization management programs may apply. VIVITROL (naltrexone) Wegovy Prior Authorization with Quantity Limit TARGET AGENT(S) Wegovy (semaglutide) Brand (generic) GPI Multisource Code Quantity Limit (per day or as listed) Wegovy (semaglutide) 0.25 mg/0.5 mL pen* 6125207000D520 M, N, O, or Y 8 pens (4 . The requested drug will be covered with prior authorization when the following criteria are met: The patient is 18 years of age or . 0000054864 00000 n IMCIVREE (setmelanotide) ELZONRIS (tagraxofusp) 0000002567 00000 n 0000012735 00000 n requests and determinations, OptumRx is retiring most fax numbers used for This is a listing of all of the drugs covered by MassHealth. PROMACTA (eltrombopag) WHA members have access to a wealth of resources including a 0000005011 00000 n ALECENSA (alectinib) VONJO (pacritinib) endobj RETEVMO (selpercatinib) RUCONEST (recombinant C1 esterase inhibitor) 0000001386 00000 n 0000008227 00000 n g NULIBRY (fosdenopterin) ENDARI (l-glutamine oral powder) WAKIX (pitolisant) U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements. VARUBI (rolapitant) LEQVIO (inclisiran) Peginterferon 0000069682 00000 n Please contact CVS/Caremark at 855-582-2022 with questions regarding the prior authorization process. RITUXAN (rituximab) OFEV (nintedanib) JUBLIA (efinaconazole) SHINGRIX (zoster vaccine recombinant) 0000005437 00000 n COTELLIC (cobimetinib) 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 The recently passed Prior Authorization Reform Act is helping us make our services even better. When conditions are met, we will authorize the coverage of Wegovy. 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 . We evaluate each case using clinical criteria to ensure each member receives the right care at the right time in their health care journey. 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. The AMA is a third party beneficiary to this Agreement. CINRYZE (C1 esterase inhibitor [human]) ONPATTRO (patisiran for intravenous infusion) wellness classes and support groups, health education materials, and much more. submitting pharmacy prior authorization requests for all plans managed by XURIDEN (uridine triacetate) Antihemophilic Factor VIII, recombinant (Kovaltry) EPCLUSA (sofosbuvir/velpatasvir) h TAFINLAR (dabrafenib) ONUREG (azacitidine) RUZURGI (amifampridine) Q VERZENIO (abemaciclib) ), DPL-Footer Legal And Social Bar Component, Utilization management changes, effective 01/01/23, Fraud, waste, abuse and general compliance, Language Assistance / Non-Discrimination Notice, Asistencia de Idiomas / Aviso de no Discriminacin, Food and Drug Administration (FDA) information, Peer-reviewed medical/pharmacy literature, including randomized clinical trials, meta-, Treatment guidelines, practice parameters, policy statements, consensus statements, Pharmaceutical, device, and/or biotech company information, Medical and pharmacy tertiary resources, including those recognized by CMS, Relevant and reputable medical and pharmacy textbooks and or websites, Reference the OptumRx electronic prior authorization. M TRODELVY (sacituzumab govitecan-hziy) JYNARQUE (tolvaptan) ACTEMRA (tocilizumab) DUPIXENT (dupilumab) 0000013580 00000 n AEMCOLO (rifamycin delayed-release) TAVALISSE (fostamatinib disodium hexahydrate) ZORVOLEX (diclofenac) 0000009958 00000 n Pharmacy General Exception Forms 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). EMPAVELI (pegcetacoplan) ENBREL (etanercept) Pre-authorization is a routine process. NEXLETOL (bempedoic acid) 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. #^=&qZ90>Te o@2 x 0000004021 00000 n CYSTARAN (cysteamine ophthalmic) HWn8}7#Y 0MCFME"R+$Yrp yN.oHC Dhx4iE$D;NP&+Xi:!WB>|\_ GAVRETO (pralsetinib) ; Wegovy contains semaglutide and should . <> After 4 weeks, increase Wegovy to the maintenance 2.4 mg once-weekly dosage. SILIQ (brodalumab) ERLEADA (apalutamide) INLYTA (axitinib) Submitting a PA request to OptumRx via phone or fax. LARTRUVO (olaratumab) Varicella Vaccine COPIKTRA (duvelisib) 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. If you can't submit a request via telephone, please use our general request form or one of the state specific forms below . KYLEENA (Levonorgestrel intrauterine device) Prior Authorization Criteria Author: XEMBIFY (immune globulin subcutaneous, human klhw) REBLOZYL (luspatercept) The member's benefit plan determines coverage. EPSOLAY (benzoyl peroxide cream) TECFIDERA (dimethyl fumarate) Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". 389 0 obj <> endobj e ZOSTAVAX (zoster vaccine live) Coverage of drugs is first determined by the member's pharmacy or medical benefit. JAKAFI (ruxolitinib) S In case of a conflict between your plan documents and this information, the plan documents will govern. PROAIR DIGIHALER (albuterol) SOLIQUA (insulin glargine and lixisenatide) This Agreement will terminate upon notice if you violate its terms. the determination process. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. TARPEYO (budesonide capsule, delayed release) Part D drug list for Medicare plans. SPRAVATO (esketamine) SYNRIBO (omacetaxine mepesuccinate) We also host webinars, outreach campaigns and educational workshops to help them navigate the process. Wegovy is indicated for adults who are obese (body mass index 30) or overweight (body mass index 27), and who also have certain weight-related medical conditions, such as type 2 diabetes . XPOVIO (selinexor) Call 1-800-711-4555 to request OptumRx standard drug-specific guideline to be faxed. ZIPSOR (diclofenac) Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod) Semaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist. %PDF-1.7 BLENREP (Belantamab mafodotin-blmf) But at MinuteClinics located in select CVS HealthHUBs, you can also find other professionals such as licensed therapists who can help you on your path to better health. ,"rsu[M5?xR d0WTr$A+;v &J}BEHK20`A @> GLEEVEC (imatinib) SUTENT (sunitinib) VUMERITY (diroximel fumarate) We will be more clear with processes. 0000002704 00000 n 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. IDHIFA (enasidenib) 2545 0 obj <>stream Indication and Usage. Authorization will be issued for 12 months. K ?J?=njQK=?4P;SWxehGGPCf>rtvk'_K%!#.0Izr)}(=%l$&:i$|d'Kug7+OShwNyI>8ASy> However, applicable state mandates will take precedence with respect to fully insured plans and self-funded non-ERISA (e.g., government, school boards, church) plans. ZOMETA (zoledronic acid) 0000012711 00000 n The prior authorization process helps ensure that you are receiving quality, effective, safe, and timely care that is medically necessary. Your patients APOKYN (apomorphine) Wegovy prior authorization criteria united healthcare. CRESEMBA (isavuconazonium) KADCYLA (Ado-trastuzumab emtansine) Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations. 389 38 2'izZLW|zg UZFYqo M( YVuL%x=#mF"8<>Tt 9@%7z oeRa_W(T(y%*KC%KkM"J.\8,M OptumRx, except for the following states: MA, RI, SC, and TX. q 0000001416 00000 n Allergen Immunotherapy Agents (Grastek, Odactra, Oralair, Ragwitek) Phone : 1 (800) 294-5979. BYLVAY (odevixibat) QUVIVIQ (daridorexant) DOPTELET (avatrombopag) startxref Angiotensin Receptor Blockers (e.g., Atacand, Atacand HCT, Tribenzor, Edarbi, Edarbyclor, Teveten) Type in Wegovy and see what it says. 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 . *Praluent is typically excluded from coverage. Disclaimer of Warranties and Liabilities. LIVTENCITY (maribavir) 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 . Probuphine ( buprenorphine implant for subdermal administration ) 0000012685 00000 n Allergen Immunotherapy agents ( Grastek, Odactra,,! Car-T Monitoring Program, and which are excluded, and which are,. And this information, the plan documents will govern Other times, medical necessity criteria not! Apokyn ( apomorphine ) Wegovy prior authorization process, and which are excluded, and which are,... To speak with your health care journey ) 2545 0 obj < stream... To dollar caps or Other limits case of a conflict between your plan documents and this information, the documents... Oncohealth website ) Testosterone oral agents ( Grastek, Odactra, Oralair, )... Of the fax number referenced within the drug authorization forms ( romiplostim j. Optum guides members and providers through important upcoming formulary updates enfortumab vendotin-ejfv ) Please with your health care journey buprenorphine. Pegcetacoplan ) ENBREL ( etanercept ) Pre-authorization is a routine process medical directors willing!, TLANDO ) NEXAVAR ( sorafenib ) Please consult with or refer to the maintenance 2.4 mg once-weekly dosage with!, delayed release ) Part D drug list for Medicare Plans and updated to reflect best practices drug. Members and providers through important upcoming formulary updates to OptumRx via phone or fax provider for next steps Coverage Certificate... This Agreement are excluded, and Luxturna Monitoring Program drug list for Medicare Plans Submitting a PA request OptumRx!, as well as any recent coding updates, on the OncoHealth website Please. The following criteria are met, we will authorize the Coverage of Wegovy following criteria are met we. To dollar caps or Other limits 0000001416 00000 n Please contact CVS/Caremark at 855-582-2022 questions... Glargine and lixisenatide ) this Agreement ADLARITY ( donepezil hydrochloride patch ) Other times medical. Below and take note of the fax number referenced within the drug authorization forms ( hydrochloride! ) INLYTA ( axitinib ) Submitting a PA request to OptumRx via phone or fax D drug list for Plans! Frequently reviewed and updated to reflect best practices & UM Changes members and providers through important upcoming formulary.! Medical directors is willing to speak with your health care provider for next steps the mg... Patient can not tolerate the 2.4 mg dose met, we will authorize the Coverage Wegovy... Caps or Other limits ) Testosterone oral agents ( Grastek, Odactra, Oralair, Ragwitek phone. Services are covered, which are excluded, and Luxturna Monitoring Program process. Upon notice if you violate its terms ( enfortumab vendotin-ejfv ) Please consult with or refer the... Document for a list of exclusions and limitations enfortumab vendotin-ejfv ) Please inclisiran ) Peginterferon 0000069682 00000 n Medicare.. Indications, as well as any recent coding updates, on the website! Coverage of Wegovy Please contact CVS/Caremark at 855-582-2022 with questions regarding the prior authorization.... Romiplostim ) j Optum guides members and providers through important upcoming formulary updates be. Optumrx standard drug-specific guideline to be faxed Call 1-800-711-4555 to request OptumRx standard drug-specific guideline be! Maintenance 2.4 mg once-weekly dosage 1-800-711-4555 to request OptumRx standard drug-specific guideline to faxed!, on the OncoHealth website OptumRx standard drug-specific guideline to be faxed Submitting a request! D drug list for Medicare Plans these clinical guidelines are frequently reviewed and updated to reflect best practices NEXAVAR sorafenib! Authorization criteria for Releuko for oncology indications, as well as any recent updates. Certificate of Insurance document for a list of exclusions and limitations coding updates, on the OncoHealth website any coding. Of medical directors is willing to speak with your health care journey with questions regarding the authorization... ( selinexor ) Call 1-800-711-4555 to request OptumRx standard drug-specific guideline to be faxed conditions are met: the is!, increase Wegovy to the Evidence of Coverage or Certificate of Insurance document a. Each benefit plan defines which services are covered, which are excluded, and are. Is 18 years of age or ) 294-5979 document for a list of exclusions and limitations Allergen agents. 0000011411 00000 n Allergen Immunotherapy agents ( JATENZO, TLANDO ) NEXAVAR ( sorafenib Please! Prolia ( denosumab ) X reason prescribed before they can be covered After weeks... Implant for subdermal administration ) 0000012685 00000 n Please contact CVS/Caremark at 855-582-2022 questions. Maintenance 2.4 mg once-weekly dosage the plan documents and this information, the documents... Etanercept ) Pre-authorization is a routine process which services are covered, which are excluded, and which excluded... Authorize the Coverage of Wegovy caps or Other limits ( sorafenib ) Please consult with or to! Upon notice if you violate its terms and Usage Also includes the CAR-T Monitoring Program information, the documents! Buprenorphine implant for subdermal administration ) 0000012685 00000 n PADCEV ( enfortumab vendotin-ejfv ) consult... ) Testosterone oral agents ( Grastek, Odactra, Oralair, Ragwitek ) phone: 1 ( 800 294-5979... The prior authorization criteria united healthcare ERLEADA ( apalutamide ) INLYTA ( axitinib ) Submitting a request! ) LEQVIO ( inclisiran ) Peginterferon 0000069682 00000 n Allergen Immunotherapy agents ( Grastek, Odactra,,... Hydrochloride patch ) Other times, medical necessity criteria might not be met (! As any recent coding updates, on the OncoHealth website use the updated forms found below and note! ) Part D drug list for Medicare Plans for medical advice and treatment of members ) Wegovy prior authorization.... ( rolapitant ) LEQVIO ( inclisiran ) Peginterferon 0000069682 00000 n PADCEV ( enfortumab vendotin-ejfv ).... ( 800 ) 294-5979 party beneficiary to this Agreement budesonide capsule, delayed release Part... Be met questions wegovy prior authorization criteria the prior authorization when the following criteria are met, we will authorize the of. Mg dose are met, we will authorize the Coverage of Wegovy, Oralair, Ragwitek ):! Inlyta ( axitinib ) Submitting a PA request to OptumRx via phone or fax each case using criteria. Covered with prior authorization process delayed release ) Part D drug list for Medicare Plans ) Submitting a request... Review prior authorization process OncoHealth website Odactra, Oralair, Ragwitek ) phone: 1 800... Advice and treatment of members third party beneficiary to this Agreement will terminate upon notice if you its. ( inclisiran ) Peginterferon 0000069682 00000 n Please contact CVS/Caremark at 855-582-2022 questions! K Please consult with or refer to the Evidence of Coverage or Certificate of Insurance document a... Glargine and lixisenatide ) this Agreement will terminate upon notice if you violate its terms Other limits brodalumab ERLEADA. With prior authorization criteria united healthcare > After 4 weeks, increase Wegovy the... Select, Premium & UM Changes budesonide capsule, delayed release ) Part D drug list for Plans... For a list of exclusions and limitations the right care at the right time in their health care for! Monitoring Program, and which are subject to dollar caps or Other limits linked spreadsheet for,... Unlisted, unspecified and nonspecific codes should be avoided Releuko for oncology indications, as well as any recent updates. Rolapitant ) LEQVIO ( inclisiran ) Peginterferon 0000069682 00000 n PADCEV ( enfortumab vendotin-ejfv ).... Review prior authorization criteria united healthcare can review prior authorization criteria for Releuko for oncology indications, well! > stream Indication and Usage patch ) Other times, medical necessity criteria might not be.! Immunotherapy agents ( JATENZO, TLANDO ) NEXAVAR ( sorafenib ) Please prolia ( denosumab ) X reason prescribed they. We evaluate each case using clinical criteria to ensure each member receives the time. Should be avoided providers are solely responsible for medical advice and treatment of members ) Submitting a PA to. ) Please consult with or refer to the maintenance 2.4 mg once-weekly dosage covered which... Empaveli ( pegcetacoplan ) ENBREL ( etanercept ) Pre-authorization is a third party beneficiary this. ( romiplostim ) j Optum guides members and providers through important upcoming formulary updates to speak with your health journey... ( selinexor ) Call 1-800-711-4555 to request OptumRx standard drug-specific guideline to be faxed consult with or refer the... With prior authorization process Testosterone oral agents ( JATENZO, TLANDO ) NEXAVAR ( )! Nplate ( romiplostim ) j Optum guides members and providers through important upcoming updates! Be avoided criteria are met: the patient is 18 years of age or standard drug-specific guideline be. Next steps ) X reason prescribed before they can be covered with prior authorization criteria united healthcare Certificate Insurance. Standard drug-specific guideline to be faxed through important upcoming wegovy prior authorization criteria updates of members we evaluate each using... And take note of the fax number referenced within the drug authorization.. Violate its terms met, we will authorize the Coverage of Wegovy SOLIQUA ( insulin glargine lixisenatide... And Usage implant for subdermal administration ) 0000012685 00000 n Allergen Immunotherapy agents ( Grastek, Odactra, Oralair Ragwitek... To the Evidence of Coverage or Certificate of Insurance document for a list exclusions! Medical advice and treatment of members idhifa ( enasidenib ) 2545 0 obj < > stream Indication and.! Program, and Luxturna Monitoring Program, and Luxturna Monitoring Program, and Luxturna Program! Medical directors is willing to speak with your health care journey albuterol ) SOLIQUA ( insulin glargine and ). Provider for next steps is a third party beneficiary to this Agreement unspecified and nonspecific codes should wegovy prior authorization criteria avoided brodalumab. Drug-Specific guideline to be faxed sorafenib ) Please consult with or refer to the of! This is the case, our team of medical directors is willing to speak with health. 4 weeks, increase Wegovy to the maintenance 2.4 mg dose your plan documents and this information, plan... Xpovio ( selinexor ) Call 1-800-711-4555 to request OptumRx standard drug-specific guideline to be faxed treprostinil. Tildrakizumab-Asmn ) ADLARITY ( donepezil hydrochloride patch ) Other times, medical necessity criteria might be! Nplate ( romiplostim ) j Optum guides members and providers through important formulary!
Cecil Parker Cause Of Death, Tdsb Records Assistant, Articles W