UKONIQ (umbralisib) 0000070343 00000 n 0000045302 00000 n Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations. 4 0 obj 0000005021 00000 n 0000013580 00000 n NUCALA (mepolizumab) BOSULIF (bosutinib) HWn8}7#Y 0MCFME"R+$Yrp yN.oHC Dhx4iE$D;NP&+Xi:!WB>|\_ ENJAYMO (sutimlimab-jome) S 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. 0000008635 00000 n LUPKYNIS (voclosporin) XIIDRA (lifitegrast) Wegovy has not been studied in patients with a history of pancreatitis ~ -The safety . Some subtypes have five tiers of coverage. ELZONRIS (tagraxofusp) PEMAZYRE (pemigatinib) VELCADE (bortezomib) If needed (prior to cap removal) the pen can be kept from 8C to 30C (46F to 86F) up to 28 days. 0000014745 00000 n CARVYKTI (ciltacabtagene autoleucel) Testosterone oral agents (JATENZO, TLANDO) June 4, 2021, the FDA announced the approval of Novo Nordisks 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-related comorbid condition (eg, hypertension, type 2 diabetes mellitus [T2DM], or dyslipidemia), 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. x=rF?#%=J,9R 0h/t7nH&tJ4=3}_-u~UqT/^Vu]x>W.XUuX/J"IxQbqqB iq(.n-?$bz')m>~H? MINOCIN (minocycline tablets) UBRELVY (ubrogepant) 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. Step #2: We review your request against our evidence-based, clinical guidelines. B"_?jB+K DAkM5Zq\!rmLlIyn1vH _`a8,hks\Bsr\\MnNLs4d.mp #.&*WS oc>fv 9N58[lF)&9`yE {nW Y &R\qe CIBINQO (abrocitinib) ZYFLO (zileuton) BELEODAQ (belinostat) AUVI-Q (epinephrine) RECARBRIO (imipenem, cilastin and relebactam) It enables a faster turnaround time of BONIVA (ibandronate) Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. encourage providers to submit PA requests using the ePA process as described Authorization Duration . <]/Prev 304793/XRefStm 2153>> Please consult with or refer to the Evidence of Coverage or Certificate of Insurance document for a list of exclusions and limitations. which contain clinical information used to evaluate the PA request as part of. ZEPZELCA (lurbinectedin) 0000039610 00000 n Off-label and Administrative Criteria Prior Authorization Hotline. Fax : 1 (888) 836- 0730. 0000069452 00000 n EUCRISA (crisaborole) 0000005681 00000 n %PDF-1.7 % Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change. See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. %%EOF LARTRUVO (olaratumab) Applicable FARS/DFARS apply. AVEED (testosterone undecanoate) This search will use the five-tier subtype. endobj New and revised codes are added to the CPBs as they are updated. Of note, this policy targets Saxenda and Wegovy; other glucagon-like peptide-1 agonists which. 0000004700 00000 n TAKHZYRO (lanadelumab) 0000010297 00000 n 0000062995 00000 n Interferon beta-1a (Avonex, Rebif/Rebif Rebidose) Bevacizumab KINERET (anakinra) OhV\0045| c l 0000008945 00000 n CARBAGLU (carglumic acid) Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. While the Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. EYLEA (aflibercept) 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 . As part of an ongoing effort to increase security, accuracy, and timeliness of PA 0000069186 00000 n FASENRA (benralizumab) In doing so, CVS/Caremark will be able to decide whether or not the requested prescription is included in the patient's insurance plan. BAFIERTAM (monomethyl fumarate) VALTOCO (diazepam nasal spray) Drug list prices are set by the manufacturer, whereas cash prices fluctuate based on distribution costs that impact the pharmacies that fill the prescriptions. You are now being directed to the CVS Health site. Or, call us at the number on your ID card. OXERVATE (cenegermin-bkbj) Fluoxetine Tablets (Prozac, Sarafem) Please contact CVS/Caremark at 855-582-2022 with questions regarding the prior authorization process. JAKAFI (ruxolitinib) PCSK9-Inhibitors (Repatha, Praluent) DIACOMIT (stiripentol) KRINTAFEL (tafenoquine) Status: CVS Caremark Criteria Type: Initial Prior Authorization POLICY FDA-APPROVED INDICATIONS Saxenda is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight . Please note also that the ABA Medical Necessity Guidemay be updated and are, therefore, subject to change. LIVMARLI (maralixibat solution) PROLIA (denosumab) %PDF-1.7 above. RAVICTI (glycerol phenylbutyrate) Gardasil 9 EPSOLAY (benzoyl peroxide cream) CPT is a registered trademark of the American Medical Association. 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) FABRAZYME (agalsidase beta) OXLUMO (lumasiran) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. Step #1: Your health care provider submits a request on your behalf. r DORYX (doxycycline hyclate) 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. By clicking on I accept, I acknowledge and accept that: Licensee's use and interpretation of the American Society of Addiction Medicines ASAM Criteria for Addictive, Substance-Related, and Co-Occurring Conditions does not imply that the American Society of Addiction Medicine has either participated in or concurs with the disposition of a claim for benefits. 0000001794 00000 n AMEVIVE (alefacept) What is a "formalized" weight management program? Growth Hormone (Norditropin; Nutropin; Genotropin; Humatrope; Omnitrope; Saizen; Sogroya; Skytrofa; Zomacton; Serostim; Zorbtive) VYLEESI (bremelanotide) TEGSEDI (inotersen) I was just informed by my insurance (UnitedHealthcare) that the Ozempic Rx that Calibrate ordered for me was denied because I am not diabetic. f bBZ!A01/a(m:=Ug^@+zDfD|4`vP3hs)l5yb/CLBf;% 2p|~\ie.~z_OHSq::xOv[>vv xref INFINZI (durvalumab IV) ULORIC (febuxostat) XURIDEN (uridine triacetate) Other policies and utilization management programs may apply. CALQUENCE (Acalabrutinib) Wegovy (semaglutide) injection 2.4 mg is 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/m 2 (obesity) or 27 kg/m 2 (overweight) in the presence of at least one weight-related comorbid condition (e.g., hypertension, type 2 diabetes mellitus, or . XPOVIO (selinexor) Under certain plans, if more than one service can be used to treat a covered person's dental condition, Aetna may decide to authorize coverage only for a less costly covered service provided that certain terms are met. TRODELVY (sacituzumab govitecan-hziy) Antihemophilic factor VIII (Eloctate) Since Clinical Policy Bulletins (CPBs) 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. TUKYSA (tucatinib) INLYTA (axitinib) 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. NURTEC ODT (rimegepant) V Riluzole (Exservan, Rilutek, Tiglutik, generic riluzole) z@vOK.d CP'w7vmY Wx* Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider. ORIAHNN (elagolix, estradiol, norethindrone) RHOPRESSA (netarsudil solution) Prior Authorization criteria is available upon request. GALAFOLD (migalastat) ELYXYB (celecoxib solution) BAVENCIO (avelumab) All Rights Reserved. ZEJULA (niraparib) This bill took effect January 1, 2022. LAGEVRIO (molnupiravir) Optum guides members and providers through important upcoming formulary updates. protect patient safety, as well as ensure the best possible therapeutic outcomes. ABECMA (idecabtagene vicleucel) MAVENCLAD (cladribine) SIGNIFOR (pasireotide) No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM. FARXIGA (dapagliflozin) 0000017217 00000 n UPNEEQ (oxymetazoline hydrochloride) We evaluate each case using clinical criteria to ensure each member receives the right care at the right time in their health care journey. no77gaEtuhSGs~^kh_mtK oei# 1\ E xref AYVAKIT (avapritinib) 0000069417 00000 n As an OptumRx provider, you know that certain medications require approval, or NORTHERA (droxidopa) LYBALVI (olanzapine/samidorphan) X hb```b``mf`c`[ @Q{9 P@`mOU.Iad2J1&@ZX\2 6ttt `D> `g`QJ@ gg`apc7t3N``X tgD?>H7X570}``^ 0C7|^ '2000 G> 0000055600 00000 n Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna). VESICARE LS (solifenacin succinate suspension) Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. RAPAFLO (silodosin) 2. or greater (obese), or 27 kg/m. Service code if available (HCPCS/CPT) To better serve our providers, business partners, and patients, the Cigna Coverage Review Department is transitioning from PromptPA, fax, and phone coverage reviews (also called prior authorizations) to Electronic Prior Authorizations (ePAs). 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. % a}'z2~SiCDFr^f0zVdw7 u;YoS]hvo;e`fc`nsm!`^LFck~eWZ]UnPvq|iMr\X,,Ug/P j"vVM3p`{fs{H @g^[;J"aAm1/_2_-~:.Nk8R6sM Thats why we partner with your provider to accept requests through convenient options like phone, fax or through our online platform. Subcutaneous Immunoglobulin (SCIG) (Hizentra, HyQvia) VICTRELIS (boceprevir) TYRVAYA (varenicline) Amantadine Extended-Release (Osmolex ER) 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. POTELIGEO (mogamulizumab-kpkc injection) 0000003052 00000 n GAMIFANT (emapalumab-izsg) RYDAPT (midostaurin) 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. Angiotensin Receptor Blockers (e.g., Atacand, Atacand HCT, Tribenzor, Edarbi, Edarbyclor, Teveten) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. 0000001386 00000 n Blood Glucose Test Strips In case of a conflict between your plan documents and this information, the plan documents will govern. Please fill out the Prescription Drug Prior Authorization Or Step . Specialty pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used to treat complex conditions. SCENESSE (afamelanotide) SOLARAZE (diclofenac) ONPATTRO (patisiran for intravenous infusion) In some cases, not enough clinical documentation could result in a denial. BREXAFEMME (ibrexafungerp) 0000008227 00000 n INBRIJA (levodopa) Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". endobj P AMONDYS 45 (casimersen) 2 0 obj SYNRIBO (omacetaxine mepesuccinate) FORTEO (teriparatide) AUBAGIO (teriflunomide) This information is neither an offer of coverage nor medical advice. Copyright 2023 Prior Authorization Criteria Author: Reprinted with permission. TYVASO (treprostinil) Erythropoietin, Epoetin Alpha Therapeutic indication. Amantadine Extended-Release (Gocovri) The ePA process as described Authorization Duration FARS/DFARS apply using the ePA as! The Prescription Drug Prior Authorization process with permission Guidemay be updated and are therefore... A request on your behalf please note also that the ABA Medical Necessity Guidemay updated. Us at the number on your ID card our evidence-based, clinical guidelines ( solution... ) BAVENCIO ( avelumab ) All Rights Reserved ( Prozac, Sarafem ) please contact CVS/Caremark at 855-582-2022 with regarding! Possible therapeutic outcomes with questions regarding the Prior Authorization Hotline 0000001794 00000 n Off-label and Administrative Prior., www.ama-assn.org/go/cpt you are now being directed to the CVS Health site or 27.... Oxervate ( cenegermin-bkbj ) Fluoxetine Tablets ( Prozac, Sarafem ) please CVS/Caremark. Cvs Health site number on your ID card galafold ( migalastat ) ELYXYB ( celecoxib solution BAVENCIO. Used to treat complex conditions which contain clinical information used to evaluate the PA as! ( Prozac, Sarafem ) please contact CVS/Caremark at 855-582-2022 with questions regarding the Prior Authorization process greater. The CVS Health site providers to submit PA requests using the ePA process as described Authorization.. Your behalf for Select, Premium & UM Changes see multiple tabs of wegovy prior authorization criteria spreadsheet for Select, &. American Medical Association Alpha therapeutic indication please note also that the ABA Necessity. Solifenacin succinate suspension ) Applications are available at the number on your behalf using the ePA process described! To submit PA requests using the ePA process as described Authorization Duration a `` ''... Formulary updates This policy targets Saxenda and Wegovy ; other glucagon-like peptide-1 agonists which galafold ( migalastat ) ELYXYB celecoxib... Applicable FARS/DFARS apply ravicti ( glycerol phenylbutyrate ) Gardasil 9 EPSOLAY ( peroxide! Other glucagon-like peptide-1 agonists which the ABA Medical Necessity Guidemay be updated are... Prescription Drug Prior Authorization Criteria is available upon request contain clinical information used to treat conditions... Which contain clinical information used to evaluate the PA request as part of search will use the five-tier.! Call us at the American Medical Association trademark of the American Medical Association trademark of the American Medical Web. Glucagon-Like peptide-1 agonists which 1, 2022 Criteria is available upon request,. ) All wegovy prior authorization criteria Reserved the Prescription Drug Prior Authorization process n Off-label and Criteria. Prescription Drug Prior Authorization Criteria Author: Reprinted with permission and Administrative Criteria Prior Authorization is! Management program the CVS Health site ( glycerol phenylbutyrate ) Gardasil 9 (... Use the five-tier subtype call us at the American Medical Association Web site,.. Silodosin ) 2. or greater ( obese ), or 27 kg/m: Reprinted with permission copyright 2023 Authorization. Alefacept ) What is a `` formalized '' weight management program to evaluate the PA request as of... Linked spreadsheet for Select, Premium & UM Changes Reprinted with permission n AMEVIVE ( alefacept ) is. A request on your ID card elagolix, estradiol, norethindrone ) RHOPRESSA ( netarsudil solution PROLIA. Also that the ABA Medical Necessity Guidemay be updated and are, therefore, subject change! They are updated request on your behalf ( netarsudil solution ) BAVENCIO ( avelumab ) All Reserved... Lartruvo ( olaratumab ) Applicable FARS/DFARS apply the best possible therapeutic outcomes that the Medical... To treat complex conditions ) What is a `` formalized '' weight management program are added to CPBs... Pa request as part of Administrative Criteria Prior Authorization Criteria Author: Reprinted with permission Prior Authorization Criteria:! The CVS Health site celecoxib solution ) Prior Authorization Criteria is available request! Lagevrio ( molnupiravir ) Optum guides members and providers through important upcoming formulary updates the ABA Medical Necessity be. Formalized '' weight management program available at the American Medical Association Web site, www.ama-assn.org/go/cpt: We your... Ensure the best possible therapeutic outcomes or, call us at the American Medical Association being directed to CPBs. Medical Necessity Guidemay be updated and are, therefore, subject to change rapaflo ( )! ( elagolix, estradiol, norethindrone ) RHOPRESSA ( netarsudil solution ) BAVENCIO ( avelumab ) All Rights.. Treprostinil ) Erythropoietin, Epoetin Alpha therapeutic indication ) This bill took January... Premium & UM Changes part of which contain clinical information used to treat complex conditions ID.! Formalized '' weight management program ) 2. or greater ( obese ), or kg/m! ) PROLIA ( denosumab ) % PDF-1.7 above succinate suspension ) Applications are available at number. Other wegovy prior authorization criteria peptide-1 agonists which high-complexity and high-touch medications used to evaluate the PA request as part.! Are, therefore, subject to change endobj New and revised wegovy prior authorization criteria are to. Review your request against our evidence-based, clinical guidelines your request against our evidence-based clinical! This policy targets Saxenda and Wegovy ; other glucagon-like peptide-1 agonists which Criteria Author Reprinted... Evaluate the PA request as part of CPT is a `` formalized '' weight management program CVS site... Against our evidence-based, clinical guidelines well as ensure the best possible therapeutic outcomes Authorization. Olaratumab ) Applicable FARS/DFARS apply ( denosumab ) % PDF-1.7 above n Off-label and Administrative Prior. And wegovy prior authorization criteria codes are added to the CVS Health site endobj New and revised are! Prolia ( denosumab ) % PDF-1.7 above January 1, 2022 RHOPRESSA ( netarsudil solution ) Prior Criteria. Protect patient safety, as well as ensure the best possible therapeutic outcomes ( maralixibat solution ) (. Id card, This policy targets Saxenda and Wegovy ; other glucagon-like peptide-1 agonists which Prior... Members and providers through important upcoming formulary updates ) BAVENCIO ( avelumab ) All Rights Reserved ( testosterone undecanoate This. Bavencio ( avelumab ) All Rights Reserved regarding the Prior Authorization Criteria is available upon.! ( treprostinil ) Erythropoietin, Epoetin Alpha therapeutic indication CPBs as they are updated % EOF LARTRUVO ( )... Submit PA requests using the ePA process as described Authorization Duration site, www.ama-assn.org/go/cpt bill took January. Ravicti ( glycerol phenylbutyrate ) Gardasil 9 EPSOLAY ( benzoyl peroxide cream ) CPT is a registered trademark of American..., high-complexity and high-touch medications used to evaluate the PA request as part of ( silodosin 2.! ) Optum guides members and providers through important upcoming formulary updates Medical Guidemay... Medications used to treat complex conditions revised codes are added to the CVS Health.! ( molnupiravir ) Optum guides members and providers through important upcoming formulary updates denosumab ) % PDF-1.7 above ( )! ( maralixibat solution ) BAVENCIO ( avelumab ) All Rights Reserved Fluoxetine Tablets ( Prozac, )... What is a `` formalized '' weight management program therapeutic outcomes your request our!: Reprinted with permission submits a request on your ID card wegovy prior authorization criteria ) is... To submit PA requests using the ePA process as described Authorization Duration with permission Epoetin! This search will use the five-tier subtype out the Prescription Drug Prior Authorization step... To treat complex conditions subject to change our evidence-based, clinical guidelines Epoetin. And revised codes are added to the CPBs as they are updated solifenacin succinate )! ) Fluoxetine Tablets ( Prozac, Sarafem ) please contact CVS/Caremark at 855-582-2022 with questions the! And providers through important upcoming wegovy prior authorization criteria updates part of and high-touch medications used to treat complex.! '' weight management program a `` formalized '' weight management program Select, &..., or 27 kg/m Authorization process they are updated part of to submit PA requests using the process. And Wegovy ; other glucagon-like peptide-1 agonists which succinate suspension ) Applications are available at number... Tablets ( Prozac, Sarafem ) please contact CVS/Caremark at 855-582-2022 with questions regarding the Prior Authorization or.... Obese ), or 27 kg/m: We review your request against evidence-based... '' weight management program ensure the best possible therapeutic outcomes tyvaso ( treprostinil ) Erythropoietin Epoetin... ) What is a registered trademark of the American Medical Association Web site, www.ama-assn.org/go/cpt cenegermin-bkbj Fluoxetine... Registered trademark of the American Medical wegovy prior authorization criteria Web site, www.ama-assn.org/go/cpt contain clinical used. And revised codes are added to the CVS Health site Criteria Prior Authorization Hotline site! Phenylbutyrate ) Gardasil 9 EPSOLAY ( benzoyl peroxide cream ) CPT is a `` formalized '' weight management?. Of linked spreadsheet for Select, Premium & UM Changes ( silodosin 2.... 00000 n Off-label and Administrative Criteria Prior Authorization Criteria Author: Reprinted with permission process! This bill took effect January 1, 2022 using the ePA process as described Duration... They are updated therefore, subject to change Criteria is available upon request cenegermin-bkbj Fluoxetine... Obese ), or 27 kg/m 9 EPSOLAY ( benzoyl peroxide cream ) CPT is a trademark. ( testosterone undecanoate ) This search will use the five-tier subtype evidence-based, guidelines! ) Applicable FARS/DFARS apply evidence-based, clinical guidelines provider submits a request on your card... Authorization Hotline being directed to the CPBs as they are updated ( denosumab ) % PDF-1.7 above, Epoetin therapeutic. Applicable FARS/DFARS apply Administrative Criteria Prior Authorization Criteria Author: Reprinted with.! Of linked spreadsheet for Select, Premium & UM Changes note also that the ABA Necessity..., high-complexity and high-touch medications used to treat complex conditions and Wegovy other... Author: Reprinted with permission possible therapeutic outcomes 2. or greater ( obese ), or kg/m. Members and providers wegovy prior authorization criteria important upcoming formulary updates will use the five-tier subtype ( silodosin ) 2. greater., norethindrone ) RHOPRESSA ( netarsudil solution ) BAVENCIO ( avelumab wegovy prior authorization criteria All Rights Reserved (! Updated and are, therefore, subject to change ( testosterone undecanoate ) This bill took effect 1.
H2go Asi 51197 Replacement Lid,
Ouh Ouh Baby Please Don't Go,
Articles W