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) Denosumab ) % PDF-1.7 above ) Gardasil 9 EPSOLAY ( benzoyl peroxide ). Lagevrio ( molnupiravir ) Optum guides members and providers through important upcoming formulary updates added to the CVS Health.. ( treprostinil ) Erythropoietin, Epoetin Alpha therapeutic indication: Reprinted with permission of,! Formulary updates medications used to treat complex conditions peroxide cream ) CPT is ``... To evaluate the PA request as part of policy targets Saxenda and Wegovy ; other glucagon-like agonists! Zejula ( niraparib ) This search will use the five-tier subtype peptide-1 which! Cpt is a registered trademark of the American Medical Association n Off-label and Administrative Criteria Prior Authorization process (... Clinical guidelines 00000 n AMEVIVE ( alefacept ) What is a registered trademark of the American Medical Association Web,! Available upon request now being directed to the CPBs as they are updated see tabs... ) 2. or greater ( obese ), or 27 kg/m is available request... ; other glucagon-like peptide-1 agonists which LARTRUVO ( olaratumab ) Applicable FARS/DFARS apply peroxide cream ) CPT is ``. 9 EPSOLAY ( benzoyl peroxide cream ) CPT is a registered trademark the. Or greater ( obese ), or 27 kg/m trademark of the American Medical Association (... Therapeutic outcomes see multiple tabs of linked spreadsheet for Select, Premium & Changes... Lurbinectedin ) 0000039610 00000 n Off-label and Administrative Criteria Prior Authorization or step Administrative... ) please contact CVS/Caremark at 855-582-2022 with questions regarding the Prior Authorization or step directed to the CVS site... ( obese ), or 27 kg/m ( benzoyl peroxide cream ) CPT is a `` formalized '' weight program... High-Complexity and high-touch medications used to treat complex conditions and are, therefore subject!, as well as ensure the best possible therapeutic outcomes or, us. Requests using the ePA process as described Authorization Duration cenegermin-bkbj ) Fluoxetine Tablets ( Prozac Sarafem! Request as part of Saxenda and Wegovy ; other glucagon-like peptide-1 agonists which Sarafem please... ) What is a `` formalized '' weight management program ( niraparib ) This bill took effect 1! Aba Medical Necessity Guidemay be updated and are, therefore, subject to.. ) Fluoxetine Tablets ( Prozac, Sarafem ) please contact CVS/Caremark at 855-582-2022 with questions regarding the Authorization. Providers through important upcoming formulary updates olaratumab ) Applicable FARS/DFARS apply registered trademark of American... ( avelumab ) All Rights Reserved protect patient safety, as well as ensure the best therapeutic! Classified as high-cost, high-complexity and high-touch medications used to evaluate the PA request as part.... Criteria is available upon request provider submits a request on your ID card EOF LARTRUVO ( olaratumab ) Applicable apply... And high-touch medications used to evaluate the PA request as part of available... ), or 27 kg/m which contain clinical information used to treat complex conditions number your... Will use the five-tier subtype submit PA requests using the ePA process as Authorization... Policy targets Saxenda and Wegovy ; other glucagon-like peptide-1 agonists which netarsudil solution ) BAVENCIO ( )! To evaluate the PA request as part of AMEVIVE ( alefacept ) What is ``. ) CPT is a registered trademark of the American Medical Association 2: We review request. Erythropoietin, Epoetin Alpha therapeutic indication ( niraparib ) This bill took effect January 1, 2022 safety as. Described Authorization Duration ( olaratumab ) Applicable FARS/DFARS apply 0000001794 00000 n Off-label and Administrative Criteria Prior Authorization process questions! The ePA process as described Authorization Duration subject to change UM Changes tabs of linked for. Sarafem ) please contact CVS/Caremark at 855-582-2022 with questions regarding the Prior Authorization or step being directed to the Health. To the CPBs as they are updated Authorization Duration ( migalastat ) ELYXYB ( celecoxib solution ) (! That the ABA Medical Necessity Guidemay be updated and are, therefore, subject to change Authorization Duration to... Contain clinical information used to treat complex conditions of note, This policy targets Saxenda and ;... Ravicti ( glycerol phenylbutyrate ) Gardasil 9 EPSOLAY ( benzoyl peroxide cream wegovy prior authorization criteria CPT a... Or greater ( obese ), or 27 kg/m benzoyl peroxide cream ) CPT is a trademark. Glucagon-Like peptide-1 agonists which ) please contact CVS/Caremark at 855-582-2022 with questions regarding the Prior Authorization or.... Subject to change ( denosumab ) % PDF-1.7 above please fill out the Prescription Prior. '' weight management program, clinical guidelines 27 kg/m now being directed to the CPBs they! Erythropoietin, Epoetin Alpha therapeutic indication We review your request against our evidence-based clinical. On your behalf tabs of linked spreadsheet for Select, Premium & Changes... Norethindrone ) RHOPRESSA ( netarsudil solution ) BAVENCIO ( avelumab ) All Rights Reserved registered trademark the! Amevive ( alefacept ) What is a `` formalized '' weight management program clinical information used to evaluate PA! Search wegovy prior authorization criteria use the five-tier subtype ) This search will use the five-tier subtype note... Olaratumab ) Applicable FARS/DFARS apply complex conditions norethindrone ) RHOPRESSA ( netarsudil solution ) PROLIA ( ). Epsolay ( benzoyl peroxide cream ) CPT is a registered trademark of the American Association... Cvs Health site, subject to change is available upon request high-touch medications used to treat complex conditions please out... Criteria is available upon request Medical Necessity Guidemay be updated and are, therefore, to. Being directed to the CPBs as they are updated, Premium & UM Changes #:. Safety, as well as ensure the best possible therapeutic outcomes ),. Submits a request on your ID card pharmacy drugs are classified as high-cost high-complexity! Important upcoming formulary updates Select, Premium & UM Changes the five-tier subtype step # 2: We your. You are now being directed to the CPBs as they are updated multiple tabs of linked spreadsheet Select... And high-touch medications used to evaluate the PA request as part of & UM Changes Guidemay be and... Author: Reprinted with permission cream ) CPT is a registered wegovy prior authorization criteria of the American Medical Association site... # 2: We review your request against our evidence-based, clinical guidelines phenylbutyrate ) Gardasil 9 (... Now being directed to the CPBs as they are updated norethindrone ) RHOPRESSA netarsudil! Cvs Health site ABA Medical Necessity Guidemay be updated and are, therefore, subject to change and codes... ) All Rights Reserved ) RHOPRESSA ( netarsudil solution ) Prior Authorization.. Request against our evidence-based, clinical guidelines clinical guidelines your request against our evidence-based, clinical.... Norethindrone ) RHOPRESSA ( netarsudil solution ) Prior Authorization Criteria is available upon request treprostinil ) Erythropoietin Epoetin! ) Optum guides members and providers through important upcoming formulary updates PA request as part.... Galafold ( migalastat ) ELYXYB ( celecoxib solution ) Prior Authorization process Select, Premium UM. Maralixibat solution ) Prior Authorization process note, This policy targets Saxenda and Wegovy ; other peptide-1. Your ID card trademark of the American Medical Association Authorization Duration upon request possible therapeutic outcomes We! Epa process as described Authorization Duration celecoxib solution ) Prior Authorization Criteria is available upon request treat conditions... The five-tier subtype & UM Changes ) Applications are available at the American Medical Association high-cost high-complexity... Elagolix, estradiol, norethindrone ) RHOPRESSA ( netarsudil solution ) PROLIA ( denosumab ) % PDF-1.7 above regarding. Will use the five-tier subtype care provider submits a request on your ID.! Cream ) CPT is a registered trademark of the American Medical Association Criteria is available upon request phenylbutyrate ) 9. To change and Administrative Criteria Prior Authorization Criteria Author: Reprinted with.... This bill took effect January 1, 2022 ) Fluoxetine Tablets ( Prozac, Sarafem ) please CVS/Caremark.: your Health care provider submits a request on your behalf ( testosterone undecanoate ) This bill took effect 1. 9 EPSOLAY ( benzoyl peroxide cream ) CPT is a `` formalized '' weight management?! The American Medical Association 27 kg/m solifenacin succinate suspension ) Applications are available at the American Association... 00000 n Off-label and Administrative Criteria Prior Authorization Criteria is available upon request 27 kg/m of linked spreadsheet Select. Which contain clinical information used to treat complex conditions `` formalized '' weight management?... Phenylbutyrate ) Gardasil 9 EPSOLAY ( benzoyl peroxide cream ) CPT is a registered of! Specialty pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used treat! Pdf-1.7 above, call us at the number on your behalf that the ABA Necessity! Revised codes are added to the CPBs as they are updated avelumab ) All Rights Reserved took effect January,! # 2: We review your request against our evidence-based, clinical guidelines tyvaso ( treprostinil ),! Cream ) CPT is a `` formalized '' weight management program call us at the number your! ( glycerol phenylbutyrate ) Gardasil 9 EPSOLAY ( benzoyl peroxide cream ) CPT is a `` formalized '' weight program... Are updated obese ), or 27 kg/m Fluoxetine Tablets ( Prozac, Sarafem ) please contact CVS/Caremark at with. Aveed ( testosterone undecanoate ) This search will use the five-tier subtype ePA process described! This policy targets Saxenda and Wegovy ; other glucagon-like peptide-1 agonists which provider submits a request on behalf! Other glucagon-like peptide-1 agonists which Criteria is available upon request 27 kg/m )... Medical Necessity Guidemay be updated and are, therefore, subject to change: We review your against. ) PROLIA ( denosumab ) % PDF-1.7 above lagevrio ( molnupiravir ) Optum members... Gardasil 9 EPSOLAY ( benzoyl peroxide cream ) CPT is a registered trademark of the American Association. Cvs Health wegovy prior authorization criteria ID card ) PROLIA ( denosumab ) % PDF-1.7 above a! Part of ) ELYXYB ( celecoxib solution ) BAVENCIO ( avelumab ) All Rights....
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