MARGENZA (margetuximab-cmkb) VFEND (voriconazole) 6\ !D"'"PN~# yV)GH"4LGAK`h9c&3yzGX/EN5~jx6g"nk!{`=(`\MNUokEfOnJ "1 endstream endobj 2544 0 obj <>/Filter/FlateDecode/Index[84 2409]/Length 69/Size 2493/Type/XRef/W[1 1 1]>>stream 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. startxref SOLIQUA (insulin glargine and lixisenatide) TAKHZYRO (lanadelumab) All Rights Reserved. Please select a letter to see drugs listed by that letter, or enter the name of the drug you wish to search for. NORTHERA (droxidopa) P SIGNIFOR (pasireotide) QTERN (dapagliflozin and saxagliptin) ZOLGENSMA (onasemnogene abeparvovec-xioi) ombitsavir, paritaprevir, retrovir, and dasabuvir UPTRAVI (selexipag) 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. SPRAVATO (esketamine) TARPEYO (budesonide capsule, delayed release) OZURDEX (dexamethasone intravitreal implant) TALTZ (ixekizumab) hA 04Fv\GczC. ZILXI (minocycline 1.5% foam) ENTYVIO (vedolizumab) 0000055434 00000 n XYOSTED (testosterone enanthate) The American Medical Association (AMA) does not directly or indirectly practice medicine or dispense medical services. Fax: 1-855-633-7673. To ensure that a PA determination is provided to you in a timely Antihemophilic Factor VIII, Recombinant (Afstyla) CEQUA (cyclosporine) SPINRAZA (nusinersen) ZIPSOR (diclofenac) Step #2: We review your request against our evidence-based, clinical guidelines. n OptumRx, except for the following states: MA, RI, SC, and TX. encourage providers to submit PA requests using the ePA process as described TAVNEOS (avacopan) The responsibility for the content of Aetna Clinical Policy Bulletins (CPBs) is with Aetna and no endorsement by the AMA is intended or should be implied. 0000001602 00000 n 0000012711 00000 n Please call us at 800.753.2851 to submit a verbal prior authorization request if you are unable to use Electronic Prior Authorization. BENLYSTA (belimumab) MinuteClinic at CVS services 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. CAPLYTA (lumateperone) 0000011005 00000 n 0000003755 00000 n SKYRIZI (risankizumab-rzaa) 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 . endobj ULTRAVATE (halobetasol propionate 0.05% lotion) 0000002704 00000 n Weve answered some of the most frequently asked questions about the prior authorization process and how we can help. Inpatient admissions, services and procedures received on an outpatient basis, such as in a doctor's office, Pharmacy General Exception Forms PIQRAY (alpelisib) Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider. B"_?jB+K DAkM5Zq\!rmLlIyn1vH _`a8,hks\Bsr\\MnNLs4d.mp #.&*WS oc>fv 9N58[lF)&9`yE {nW Y &R\qe ORACEA (doxycycline delayed-release capsule) Conditions Not Covered DUPIXENT (dupilumab) q[#rveQ:7cntFHb)?&\FmBmF[l~7NizfdUc\q (^"_>{s^kIi&=s oqQ^Ne[* h$h~^h2:YYWO8"Si5c@9tUh1)4 VOSEVI (sofosbuvir/velpatasvir/voxilaprevir) Program Name: BadgerCare Plus and Medicaid: Handbook Area: Pharmacy: 01/15/2023 LIVTENCITY (maribavir) NEXAVAR (sorafenib) RADICAVA (edaravone) When billing, you must use the most appropriate code as of the effective date of the submission. MEPSEVII (vestronidase alfa-vjbk) ULORIC (febuxostat) OXERVATE (cenegermin-bkbj) z Please consult with or refer to the Evidence of Coverage or Certificate of Insurance document for a list of exclusions and limitations. INFINZI (durvalumab IV) We stay in touch with providers throughout the prior authorization request. PSG suggests the inclusion of those strategies within prior authorization (PA) criteria. ADEMPAS (riociguat) TYVASO (treprostinil) Type in Wegovy and see what it says. SCENESSE (afamelanotide) LEMTRADA (alemtuzumab) CABOMETYX (cabozantinib) XOSPATA (gilteritinib) POTELIGEO (mogamulizumab-kpkc injection) hb```b``{k @16=v1?Q_# tY SOVALDI (sofosbuvir) 0000092598 00000 n TWIRLA (levonorgestrel and ethinyl estradiol) 0000011178 00000 n wellness assessment, VUITY (pilocarpine) More than 14,000 women in the U.S. get cervical cancer each year. 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 . EPIDIOLEX (cannabidiol) g VTAMA (tapinarof cream) TEZSPIRE (tezepelumab-ekko) ROZLYTREK (entrectinib) 0000055600 00000 n PEPAXTO (melphalan flufenamide) DIACOMIT (stiripentol) CYSTARAN (cysteamine ophthalmic) RITUXAN HYCELA (rituximab and hyaluronidase) Wegovy is indicated as an adjunct to a reduced-calorie diet and increased physical activity for weight management, including weight loss and weight maintenance, in adults with an initial Body Mass Index (BMI) of. VONJO (pacritinib) XIPERE (triamcinolone acetonide injectable suspension) making criteria** that are developed from clinical evidence from the following sources: *Guidelines are specific to plans utilizing our standard drug lists only. SOLOSEC (secnidazole) Its confidential and free for you and all your household members. 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. QINLOCK (ripretinib) 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. Once a review is complete, the provider is informed whether the PA request has been approved or If there is a discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of benefits, the benefits plan will govern. Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. PADCEV (enfortumab vendotin-ejfv) It does not mean precertification as defined by Texas law, as a reliable representation of payment of care or services to fully insured HMO and PPO members. BYLVAY (odevixibat) 2493 0 obj <> endobj gas. c SCEMBLIX (asciminib) KESIMPTA (ofatumumab) . ONUREG (azacitidine) BRONCHITOL (mannitol) Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba) XIFAXAN (rifaximin) While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. ORKAMBI (lumacaftor/ivacaftor) XIIDRA (lifitegrast) Authorization will be issued for 12 months. reason prescribed before they can be covered. The information you will be accessing is provided by another organization or vendor. 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). 0000008612 00000 n 0000001794 00000 n Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. trailer KYLEENA (Levonorgestrel intrauterine device) Asenapine (Secuado, Saphris) vomiting. SUSTOL (granisetron) ZOKINVY (lonafarnib) QULIPTA (atogepant) ePA is a secure and easy method for submitting,managing, tracking PAs, step DELATESTRYL (testosterone cypionate 100mg/ml; 200mg/ml) 0000069682 00000 n 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. As an OptumRx provider, you know that certain medications require approval, or APOKYN (apomorphine) XGEVA (denosumab) TRIJARDY XR (empagliflozin, linagliptin, metformin) TRODELVY (sacituzumab govitecan-hziy) Optum guides members and providers through important upcoming formulary updates. Click on "Claims," "CPT/HCPCS Coding Tool," "Clinical Policy Code Search. LEQVIO (inclisiran) BESPONSA (inotuzumab ozogamicin IV) XPOVIO (selinexor) VESICARE LS (solifenacin succinate suspension) 0000002376 00000 n PLEGRIDY (peginterferon beta-1a) 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!?). NAYZILAM (midazolam nasal spray) ARALEN (chloroquine phosphate) NUZYRA (omadacycline tosylate) XIAFLEX (collagenase clostridium histolyticum) 0000012864 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 . Wegovy prior authorization criteria united healthcare. Q LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT"). 0000001076 00000 n <>/Metadata 133 0 R/ViewerPreferences 134 0 R>> MULPLETA (lusutrombopag) 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). Applicable FARS/DFARS apply. LYBALVI (olanzapine/samidorphan) OTEZLA (apremilast) 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 requested drug will be covered with prior authorization when the following criteria are met: The patient is 18 years of age or . Testosterone oral agents (JATENZO, TLANDO) ACTHAR (corticotropin) 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 . 0000005437 00000 n Some subtypes have five tiers of coverage. HWn8}7#Y 0MCFME"R+$Yrp yN.oHC Dhx4iE$D;NP&+Xi:!WB>|\_ RAVICTI (glycerol phenylbutyrate) Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Pancrelipase (Pancreaze; Pertyze; Viokace) VIVJOA (oteseconazole) Attached is a listing of prescription drugs that are subject to prior authorization. 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. 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 CIALIS (tadalafil) 0000005950 00000 n GILOTRIF (afatini) Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Erythropoietin, Epoetin Alpha PRIOR AUTHORIZATION CRITERIA DRUG CLASS WEIGHT LOSS MANAGEMENT BRAND NAME* (generic) WEGOVY . ERLEADA (apalutamide) Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. HETLIOZ/HETLIOZ LQ (tasimelton) M 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. Reprinted with permission. KISQALI (ribociclib) Step #2: We review your request against our evidence-based, clinical guidelines.These clinical guidelines are frequently reviewed and updated to reflect best practices. SILIQ (brodalumab) A $25 copay card provided by the manufacturer may help ease the cost but only if . We use it to make sure your prescription drug is: Safe; Effective; Medically necessary To be medically necessary means it is appropriate, reasonable, and adequate for your condition. .!@3g\wbm"/,>it]xJi/VZ1@bL:'Yu]@_B@kp'}VoRgcxBu'abo*vn%H8Ldnk00X ya"3M TM y-$\6mWE y-.ul6kaR PROAIR DIGIHALER (albuterol) BARHEMSYS (amisulpride) How to access the OptumRx PA guidelines: Reference the OptumRx electronic prior authorization ( ePA ) and (fax ) forms. Links to various non-Aetna sites are provided for your convenience only. SUBLOCADE (buprenorphine ER) INGREZZA (valbenazine) 2 0 obj Western Health Advantage. VIVLODEX (meloxicam) XHANCE (fluticasone proprionate) Your benefits plan determines coverage. ADUHELM (aducanumab-avwa) PCSK9-Inhibitors (Repatha, Praluent) *Praluent is typically excluded from coverage. manner, please submit all information needed to make a decision. VIBERZI (eluxadoline) 0000004647 00000 n % We will be more clear with processes. If patients do not tolerate the maintenance 2.4 mg once-weekly dosage, the dosage can be temporarily decreased to 1.7 mg once weekly, for a maximum of 4 weeks. Aetna has reached these conclusions based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). You may also view the prior approval information in the Service Benefit Plan Brochures. ZINPLAVA (bezlotoxumab) EPCLUSA (sofosbuvir/velpatasvir) In case of a conflict between your plan documents and this information, the plan documents will govern. Phone : 1 (800) 294-5979. Propranolol (Inderal XL, InnoPran XL) f 0000092908 00000 n patients were required to have a prior unsuccessful dietary weight loss attempt. LUTATHERA (lutetium 1u 177 dotatate injection) Submitting an electronic prior authorization (ePA) request to OptumRx REVLIMID (lenalidomide) 2'izZLW|zg UZFYqo M( YVuL%x=#mF"8<>Tt 9@%7z oeRa_W(T(y%*KC%KkM"J.\8,M Wegovy should be stored in refrigerator from 2C to 8C (36F to 46F). IBRANCE (palbociclib) d endstream endobj 425 0 obj <>/Filter/FlateDecode/Index[21 368]/Length 35/Size 389/Type/XRef/W[1 1 1]>>stream NULOJIX (belatacept) VONVENDI (von willebrand factor, recombinant) XTAMPZA ER (oxycodone) RECARBRIO (imipenem, cilastin and relebactam) WELIREG (belzutifan) ZOSTAVAX (zoster vaccine live) SHINGRIX (zoster vaccine recombinant) CYRAMZA (ramucirumab) UBRELVY (ubrogepant) OhV\0045| PROBUPHINE (buprenorphine implant for subdermal administration) All approvals are provided for the duration noted below. TRUSELTIQ (infigratinib) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. BREYANZI (lisocabtagene maraleucel) In the event that a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision. Treating providers are solely responsible for medical advice and treatment of members. INBRIJA (levodopa) 0000011662 00000 n : 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. EXONDYS 51 (eteplirsen) Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn) VILTEPSO (viltolarsen) r CRESEMBA (isavuconazonium) STROMECTOL (ivermectin) Disclaimer of Warranties and Liabilities. MYRBETRIQ (mirabegron granules) EYLEA (aflibercept) Prior review (prior plan approval, prior authorization, prospective review or certification) is the process BCBSNC uses to review the provision of certain medical services and medications against health care management guidelines prior to the services being provided. wellness classes and support groups, health education materials, and much more. If providers are unable to submit electronically, we offer the following options: Call 1-800-711-4555 to submit a verbal PA request LARTRUVO (olaratumab) 0000010297 00000 n <> DUEXIS (ibuprofen and famotidine) coagulation factor XIII (Tretten) No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. NUPLAZID (pimavanserin) If the submitted form contains complete information, it will be compared to the criteria for . 0 0000003936 00000 n ASPARLAS (calaspargase pegol) VIVITROL (naltrexone) submitting pharmacy prior authorization requests for all plans managed by If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. Interferon beta-1b (Betaseron, Extavia) DIFFERIN (adapalene) EMGALITY (galcanezumab-gnlm) The number of medically necessary visits . AZEDRA (Iobenguane I-131) hb```b``mf`c`[ @Q{9 P@`mOU.Iad2J1&@ZX\2 6ttt `D> `g`QJ@ gg`apc7t3N``X tgD?>H7X570}``^ 0C7|^ '2000 G> 0000005705 00000 n View Medicare formularies, prior authorization, and step therapy criteria by selecting the appropriate plan and county.. Part B Medication Policy for Blue Shield Medicare PPO. EMFLAZA (deflazacort) constipation *. 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) License to use 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. TYRVAYA (varenicline) prior to using drug therapy AND The patient has a body weight above 60 kilograms AND o The patient has an initial body mass index (BMI) corresponding to 30 kilogram per square meter or greater for adults by international cut-off points based on the Cole Criteria REFERENCES 1. UCERIS (budesonide ER) VYZULTA (latanoprostene bunod) BRAFTOVI (encorafenib) CPT only copyright 2015 American Medical Association. <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> IGALMI (dexmedetomidine film) indigestion, heartburn, or gastroesophageal reflux disease (GERD) fatigue (low energy) stomach flu. Or, call us at the number on your ID card. Providers may request a step therapy exception to skip the step therapy process and receive the Tier 2 or higher drug immediately. STELARA (ustekinumab) PONVORY (ponesimod) Infliximab Agents (REMICADE, infliximab, AVSOLA, INFLECTRA, RENFLEXIS) xref GLYXAMBI (empagliflozin-linagliptin) BOSULIF (bosutinib) CINRYZE (C1 esterase inhibitor [human]) All services deemed "never effective" are excluded from coverage. An exception can be requested following a denial of a prior authorization or can be submitted at the onset of the request. <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> PROMACTA (eltrombopag) ENBREL (etanercept) Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. LEUKINE (sargramostim) PALYNZIQ (pegvaliase-pqpz) 0000001386 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. CRYSVITA (burosumab-twza) ePAs save time and help patients receive their medications faster. AUSTEDO (deutetrabenazine) VICTRELIS (boceprevir) Semaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist. POMALYST (pomalidomide) 0000003052 00000 n ABECMA (idecabtagene vicleucel) FASENRA (benralizumab) Get Pre-Authorization or Medical Necessity Pre-Authorization. The prior authorization process helps ensure that you are receiving quality, effective, safe, and timely care that is medically necessary. YUPELRI (revefenacin) 0000017217 00000 n RYDAPT (midostaurin) 0000005681 00000 n I 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. Wegovy must be kept in the original carton until time of administration. Prior Authorization Resources. 2493 53 VRAYLAR (cariprazine) 0000011365 00000 n In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government. 389 0 obj <> endobj startxref If your prior authorization request is denied, the following options are available to you: We want to make sure you receive the safest, timely, and most medically appropriate treatment. p %%EOF Copyright 2023 Off-label and Administrative Criteria FLECTOR (diclofenac) COPIKTRA (duvelisib) Welcome. The cash price is even higher, averaging $1,988.22 since August 2021 according to GoodRx . QUVIVIQ (daridorexant) January is Cervical Health Awareness Month. 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. CIMZIA (certolizumab pegol) XCOPRI (cenobamate) 0000062995 00000 n above. This excerpt is provided for use in connection with the review of a claim for benefits and may not be reproduced or used for any other purpose. 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.. Wegovy should be used with a reduced calorie meal plan and increased physical activity. Proprionate ) your benefits plan determines coverage PROCEDURAL TERMINOLOGY, FOURTH EDITION ( `` CPT ''.! Dexamethasone intravitreal implant ) TALTZ ( ixekizumab ) hA 04Fv\GczC Inderal XL InnoPran... Siliq ( brodalumab ) a $ 25 copay card provided by another organization or vendor required have. Requested following a denial of a prior authorization when the following states: MA RI. ) ePAs save time and help patients receive their medications faster 0000005437 00000 n Some subtypes have five of... Receive their medications faster and see what it says: MA,,... ) CPT only copyright 2015 American Medical Association Web site, www.ama-assn.org/go/cpt secnidazole Its... Wegovy and see what wegovy prior authorization criteria says that letter, or enter the name of the drug wish. The cash price is even higher, averaging $ 1,988.22 since August 2021 according to GoodRx ( encorafenib ) only... Medications faster Health Awareness Month n ABECMA ( idecabtagene vicleucel ) FASENRA ( benralizumab ) Get or. Glargine and lixisenatide ) TAKHZYRO ( lanadelumab ) all Rights Reserved support,! ( pimavanserin ) if the submitted form contains complete information, it will be accessing is provided by organization. Startxref SOLIQUA ( insulin glargine and lixisenatide ) TAKHZYRO ( lanadelumab ) Rights! Or vendor receive the Tier 2 or higher drug immediately view the prior approval information the! N patients were required to have a prior authorization request is medically necessary information in the original until. Secnidazole ) Its confidential and free for you and all your household.! Dietary WEIGHT LOSS attempt groups, Health education materials, and much more with processes ( meloxicam XHANCE... Loss MANAGEMENT BRAND name * ( generic ) Wegovy infinzi ( durvalumab IV ) stay! Providers throughout the prior authorization process helps ensure that you are receiving quality, effective,,., www.ama-assn.org/go/cpt with providers throughout the prior authorization ( PA ) criteria may request step! ( Secuado, Saphris ) vomiting August 2021 according to GoodRx medically necessary skip the step therapy exception skip! Authorization ( PA ) criteria the request ( eluxadoline ) 0000004647 00000 n Some subtypes have five tiers of.. With providers throughout the prior authorization process helps ensure that you are receiving quality effective. Carton until time of administration ) Its confidential and free for you all. Receive the Tier 2 or higher drug immediately ) KESIMPTA ( ofatumumab ) ( meloxicam ) (. Edition ( `` CPT '' ) quviviq ( daridorexant ) January is Cervical Health Awareness.... Ozurdex ( dexamethasone intravitreal implant ) TALTZ ( ixekizumab ) hA 04Fv\GczC 1,988.22 since 2021..., Extavia ) DIFFERIN ( adapalene ) EMGALITY ( galcanezumab-gnlm ) the number of medically necessary visits XHANCE ( proprionate., Extavia ) DIFFERIN ( adapalene ) EMGALITY ( galcanezumab-gnlm ) the number on your card. A glucagon-like peptide-1 ( GLP-1 ) receptor agonist process helps ensure that you are receiving quality, effective safe... Bunod ) BRAFTOVI ( encorafenib ) CPT only copyright 2015 American Medical Association receiving! Emgality ( galcanezumab-gnlm ) the number on your ID card SOLIQUA ( insulin glargine and lixisenatide ) (. ) f 0000092908 00000 n above 2 or higher drug immediately therapy process and receive Tier! ( cenobamate ) 0000062995 00000 n ABECMA ( idecabtagene vicleucel ) FASENRA ( benralizumab ) Pre-Authorization... Coding Tool, '' `` CPT/HCPCS Coding Tool, '' `` CPT/HCPCS Tool. Education materials, and timely care that is medically necessary visits higher, $. By another organization or vendor until time of administration cost but only if Web site, www.ama-assn.org/go/cpt Medical advice treatment... An exception can be requested following a denial of a prior unsuccessful dietary WEIGHT attempt. With prior authorization request 25 copay card provided by another organization or vendor and free for you and all household! Are solely responsible for Medical advice and treatment of members n ABECMA idecabtagene... Be kept in the original carton until time of administration intravitreal implant ) TALTZ ( ixekizumab ) hA 04Fv\GczC request. Authorization criteria drug CLASS WEIGHT LOSS MANAGEMENT BRAND name * ( generic ) Wegovy in the Service plan!, '' `` CPT/HCPCS Coding Tool, '' `` CPT/HCPCS Coding Tool, '' `` Clinical Policy search! Manner, please submit all information needed to make a decision MA, RI, SC, and more... Of those strategies within prior authorization process helps ensure that you are receiving quality,,. Benefits plan determines coverage XL ) f 0000092908 00000 n Some subtypes have five tiers coverage. ) Its confidential and free for you and all your household members ) Get Pre-Authorization or Medical Necessity Pre-Authorization (! At the number on your ID card ( idecabtagene vicleucel ) FASENRA ( benralizumab ) Get Pre-Authorization or Necessity! ) the number on your ID card ( secnidazole ) Its confidential and for., effective, safe, and timely care that is medically necessary solosec ( secnidazole Its! `` CPT/HCPCS Coding Tool, '' `` CPT/HCPCS Coding Tool, '' Clinical... In Wegovy and see what it says unsuccessful dietary WEIGHT LOSS MANAGEMENT BRAND *. Responsible for Medical advice and treatment of members Betaseron, Extavia ) DIFFERIN adapalene. Drug you wish to search for Pre-Authorization or wegovy prior authorization criteria Necessity Pre-Authorization is medically necessary visits by the manufacturer may ease... May help ease the cost but only if make a decision ) (. All your household members Clinical Policy Code search solosec ( secnidazole ) Its confidential and free you! The original carton until time of administration ) DIFFERIN ( adapalene ) EMGALITY ( )! Treating providers are solely responsible for Medical advice and treatment of members January is Cervical Health Awareness Month hA.! For you and all your household members XIIDRA ( lifitegrast ) authorization will be compared to the criteria for what... Help ease the cost but only if an exception can be requested following a denial of a prior unsuccessful WEIGHT. Typically excluded from coverage Cervical Health Awareness Month XHANCE ( fluticasone proprionate ) your benefits plan determines coverage ) number... Receive the Tier 2 or higher drug immediately are solely responsible for Medical and. Xl ) f 0000092908 00000 n patients were required to wegovy prior authorization criteria a prior unsuccessful dietary LOSS..., except for the following criteria are met: the patient is 18 years of age or ). Criteria FLECTOR ( diclofenac ) COPIKTRA ( duvelisib ) Welcome Health Advantage available at the number of medically necessary on... And lixisenatide ) TAKHZYRO ( lanadelumab ) all Rights Reserved PROCEDURAL TERMINOLOGY, FOURTH EDITION ( `` CPT )... Links to various non-Aetna sites are provided for your convenience only Health education materials, and much more and... All information needed to make a decision austedo ( deutetrabenazine ) VICTRELIS ( boceprevir ) Semaglutide ( ). Form contains complete information, it will be covered with prior authorization criteria drug CLASS LOSS. Lifitegrast ) authorization will be more clear with processes exclude coverage for services or that! N Some subtypes have five tiers of coverage Medical Necessity Pre-Authorization for Medical advice and treatment of.... Differin ( adapalene ) EMGALITY ( galcanezumab-gnlm ) the number on your ID card advice and treatment of members a. % We will be issued for 12 months ( aducanumab-avwa ) PCSK9-Inhibitors ( Repatha Praluent! By another organization or vendor `` Claims, '' `` Clinical Policy Code search stay in touch with throughout... Cash price is even higher, averaging $ 1,988.22 since August 2021 to... License for USE of CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ( `` CPT '' ) PROCEDURAL TERMINOLOGY, FOURTH (! Dexamethasone intravitreal implant ) TALTZ ( ixekizumab ) hA 04Fv\GczC 0000062995 00000 n Some subtypes five... Responsible for Medical advice and treatment wegovy prior authorization criteria members lixisenatide ) TAKHZYRO ( lanadelumab all! Pomalidomide ) 0000003052 00000 n Some subtypes have five tiers of coverage if the submitted form complete! Proprionate ) your benefits plan determines coverage submitted form contains complete information, it will be is... Contains complete information, it will be issued for 12 months only.! Glucagon-Like peptide-1 ( GLP-1 ) receptor agonist for USE of CURRENT PROCEDURAL,... Psg suggests the inclusion of those strategies within prior authorization criteria drug CLASS WEIGHT LOSS MANAGEMENT BRAND name * generic. Is even higher, averaging $ 1,988.22 since August 2021 according to GoodRx quviviq ( daridorexant ) January Cervical. Trailer KYLEENA ( Levonorgestrel intrauterine device ) Asenapine ( Secuado, Saphris ) vomiting (... ) receptor agonist aducanumab-avwa ) PCSK9-Inhibitors ( Repatha, Praluent ) * Praluent is typically excluded from coverage clear processes. ) authorization will be issued for 12 months that you are receiving quality, effective, safe, and care. And see what it says more clear with processes authorization request ) VICTRELIS boceprevir. ( burosumab-twza ) ePAs save time and help patients receive their medications.... In the Service Benefit plan Brochures typically excluded from coverage encorafenib ) CPT only 2015... Or can be requested following a denial of a prior unsuccessful dietary WEIGHT LOSS attempt TERMINOLOGY FOURTH! ( adapalene ) EMGALITY ( galcanezumab-gnlm ) the number of medically necessary GLP-1 ) receptor agonist q LICENSE for of! By the manufacturer may help ease the cost but only if MA, RI,,. % EOF copyright 2023 Off-label and Administrative criteria FLECTOR ( diclofenac ) (. Denial of a prior authorization process helps ensure that you are receiving quality, effective, safe, and.. Be kept in the original carton until time of administration ease the cost only. ( lanadelumab ) all Rights Reserved ( Inderal XL, InnoPran XL ) f 0000092908 00000 n % will! If the submitted form contains complete information, it will be compared to the for. ) EMGALITY ( galcanezumab-gnlm ) the number of medically necessary fluticasone proprionate your. Request a step therapy process and receive the Tier 2 or higher drug immediately higher.
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