While I await the supply issue to be resolved for Wegovy, I am trying to see if I can get it covered by my insurance so I am ready (my doctor has already prescribed it). ), 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. Antihemophilic Factor [recombinant] pegylated-aucl (Jivi) What is a "formalized" weight management program? Your health care provider will communicate with us directly, and generally within 14 days or less, you and your physician will be notified of a decision. Medicare Plans. AIMOVIG (erenumab-aooe) You, your employees and agents are authorized to use CPT only as contained in Aetna Clinical Policy Bulletins (CPBs) solely for your own personal use in directly participating in healthcare programs administered by Aetna, Inc. You acknowledge that AMA holds all copyright, trademark and other rights in CPT. AUSTEDO (deutetrabenazine) SCEMBLIX (asciminib) 0000000016 00000 n Testosterone oral agents (JATENZO, TLANDO) 0000003404 00000 n Has anyone been able to jump through this type of hoop? Explore differences between MinuteClinic and HealthHUB. While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. ACTEMRA (tocilizumab) MassHealth Pharmacy Initiatives and Clinical Information. ZEPATIER (elbasvir-grazoprevir) Thats why we partner with your provider to accept requests through convenient options like phone, fax or through our online platform. ENDARI (l-glutamine oral powder) AMEVIVE (alefacept) Others have four tiers, three tiers or two tiers. XEPI (ozenoxacin) AJOVY (fremanezumab-vfrm) MinuteClinic at CVS services VIVJOA (oteseconazole) Fax: 1-855-633-7673. AUVI-Q (epinephrine) ALUNBRIG (brigatinib) VERQUVO (vericiguat) ALIQOPA (copanlisib) Providers may request a step therapy exception to skip the step therapy process and receive the Tier 2 or higher drug immediately. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. 0000055434 00000 n 0000011662 00000 n Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change. /wHqy5}r``Tgxkt2&!WKUN|\2KuS/esjlf2y|X*i&YgmL -oxBXWt[]k+E.k6K%,~'nuM Ih QTERN (dapagliflozin and saxagliptin) #^=&qZ90>Te o@2 ZURAMPIC (lesinurad) Hyaluronic Acid derivatives (Synvisc, Hyalgan, Orthovisc, Euflexxa, Supartz) uG4A4O9WbAtfwZj6_[X3 @[gL(vJ2U'=-"g~=G2^VZOgae8JG 2|@sGb 7ow@u"@|)7YRx$nhV;p^\ sAk ;ZM>u~^u)pOq%cB=J zY^4fz{ ; t$ x$nI9N$v\ArN{Jg~,+&*14 jz\-9\j9 LS${ 5qmfU'@Nj,hI)~^ }/ 6ryCUNu 'u ;7`@X. 0000013911 00000 n VYNDAQEL (tafamidis meglumine) 4 0 obj UPNEEQ (oxymetazoline hydrochloride) Guidelines are based on written objective pharmaceutical UM decision- <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> Applicable FARS/DFARS apply. The information you will be accessing is provided by another organization or vendor. IMCIVREE (setmelanotide) Specialty drugs and prior authorizations. Reauthorization approval duration is up to 12 months . Get Pre-Authorization or Medical Necessity Pre-Authorization. INGREZZA (valbenazine) SEGLENTIS (celecoxib/tramadol) hb```b``mf`c`[ @Q{9 P@`mOU.Iad2J1&@ZX\2 6ttt `D> `g`QJ@ gg`apc7t3N``X tgD?>H7X570}``^ 0C7|^ '2000 G> EVKEEZA (evinacumab-dgnb) 3. XGEVA (denosumab) review decisions on sound clinical evidence and make a determination within the timeframe FULYZAQ (crofelemer) LAGEVRIO (molnupiravir) EMPAVELI (pegcetacoplan) 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 . m SOVALDI (sofosbuvir) 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. Please . XULTOPHY (insulin degludec and liraglutide) TRACLEER (bosentan) endobj Learn about reproductive health. LONSURF (trifluridine and tipiracil) Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn) 0000005437 00000 n The maintenance dosage of Wegovy is 2.4 mg injected subcutaneously once weekly. TECENTRIQ (atezolizumab) VUITY (pilocarpine) You are now being directed to CVS Caremark site. TREMFYA (guselkumab) CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. EMGALITY (galcanezumab-gnlm) 6. DAURISMO (glasdegib) XTAMPZA ER (oxycodone) Aetna makes no representations and accepts no liability with respect to the content of any external information cited or relied upon in the Clinical Policy Bulletins (CPBs). MOZOBIL (plerixafor) 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 . 0000013029 00000 n CYSTARAN (cysteamine ophthalmic) TAKHZYRO (lanadelumab) iMo::>91}h9 therapy and non-formulary exception requests. Wegovy should be used with a reduced calorie meal plan and increased physical activity. RETEVMO (selpercatinib) Blue Shield Medicare plans follow Medicare guidelines for risk allocation and Medicare national and local coverage guideline. BLENREP (Belantamab mafodotin-blmf) DIACOMIT (stiripentol) 0000001751 00000 n NINLARO (ixazomib) GALAFOLD (migalastat) If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537. HALAVEN (eribulin) In addition, a member may have an opportunity for an independent external review of coverage denials based on medical necessity or regarding the experimental and investigational status when the service or supply in question for which the member is financially responsible is $500 or greater. ZEJULA (niraparib) The prior authorization process helps ensure that you are receiving quality, effective, safe, and timely care that is medically necessary. See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. Attached is a listing of prescription drugs that are subject to prior authorization. REZUROCK (belumosudil) 0000003481 00000 n Of note, this policy targets Saxenda and Wegovy; other glucagon-like peptide-1 agonists which. This information is neither an offer of coverage nor medical advice. In some cases, not enough clinical documentation could result in a denial. no77gaEtuhSGs~^kh_mtK oei# 1\ Optum guides members and providers through important upcoming formulary updates. STEGLATRO (ertugliflozin) G Prior Authorization Criteria Author: RHOPRESSA (netarsudil solution) Growth Hormone (Norditropin; Nutropin; Genotropin; Humatrope; Omnitrope; Saizen; Sogroya; Skytrofa; Zomacton; Serostim; Zorbtive) REVLIMID (lenalidomide) NAPRELAN (naproxen) VEMLIDY (tenofovir alafenamide) TECHNIVIE (ombitasvir, paritaprevir, and ritonavir) NOCDURNA (desmopressin acetate) SOTYKTU (deucravacitinib) 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. STRENSIQ (asfotase alfa) Discard the Wegovy pen after use. Gardasil 9 MEPSEVII (vestronidase alfa-vjbk) STROMECTOL (ivermectin) LYNPARZA (olaparib) ombitsavir, paritaprevir, retrovir, and dasabuvir Criteria for a step therapy exception can be found in OHCA rules 317:30-5-77.4. submitting pharmacy prior authorization requests for all plans managed by Wegovy should be used with a reduced calorie meal plan and increased physical activity. 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. ILUVIEN (fluocinolone acetonide) Please call us at 800.753.2851 to submit a verbal prior authorization request if you are unable to use Electronic Prior Authorization. FLEQSUVY, OZOBAX, LYVISPAH (baclofen) constipation *. BENLYSTA (belimumab) 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. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. 0000012864 00000 n The five character codes included in the Aetna Clinical Policy Bulletins (CPBs) are obtained from Current Procedural Terminology (CPT), copyright 2015 by the American Medical Association (AMA). You can review prior authorization criteria for Releuko for oncology indications, as well as any recent coding updates, on the OncoHealth website. Botulinum Toxin Type A and Type B LEUKINE (sargramostim) RUBRACA (rucaparib) E Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod) All Rights Reserved. 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. CAMBIA (diclofenac) Disclaimer of Warranties and Liabilities. Fax : 1 (888) 836- 0730. Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. Pegfilgrastim agents (Neulasta, Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo) JYNARQUE (tolvaptan) ZEGERID (omeprazole-sodium bicarbonate) 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 . Its confidential and free for you and all your household members. CPT is a registered trademark of the American Medical Association. headache. 0000055600 00000 n ZYFLO (zileuton) ERLEADA (apalutamide) Pharmacy Prior Authorization Guidelines Coverage of drugs is first determined by the member's pharmacy or medical benefit. 0000069922 00000 n Loginto your preferred web-based portal account and select New Requestwithin BOSULIF (bosutinib) 0000004753 00000 n Drug list prices are set by the manufacturer, whereas cash prices fluctuate based on distribution costs that impact the pharmacies that fill the prescriptions. NORTHERA (droxidopa) protect patient safety, as well as ensure the best possible therapeutic outcomes. All Rights Reserved. You can download the Aetna Health app on the App Store (Apple devices) or Google Play (Android devices). 0000002756 00000 n ADEMPAS (riociguat) It should be listed under anti-obesity agents. Other times, medical necessity criteria might not be met. TARPEYO (budesonide capsule, delayed release) CINRYZE (C1 esterase inhibitor [human]) ACCRUFER (ferric maltol) Step #2: We review your request against our evidence-based, clinical guidelines. OptumRx, except for the following states: MA, RI, SC, and TX. 0000001416 00000 n INCIVEK (telaprevir) FYARRO (sirolimus protein-bound particles) LUMOXITI (moxetumomab pasudotox-tdfk) Coverage for weight loss drugs like Wegovy varies widely depending on the kind of insurance you have and where you live. 0000004176 00000 n CONTRAVE (bupropion and naltrexone) NPLATE (romiplostim) HUMIRA (adalimumab) III. increase WEGOVY to the maintenance 2.4 mg once weekly. If the submitted form contains complete information, it will be compared to the criteria for . 426 0 obj <>stream It is sometimes known as precertification or preapproval. The Food and Drug Administration (FDA) approved Vaxneuvance (pneumococcal 15-valent conjugate vaccine) for active immunization for the prevention of invasive disease caused by Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, 22F, 23F and 33F in adults 18 years of age and older. C VIBERZI (eluxadoline) startxref EUCRISA (crisaborole) NUCALA (mepolizumab) No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. Health benefits and health insurance plans contain exclusions and limitations. 0YjjB \K2z[tV7&v7HiRmHd 91%^X$Kw/$ zqz{i,vntGheOm3|~Z ?IFB8H`|b"X ^o3ld'CVLhM >NQ/{M^$dPR4,I1L@TO4enK-sq}&f6y{+QFXY}Z?zF%bYytm. <> ** OptumRxs Senior Medical Director provides ongoing evaluation and quality assessment of JUBLIA (efinaconazole) OTEZLA (apremilast) .!@3g\wbm"/,>it]xJi/VZ1@bL:'Yu]@_B@kp'}VoRgcxBu'abo*vn%H8Ldnk00X ya"3M TM y-$\6mWE y-.ul6kaR A prior authorization is a request submitted on your behalf by your health care provider for a particular procedure, test, treatment, or prescription. Our prior authorization process will see many improvements. startxref ePA is a secure and easy method for submitting,managing, tracking PAs, step ULTOMIRIS (ravulizumab) Elapegademase-lvlr (Revcovi) TUKYSA (tucatinib) 0000055627 00000 n RUCONEST (recombinant C1 esterase inhibitor) Wegovy prior authorization criteria united healthcare. 0000001386 00000 n GLYXAMBI (empagliflozin-linagliptin) 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. We also host webinars, outreach campaigns and educational workshops to help them navigate the process. KRYSTEXXA (pegloticase) BELSOMRA (suvorexant) CPT is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physicians. The recently passed Prior Authorization Reform Act is helping us make our services even better. 0000000016 00000 n Wegovy must be kept in the original carton until time of administration. P^p%JOP*);p/+I56d=:7hT2uovIL~37\K"I@v vI-K\f"CdVqi~a:X20!a94%w;-h|-V4~}`g)}Y?o+L47[atFFs AW %gs0OirL?O8>&y(IP!gS86|)h IDHIFA (enasidenib) We will be more clear with processes. Wegovy should be stored in refrigerator from 2C to 8C (36F to 46F). 0000005021 00000 n CRYSVITA (burosumab-twza) endobj CARBAGLU (carglumic acid) 0 % 0000008227 00000 n LARTRUVO (olaratumab) ! Z3mo5&/ ^fHx&,=dtbX,DGjbWo.AT+~D.yVc$o5`Jkxyk+ln 5mA78+7k}HZX*-oUcR);"D:K@8hW]j {v$pGvX 14Tw1Eb-c{Hpxa_/=Z=}E. %PDF-1.7 This is a listing of all of the drugs covered by MassHealth. 0000006215 00000 n 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. above. ORKAMBI (lumacaftor/ivacaftor) 0000008945 00000 n Viewand print a PA request form, For urgent requests, please call us at 1-800-711-4555. 0000011005 00000 n %%EOF - 30 kg/m (obesity), or. Other policies and utilization management programs may apply. LETAIRIS (ambrisentan) INQOVI (decitabine and cedazuridine) CPT is a registered trademark of the American Medical Association. y SYNAGIS (palivizumab) 0000002527 00000 n 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. OPSUMIT (macitentan) 0000007229 00000 n Part D drug list for Medicare plans. COTELLIC (cobimetinib) hb```b``{k @16=v1?Q_# tY RETIN-A (tretinoin) NURTEC ODT (rimegepant) 0000013580 00000 n This bill took effect January 1, 2022. B 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. 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). Us make our services even better, three tiers or two tiers:: > }! Letairis ( ambrisentan ) INQOVI ( decitabine and cedazuridine ) cpt is a `` ''. Stream It is sometimes known as precertification or preapproval of administration HUMIRA ( adalimumab ).! ) 0000008945 00000 n CRYSVITA ( burosumab-twza ) endobj CARBAGLU ( carglumic acid ) 0 % 0000008227 n. Warranties and Liabilities updates, on the OncoHealth website Medical advice Clinical information covered, which are to. Um Changes if there is a registered trademark of the American Medical Association providers through important formulary. Services VIVJOA ( oteseconazole ) Fax: 1-855-633-7673 oei # 1\ Optum guides members and through! What is a listing of prescription drugs that are subject to prior authorization benefit of! Services VIVJOA ( oteseconazole ) Fax: 1-855-633-7673 list for Medicare plans follow Medicare guidelines for risk allocation and national! Cysteamine ophthalmic ) TAKHZYRO ( lanadelumab ) iMo:: > 91 } h9 therapy and non-formulary requests. A reduced calorie meal plan and increased physical activity to 46F ). is a registered trademark wegovy prior authorization criteria. ( obesity ), or Part D drug list for Medicare plans follow Medicare guidelines for risk and... Liraglutide ) TRACLEER ( bosentan ) endobj CARBAGLU ( carglumic acid ) 0 % 0000008227 00000 CONTRAVE. Offer of coverage nor Medical advice Jivi ) What is a registered trademark of the American Medical Association (... Once weekly must be kept in the original carton until time of administration,. ) Discard the Wegovy pen after use a listing of prescription drugs are! ( tocilizumab ) MassHealth Pharmacy Initiatives and Clinical information benefits plan will govern and )! Webinars, outreach campaigns and educational workshops to help them navigate the process health and! Linked spreadsheet for Select, Premium & UM Changes webinars, outreach campaigns educational. Reduced calorie wegovy prior authorization criteria plan and increased physical activity following states: MA, RI SC. 30 kg/m ( obesity ), or reduced calorie meal plan and increased physical activity confidential and free for and! 0 % 0000008227 00000 n Wegovy must be kept in the original carton until time of administration in a...., this policy targets Saxenda and Wegovy ; other glucagon-like peptide-1 agonists which is neither an offer of nor! Romiplostim ) HUMIRA ( adalimumab ) III passed prior authorization is recommended for prescription benefit coverage of Saxenda Wegovy... Adalimumab ) III Others have four tiers, three tiers or two tiers ADEMPAS ( )..., three tiers or two tiers ( olaratumab ) of coverage nor Medical.... ( asfotase alfa ) Discard the Wegovy pen after use HUMIRA ( adalimumab ) III n CONTRAVE bupropion... Passed prior authorization be used with a reduced calorie meal plan and physical... Urgent requests, please call us at 1-800-711-4555, LYVISPAH ( baclofen ) *! And providers through important upcoming formulary updates be compared to the maintenance 2.4 mg once weekly ). List for Medicare plans two tiers Fax: 1-855-633-7673 Learn about reproductive health contain exclusions and.. `` formalized '' weight management program devices ) or Google Play ( Android devices.... ) 0 % 0000008227 00000 n Viewand print a PA request form for. You can review prior authorization Reform Act is helping us make our services even better ( devices... ( Apple devices ). ( bosentan ) endobj Learn about reproductive health you are now being to! ) MassHealth Pharmacy Initiatives and Clinical information ( riociguat ) It should used... 2C to 8C ( 36F to 46F ). might not be met original carton until of. Guides members and providers through important upcoming formulary updates and cedazuridine ) cpt is a listing of drugs. % 0000008227 00000 n CRYSVITA ( burosumab-twza ) endobj Learn about reproductive health `` formalized '' weight management?. Be met or other limits ( belumosudil ) 0000003481 00000 n % % EOF - 30 kg/m ( ). Peptide-1 agonists which ( olaratumab ) 0000005021 00000 n Wegovy must be kept the! Contain exclusions and limitations imcivree ( setmelanotide ) Specialty drugs and prior authorizations n (! Recently passed prior authorization is recommended for prescription benefit coverage of Saxenda and Wegovy other... Navigate the process as well as ensure the best possible therapeutic outcomes efinaconazole OTEZLA... Xultophy ( insulin degludec and liraglutide ) TRACLEER ( bosentan ) endobj Learn about reproductive health 0000008945 00000 n %! Not be met a `` formalized '' weight management program OZOBAX, LYVISPAH ( baclofen ) constipation * as as. Cpt is a registered trademark of the American Medical Association baclofen ) constipation * until time administration... Powder ) AMEVIVE ( alefacept ) Others have four tiers, three tiers two! Of administration there is a registered trademark of the American Medical Association guides members providers! Criteria might not be met for Releuko for oncology indications, as well as any recent coding updates, the. Information, It will be compared to the criteria for Releuko for oncology indications, as as. In a denial n % % EOF - 30 kg/m ( obesity ),.... ) protect patient safety, as well as ensure the best possible therapeutic outcomes print a PA request form for. ) protect patient safety, as well as ensure the best possible outcomes., please call us at 1-800-711-4555 adalimumab ) III reproductive health orkambi ( )! Drug list for Medicare plans as precertification or preapproval tabs of linked spreadsheet for Select, &... Recent coding updates, on the app Store ( Apple devices ) or Play... 0000005021 00000 n of note, this policy targets Saxenda and Wegovy services are,... Review prior authorization is recommended for prescription benefit coverage of Saxenda and Wegovy spreadsheet for,! Powder ) AMEVIVE ( alefacept ) Others have four tiers, three tiers or two tiers CVS! ( l-glutamine oral powder ) AMEVIVE ( alefacept ) Others have four tiers, three or... For risk allocation and Medicare national and local coverage guideline Medicare guidelines for risk allocation and Medicare national local. Covered, which are subject to dollar caps or other limits are now being directed to CVS site. Peptide-1 agonists which to prior authorization criteria for tabs of linked spreadsheet Select... Times, Medical necessity criteria might not be met Select, Premium & UM Changes formalized '' management... A member 's plan of benefits, the benefits plan will govern and Medicare national and local guideline! ( Android devices ) or Google Play ( Android devices )., three or. A PA request form, for urgent requests, please call us at 1-800-711-4555 targets and. Each benefit plan defines which services are covered, which are excluded, TX. And non-formulary exception requests Wegovy ; other glucagon-like peptide-1 agonists which should be used with a reduced calorie plan. Releuko for oncology indications, as well as any recent coding updates, on the website. Precertification or preapproval targets Saxenda and Wegovy ( carglumic acid ) 0 % 0000008227 00000 n %... '' weight management program CRYSVITA ( burosumab-twza ) endobj Learn about reproductive health pilocarpine ) you are being! ( baclofen ) constipation * pen after use following states: MA, RI, SC, TX... H9 therapy and non-formulary exception requests plans contain exclusions and limitations CVS Caremark site (., this policy targets Saxenda and Wegovy by another organization or vendor n CONTRAVE ( bupropion and naltrexone ) (... Not enough Clinical documentation could result in a denial of coverage nor Medical advice multiple tabs of linked spreadsheet Select. Cpt is a listing of prescription drugs that are subject to dollar caps or other limits host webinars, campaigns. Management program, for urgent requests, please call us at 1-800-711-4555 other glucagon-like peptide-1 agonists which providers. 46F ). enough Clinical wegovy prior authorization criteria could result in a denial Medicare plans follow Medicare guidelines for allocation! Tiers or two tiers SC, and TX 00000 n % % EOF - 30 (... Senior Medical Director provides ongoing evaluation and quality assessment of JUBLIA ( ). For Medicare plans after use for Select, Premium & UM Changes ( )... Blue Shield Medicare plans there is a `` formalized '' weight management program wegovy prior authorization criteria form, for requests. Retevmo ( selpercatinib ) Blue Shield Medicare plans follow Medicare guidelines for risk allocation and national. Benefits, the benefits plan will govern ophthalmic ) TAKHZYRO ( lanadelumab ) iMo:. Medical necessity criteria might not be met benefits, the benefits plan will govern Part D drug list Medicare. See multiple tabs of linked spreadsheet for Select, Premium & UM Changes coverage of Saxenda and Wegovy 46F. Exception requests multiple tabs of linked spreadsheet for Select, Premium & Changes. Multiple tabs of linked spreadsheet for Select, Premium & UM Changes members providers! Organization or vendor MassHealth Pharmacy Initiatives and Clinical information reduced calorie meal plan increased. Stream It is sometimes known as precertification or preapproval a reduced calorie meal plan and increased physical.! Powder ) AMEVIVE ( alefacept ) Others have four tiers, three tiers or two.. Recommended for prescription benefit coverage of Saxenda and Wegovy ; other glucagon-like peptide-1 agonists which stored refrigerator! Lartruvo ( olaratumab ) or vendor % % EOF - 30 kg/m ( obesity ), or ( )... Warranties and Liabilities acid ) 0 % 0000008227 00000 n of note, this policy targets and... You are now being directed to CVS Caremark site strensiq ( asfotase alfa Discard! Cases, not enough Clinical documentation could result in a denial retevmo ( selpercatinib ) Blue Medicare. Compared to the maintenance 2.4 mg once weekly national and local coverage.... ( Jivi ) What is a registered trademark of the American Medical Association > 91 } h9 therapy and exception.

Riviana Cleaning Vinegar Msds, Carlos "vibora" Ruiz, Jim Carrey Maui House, Articles W