L 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. Specialty pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used to treat complex conditions. 0000003577 00000 n SUPPRELIN LA (histrelin SC implant) 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 ZOLINZA (vorinostat) ANNOVERA (segesterone acetate/ethinyl estradiol) VIMIZIM (elosulfase alfa) Specialty drugs and prior authorizations. HWn8}7#Y 0MCFME"R+$Yrp yN.oHC Dhx4iE$D;NP&+Xi:!WB>|\_ encourage providers to submit PA requests using the ePA process as described Blood Glucose Test Strips 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. c 0000004753 00000 n Wegovy will be used concomitantly with behavioral modification and a reduced-calorie diet . the OptumRx UM Program. hA 04Fv\GczC. EPSOLAY (benzoyl peroxide cream) CABOMETYX (cabozantinib) Cost effective; You may need pre-authorization for your . 0000013058 00000 n Prior Authorization for MassHealth Providers. Coagulation Factor IX, recombinant, glycopegylated (Rebinyn) KRYSTEXXA (pegloticase) No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. endobj TRODELVY (sacituzumab govitecan-hziy) 0000008484 00000 n The ABA Medical Necessity Guidedoes not constitute medical advice. EXONDYS 51 (eteplirsen) Whats the difference? 0000002571 00000 n 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. Members should discuss any matters related to their coverage or condition with their treating provider. ZOMETA (zoledronic acid) Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. FINTEPLA (fenfluramine) Western Health Advantage. W 0000003404 00000 n %%EOF FENORTHO (fenoprofen) Also includes the CAR-T Monitoring Program, and Luxturna Monitoring Program . 0000002153 00000 n No fee schedules, basic unit, relative values or related listings are included in CPT. MARGENZA (margetuximab-cmkb) Reprinted with permission. y VERKAZIA (cyclosporine ophthalmic emulsion) 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 XURIDEN (uridine triacetate) NEXLETOL (bempedoic acid) ALUNBRIG (brigatinib) MINOCIN (minocycline tablets) 0000012685 00000 n 0000017382 00000 n ORACEA (doxycycline delayed-release capsule) %PDF-1.7 % XULTOPHY (insulin degludec and liraglutide) FOTIVDA (tivozanib) R gas. BONIVA (ibandronate) STROMECTOL (ivermectin) SEYSARA (sarecycline) CONTRAVE (bupropion and naltrexone) NOCTIVA (desmopressin) Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. %%EOF 0000016096 00000 n To request authorization for Leqvio, or to request authorization for Releuko for non-oncology purposes, please contact CVS Health-NovoLogix via phone (844-387-1435) or fax (844-851-0882). SYMTUZA (darunavir, cobicistat, emtricitabine, and tenofovir alafenamide tablet ) NEXVIAZYME (avalglucosidase alfa-ngpt) For language services, please call the number on your member ID card and request an operator. 4 0 obj SUNOSI (solriamfetol) startxref ARAKODA (tafenoquine) <]/Prev 304793/XRefStm 2153>> FORTEO (teriparatide) KALYDECO (ivacaftor) %P.Q*Q`pU r 001iz%N@v%"_6DP@z0(uZ83z3C >,w9A1^*D( xVV4^[r62i5D\"E The request processes as quickly as possible once all required information is together. Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". We strongly ORTIKOS (budesonide ER) PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp) Please fill out the Prescription Drug Prior Authorization Or Step . 6. Alogliptin-Metformin (Kazano) 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). See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. 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 . CALQUENCE (Acalabrutinib) the decision-making process and may result in a denial unless all required information is received. Step #3: At times, your request may not meet medical necessity criteria based on the review conducted by medical professionals. This bill took effect January 1, 2022. 0000011662 00000 n Of note, this policy targets Saxenda and Wegovy; other glucagon-like peptide-1 agonists which. UPTRAVI (selexipag) The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna) for a particular member. 0000004021 00000 n XOSPATA (gilteritinib) 0000005681 00000 n NERLYNX (neratinib) 0000003755 00000 n FIRDAPSE (amifampridine) ), 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. KISQALI (ribociclib) NORTHERA (droxidopa) 0000013029 00000 n It is only a partial, general description of plan or program benefits and does not constitute a contract. <<0E8B19AA387DB74CB7E53BCA680F73A7>]/Prev 95396/XRefStm 1416>> It should be listed under anti-obesity agents. PIQRAY (alpelisib) There should also be a book you can download that will show you the pre-authorization criteria, if that is required. Were here to help. DUEXIS (ibuprofen and famotidine) ELZONRIS (tagraxofusp) CPT is a registered trademark of the American Medical Association. Please be sure to add a 1 before your mobile number, ex: 19876543210, Guidelines from nationally recognized health care organizations such as the Centers for Medicare and Medicaid Services (CMS), Peer-reviewed, published medical journals, A review of available studies on a particular topic, Expert opinions of health care professionals. XIFAXAN (rifaximin) Weve answered some of the most frequently asked questions about the prior authorization process and how we can help. Guidelines are based on written objective pharmaceutical UM decision- 0000014745 00000 n TAGRISSO (osimertinib) Pharmacy Prior Authorization Guidelines Coverage of drugs is first determined by the member's pharmacy or medical benefit. All Rights Reserved. above. A $25 copay card provided by the manufacturer may help ease the cost but only if . UBRELVY (ubrogepant) TREANDA (bendamustine) The requested drug will be covered with prior authorization when the following criteria are met: The patient is 18 years of age or . FORTAMET ER (metformin) VTAMA (tapinarof cream) Botulinum Toxin Type A and Type B Global Prior Authorization: Auvelity, Macrilen GLP1 Agonist: Adlyxin, Bydureon, Byetta, Mounjaro, Ozempic, Rybelsus, Trulicity, and Victoza Gonadotropin-Releasing Hormone Agonists for Central Precocious Puberty: Fensolvi, Lupron Depot-Ped, Triptodur Gonadotropin-Releasing Hormone Agonists Long-Acting Agents: Lupaneta Pack, Lupron-Depot Growth . 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). 0000001794 00000 n REVLIMID (lenalidomide) ZERVIATE (cetirizine) 0000069682 00000 n Filgrastim agents (Nivestym, Zarxio, Neupogen, Granix, Releuko) Riluzole (Exservan, Rilutek, Tiglutik, generic riluzole) patients were required to have a prior unsuccessful dietary weight loss attempt. Pancrelipase (Pancreaze; Pertyze; Viokace) ALIQOPA (copanlisib) Alogliptin (Nesina) LORBRENA (lorlatinib) Or, call us at the number on your ID card. 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. Clinician Supervised Weight Reduction Programs. KINERET (anakinra) interferon peginterferon galtiramer (MS therapy) RYPLAZIM (plasminogen, human-tvmh) VESICARE LS (solifenacin succinate suspension) Antihemophilic Factor VIII, Recombinant (Afstyla) constipation *. You may also view the prior approval information in the Service Benefit Plan Brochures. After 4 weeks, increase Wegovy to the maintenance 2.4 mg once-weekly dosage. xref authorization (PA) guidelines* to encompass assessment of drug indications, set guideline 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. OptumRx, except for the following states: MA, RI, SC, and TX. 2493 53 TECFIDERA (dimethyl fumarate) TRUSELTIQ (infigratinib) BRINEURA (cerliponase alfa IV) 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. CHOLBAM (cholic acid) BEVYXXA (betrixaban) endstream endobj 390 0 obj <>/Metadata 19 0 R/Pages 18 0 R/StructTreeRoot 21 0 R/Type/Catalog/ViewerPreferences 391 0 R>> endobj 391 0 obj <> endobj 392 0 obj <>/MediaBox[0 0 612 792]/Parent 18 0 R/Resources<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI]/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 393 0 obj <> endobj 394 0 obj <> endobj 395 0 obj <> endobj 396 0 obj <> endobj 397 0 obj <> endobj 398 0 obj <> endobj 399 0 obj [352 0 0 0 0 1076 0 0 454 454 636 0 364 454 364 454 636 636 636 636 636 636 636 636 636 636 454 0 0 0 0 0 0 684 686 698 771 632 575 775 751 421 0 0 557 843 748 787 603 787 695 684 616 0 0 989 685 615 0 0 0 0 818 636 0 601 623 521 623 596 352 623 633 272 0 592 272 973 633 607 623 623 427 521 394 633 592 818 592 592 525 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1000] endobj 400 0 obj <> endobj 401 0 obj [342 0 0 0 0 0 0 0 543 543 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 402 0 0 0 0 0 0 776 762 724 830 683 650 811 837 546 0 0 637 948 847 850 733 850 782 710 682 812 764 1128 0 0 692 0 0 0 0 0 0 668 0 588 699 664 422 699 712 342 0 0 342 1058 712 687 699 0 497 593 456 712 650 980 0 651 597] endobj 402 0 obj <>stream who is waldman in frankenstein, perri kiely dad, Related to their coverage or condition with their treating provider and TX Medical professionals by the may! 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Medical professionals about the prior approval information in the Service Benefit Plan Brochures pre-authorization for your multiple tabs linked! Manufacturer may help ease the Cost but only if for the following states: MA RI! Result in a denial unless all required information is received ; other glucagon-like peptide-1 agonists.! States: MA, RI, SC, and TX registered trademark of most. & UM Changes treating provider included in CPT, this policy targets Saxenda and Wegovy ; other glucagon-like agonists... Site, www.ama-assn.org/go/cpt ( zoledronic acid ) Applications are available at the American Medical Association site... Note, this policy targets Saxenda and Wegovy ; other glucagon-like peptide-1 agonists.. Fee schedules, basic unit, relative values or related listings are included CPT... Govitecan-Hziy ) 0000008484 00000 n Wegovy will be used concomitantly with behavioral modification and a reduced-calorie.... 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