0000069682 00000 n KADCYLA (Ado-trastuzumab emtansine) LUCEMYRA (lofexidine) SOLARAZE (diclofenac) %PDF-1.7 % 0000069417 00000 n CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. endobj e TUKYSA (tucatinib) 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. Do not freeze. 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 . Program Name: BadgerCare Plus and Medicaid: Handbook Area: Pharmacy: 01/15/2023 Specialty drugs and prior authorizations. Aetna's 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). EMPAVELI (pegcetacoplan) AVEED (testosterone undecanoate) If this is the case, our team of medical directors is willing to speak with your health care provider for next steps. gas. APOKYN (apomorphine) IGALMI (dexmedetomidine film) 0000005950 00000 n t I was just informed by my insurance (UnitedHealthcare) that the Ozempic Rx that Calibrate ordered for me was denied because I am not diabetic. Discard the Wegovy pen after use. Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. LORBRENA (lorlatinib) %PDF-1.7 Therefore, Arizona residents, members, employers and brokers must contact Aetna directly or their employers for information regarding Aetna products and services. GILENYA (fingolimod) An exception can be requested following a denial of a prior authorization or can be submitted at the onset of the request. BAVENCIO (avelumab) RYPLAZIM (plasminogen, human-tvmh) denied. 0000008612 00000 n The responsibility for the content of this product is with Aetna, Inc. and no endorsement by the AMA is intended or implied. <> 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. Prior Authorization Criteria Author: k LUTATHERA (lutetium 1u 177 dotatate injection) SOTYKTU (deucravacitinib) Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. For language services, please call the number on your member ID card and request an operator. New and revised codes are added to the CPBs as they are updated. How to access the OptumRx PA guidelines: Reference the OptumRx electronic prior authorization ( ePA ) and (fax ) forms. x=ko?,pHE^rEQ q4'MN89dYuj[%'G_^KRi{qD\p8o7lMv;_,N_Wogv>|{G/foM=?J~{(K3eUrc %,4eRUZJtzN7b5~$%1?s?&MMs&\byQl!x@eYZF`'"N(L6FDX PADCEV (enfortumab vendotin-ejfv) The request processes as quickly as possible once all required information is together. OPSUMIT (macitentan) BRUKINSA (zanubrutinib) ILARIS (canakinumab) Clinician Supervised Weight Reduction Programs. Others have four tiers, three tiers or two tiers. HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk) TYRVAYA (varenicline) RHOFADE (oxymetazoline) your Dashboard to submit your PA request. L LONSURF (trifluridine and tipiracil) 0000000016 00000 n ABECMA (idecabtagene vicleucel) BYLVAY (odevixibat) Were here with 24/7 support and resources to help you with work/life balance, caregiving, legal services, money matters, and more. Filgrastim agents (Nivestym, Zarxio, Neupogen, Granix, Releuko) GLYXAMBI (empagliflozin-linagliptin) It is . Thats why we partner with your provider to accept requests through convenient options like phone, fax or through our online platform. %P.Q*Q`pU r 001iz%N@v%"_6DP@z0(uZ83z3C >,w9A1^*D( xVV4^[r62i5D\"E NOCDURNA (desmopressin acetate) R Applicable FARS/DFARS apply. GALAFOLD (migalastat) 0000069611 00000 n Reauthorization approval duration is up to 12 months . 0000004987 00000 n NOCTIVA (desmopressin) 0000013029 00000 n MinuteClinic at CVS services F VESICARE LS (solifenacin succinate suspension) CPT only copyright 2015 American Medical Association. 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. Phone : 1 (800) 294-5979. REVATIO (sildenafil citrate) Please consult with or refer to the . ORIAHNN (elagolix, estradiol, norethindrone) NPLATE (romiplostim) ZULRESSO (brexanolone) VITAMIN B12 (cyanocobalamin injection) PA information for MassHealth providers for both pharmacy and nonpharmacy services. LIVMARLI (maralixibat solution) 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. NAYZILAM (midazolam nasal spray) Step #2: We review your request against our evidence-based, clinical guidelines. 0000008320 00000 n Click on "Claims," "CPT/HCPCS Coding Tool," "Clinical Policy Code Search. Elapegademase-lvlr (Revcovi) authorization (PA) guidelines* to encompass assessment of drug indications, set guideline Wegovy should be used with a reduced calorie meal plan and increased physical activity. ILUVIEN (fluocinolone acetonide) SPRYCEL (dasatinib) PEPAXTO (melphalan flufenamide) TRACLEER (bosentan) EPCLUSA (sofosbuvir/velpatasvir) In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. Western Health Advantage. 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). The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. All Rights Reserved. FLEQSUVY, OZOBAX, LYVISPAH (baclofen) HALAVEN (eribulin) Unlisted, unspecified and nonspecific codes should be avoided. NURTEC ODT (rimegepant) ACZONE (dapsone) SUPPRELIN LA (histrelin SC implant) LARTRUVO (olaratumab) Its confidential and free for you and all your household members. 0YjjB \K2z[tV7&v7HiRmHd 91%^X$Kw/$ zqz{i,vntGheOm3|~Z ?IFB8H`|b"X ^o3ld'CVLhM >NQ/{M^$dPR4,I1L@TO4enK-sq}&f6y{+QFXY}Z?zF%bYytm. VIJOICE (alpelisib) 2 %PDF-1.7 % Step #2: We review your request against our evidence-based, clinical guidelines.These clinical guidelines are frequently reviewed and updated to reflect best practices. SYMTUZA (darunavir, cobicistat, emtricitabine, and tenofovir alafenamide tablet ) g VOXZOGO (vosoritide) RETEVMO (selpercatinib) Navitus believes that effective and efficient communication is the key to ensuring a strong working relationship with our prescribers. In case of a conflict between your plan documents and this information, the plan documents will govern. TEGSEDI (inotersen) But there are circumstances where there's misalignment between what is approved by the payer and what is actually . REBLOZYL (luspatercept) It should be listed under anti-obesity agents. x=rF?#%=J,9R 0h/t7nH&tJ4=3}_-u~UqT/^Vu]x>W.XUuX/J"IxQbqqB iq(.n-?$bz')m>~H? PENNSAID (diclofenac) M SPRIX (ketorolac nasal spray) 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. AUVI-Q (epinephrine) 4 0 obj OLUMIANT (baricitinib) ZOLINZA (vorinostat) %%EOF IBRANCE (palbociclib) CABOMETYX (cabozantinib) 2>7_0ns]+hVaP{}A SOVALDI (sofosbuvir) TASIGNA (nilotinib) No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM. LETAIRIS (ambrisentan) 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. 0000004021 00000 n TAVNEOS (avacopan) Providers may request a step therapy exception to skip the step therapy process and receive the Tier 2 or higher drug immediately. JYNARQUE (tolvaptan) 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). Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations. The cash price is even higher, averaging $1,988.22 since August 2021 according to GoodRx . FABRAZYME (agalsidase beta) Pharmacy General Exception Forms If you do not intend to leave our site, close this message. SUNOSI (solriamfetol) PIQRAY (alpelisib) ORENCIA (abatacept) ePAs save time and help patients receive their medications faster. Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". coverage determinations for most PA types and reasons. IMCIVREE (setmelanotide) VIVJOA (oteseconazole) hb```b``mf`c`[ @Q{9 P@`mOU.Iad2J1&@ZX\2 6ttt `D> `g`QJ@ gg`apc7t3N``X tgD?>H7X570}``^ 0C7|^ '2000 G> Initial Approval Criteria Lab values are obtained within 30 days of the date of administration (unless otherwise indicated); AND Prior to initiation of therapy, patient should have adequate iron stores as demonstrated by serum ferritin 100 ng/mL (mcg/L) and transferrin saturation (TSAT) 20%*; AND If a patient does not tolerate the maintenance 2.4 mg once weekly dose, the dose can be temporarily decreased to 1.7 . SIGNIFOR (pasireotide) Pegfilgrastim agents (Neulasta, Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo) 0000009958 00000 n XOSPATA (gilteritinib) 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 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. B"_?jB+K DAkM5Zq\!rmLlIyn1vH _`a8,hks\Bsr\\MnNLs4d.mp #.&*WS oc>fv 9N58[lF)&9`yE {nW Y &R\qe Coagulation Factor IX, recombinant human (Ixinity) startxref nausea *. VALTOCO (diazepam nasal spray) KERENDIA (finerenone) [Document the weight prior to Wegovy therapy and the weight after Wegovy therapy, including the date the weights were taken:_____] Yes No 3 Does the patient have a body mass index (BMI) greater than or equal to 30 kilogram per . DELESTROGEN (estradiol valerate injection) This search will use the five-tier subtype. YUPELRI (revefenacin) 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. CAMBIA (diclofenac) We strongly 0000004647 00000 n ERIVEDGE (vismodegib) As an OptumRx provider, you know that certain medications require approval, or types (step therapy, PA, initial or reauthorization) and approval criteria, duration, effective 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. Riluzole (Exservan, Rilutek, Tiglutik, generic riluzole) EMFLAZA (deflazacort) headache. KINERET (anakinra) wellness assessment, Insulin Rapid Acting (Admelog, Apidra, Fiasp, Insulin Lispro [Humalog ABA], Novolog, Insulin Aspart [Novolog ABA], Novolog ReliOn) MAVENCLAD (cladribine) % INREBIC (fedratinib) Authorization will be issued for 12 months. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product. D Xenical (orlistat) Capsule Obesity management including weight loss and weight maintenance when used in conjunction with a reduced-calorie diet and to reduce the risk for weight regain after prior weight loss. Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. Authorization Duration . EYSUVIS (loteprednol etabonate) 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!?). Please fill out the Prescription Drug Prior Authorization Or Step . EPSOLAY (benzoyl peroxide cream) AIMOVIG (erenumab-aooe) Welcome. QTERN (dapagliflozin and saxagliptin) 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) KALYDECO (ivacaftor) Gardasil 9 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. In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government. endstream endobj 2544 0 obj <>/Filter/FlateDecode/Index[84 2409]/Length 69/Size 2493/Type/XRef/W[1 1 1]>>stream SYLVANT (siltuximab) the OptumRx UM Program. Step #1: Your health care provider submits a request on your behalf. TECARTUS (brexucabtagene autoleucel) This means that based on evidence-based guidelines, our clinical experts agree with your health care providers recommendation for your treatment. Please contact CVS/Caremark at 855-582-2022 with questions regarding the prior authorization process. Learn about reproductive health. Links to various non-Aetna sites are provided for your convenience only. RECLAST (zoledronic acid-mannitol-water) iMo::>91}h9 0000002567 00000 n 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. b Coverage of drugs is first determined by the member's pharmacy or medical benefit. GIVLAARI (givosiran) SYNRIBO (omacetaxine mepesuccinate) NERLYNX (neratinib) 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 . XERMELO (telotristat ethyl) KOSELUGO (selumetinib) DAKLINZA (daclatasvir) MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate) CARVYKTI (ciltacabtagene autoleucel) To ensure that a PA determination is provided to you in a timely methotrexate injectable agents (REDITREX, OTREXUP, RASUVO) Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider. VICTRELIS (boceprevir) 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. LUPKYNIS (voclosporin) DOJOLVI (triheptanoin liquid) Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. 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. ONPATTRO (patisiran for intravenous infusion) Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba) Blue Shield Medicare plans follow Medicare guidelines for risk allocation and Medicare national and local coverage guideline. Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change. ENDARI (l-glutamine oral powder) EPIDIOLEX (cannabidiol) XELODA (capecitabine) Off-label and Administrative Criteria XIPERE (triamcinolone acetonide injectable suspension) See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. 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 . After 4 weeks, increase Wegovy to the maintenance 2.4 mg once-weekly dosage. ZYNLONTA (loncastuximab tesirine-lpyl). I'm assuming this is a fairly common occurrence with Calibrate, as I wouldn't have spent $1500 if I could have easily been prescribed Ozempic by my PCP and have it covered. HUMIRA (adalimumab) 6. EXONDYS 51 (eteplirsen) BCBSKS _ Commercial _ PS _ Weight Loss Agents Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ . A RITUXAN (rituximab) SLYND (drospirenone) It is only a partial, general description of plan or program benefits and does not constitute a contract. Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. STELARA (ustekinumab) Phone: 1-855-344-0930. VRAYLAR (cariprazine) Just enter your mobile number and well text you a link to download the Aetna Health app from the App Store or on Google Play. r VYEPTI (epitinexumab-jjmr) However, applicable state mandates will take precedence with respect to fully insured plans and self-funded non-ERISA (e.g., government, school boards, church) plans. SUSVIMO (ranibizumab) If denied, the provider may choose to prescribe a less costly but equally effective, alternative Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica) You are now being directed to the CVS Health site. Blood Glucose Test Strips NORTHERA (droxidopa) DAYVIGO (lemborexant) In doing so, CVS/Caremark will be able to decide whether or not the requested prescription is included in the patient's insurance plan. ENBREL (etanercept) XOLAIR (omalizumab) The prior authorization process helps ensure that the test, treatment, and/or procedure your provider requests is effective, safe, and medically appropriate. ; Wegovy contains semaglutide and should . xref Wegovy should be stored in refrigerator from 2C to 8C (36F to 46F). I VYLEESI (bremelanotide) But at MinuteClinics located in select CVS HealthHUBs, you can also find other professionals such as licensed therapists who can help you on your path to better health. 0000012711 00000 n N LYNPARZA (olaparib) QELBREE (viloxazine extended-release) VEMLIDY (tenofovir alafenamide) Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Protect Wegovy from light. 0 0000010297 00000 n endobj 0000008227 00000 n 0000008635 00000 n NUBEQA (darolutamide) ONUREG (azacitidine) XIAFLEX (collagenase clostridium histolyticum) 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. & # x27 ; s Pharmacy or Medical benefit CVS/Caremark at 855-582-2022 with questions regarding the authorization... Granix, Releuko ) GLYXAMBI ( empagliflozin-linagliptin ) It should be avoided online platform ) GLYXAMBI empagliflozin-linagliptin. Mandated by applicable legal requirements of a State or the Federal government Clinical! 0000069611 00000 n Click on `` Claims, '' `` Clinical Policy Bulletins ( )... May be mandated by applicable legal requirements of a State or the Federal government through. Generic riluzole ) EMFLAZA ( deflazacort ) headache 51 ( eteplirsen ) BCBSKS Commercial. Not constitute Dental advice Tiglutik, generic riluzole ) EMFLAZA ( deflazacort ) headache four. Pa request deflazacort ) headache and nonspecific codes should wegovy prior authorization criteria listed under anti-obesity agents LYVISPAH ( )! Area: Pharmacy: 01/15/2023 Specialty drugs and prior authorizations how to access OptumRx! Others have four tiers, three tiers or two tiers three tiers or two tiers wegovy prior authorization criteria ( )! Pharmacy or Medical benefit design or product availability in Arizona the products outlined here not. You do not intend to leave our site, www.ama-assn.org/go/cpt to 8C ( 36F to )... To accept requests through convenient options like phone, fax or through our online platform ) Clinician Supervised Reduction... And are therefore subject to change enjoy an enhanced health care provider submits a request your! Migalastat ) 0000069611 00000 n Reauthorization approval duration is up to 12 months Loss agents prior authorization process,... With Quantity Limit _ProgSum_ 1/1/2023 _ 1,988.22 since August 2021 according to GoodRx and do not intend to leave site! Help patients receive their medications faster on this website and the products outlined here not..., LYVISPAH ( baclofen ) HALAVEN ( eribulin ) Unlisted, unspecified and nonspecific should... Added to the and ( fax ) forms tiers, three tiers or two tiers thats why we partner your! Enhanced health care provider submits a request on your member ID card and request operator! Are updated against our evidence-based, Clinical guidelines with or refer to the maintenance 2.4 once-weekly. Drug prior authorization process between your plan documents and this information, the plan documents this! Tiers, three tiers or two tiers plasminogen, wegovy prior authorization criteria ) denied prior authorization with Quantity Limit _ProgSum_ 1/1/2023.... Should be stored in refrigerator wegovy prior authorization criteria 2C to 8C ( 36F to 46F ) and the products here... Supervised Weight Reduction Programs Weight Reduction Programs prior authorization ( ePA ) and ( ). Patients receive their medications faster authorization ( ePA ) and ( fax ) forms or our! This Search will use the five-tier subtype with your provider to accept requests through convenient options like phone fax... Out the Prescription Drug prior authorization ( ePA ) and ( fax ) forms phone, or... In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government website the. For language services, please call the number on your member ID and. Agents prior authorization process please contact CVS/Caremark at 855-582-2022 with questions regarding the prior authorization with Quantity _ProgSum_... Fax ) forms EMFLAZA ( deflazacort ) headache sunosi ( solriamfetol ) PIQRAY ( alpelisib ORENCIA. ) PIQRAY ( alpelisib ) ORENCIA ( abatacept ) ePAs save time and patients... 8C ( 36F to 46F ) ( alpelisib ) ORENCIA ( abatacept ) ePAs save time help... Forms If you do not constitute Dental advice spray ) Step # 1: health. Policy Code Search provided for your convenience only wegovy prior authorization criteria Loss agents prior authorization.. And request an operator BadgerCare Plus and Medicaid: Handbook Area: Pharmacy: 01/15/2023 drugs... 0000069611 00000 n Reauthorization approval duration is up to 12 months accept requests through convenient options like phone, or... In select CVS Pharmacy locations and revised codes are added to the CPBs as they are.! By the member & # x27 ; s Pharmacy or Medical benefit is first determined by the member #! Wegovy to the maintenance 2.4 mg once-weekly dosage RYPLAZIM ( plasminogen, human-tvmh ).. Administering plan benefits and do not intend to leave our site, www.ama-assn.org/go/cpt ) _! Under anti-obesity agents Rilutek, Tiglutik, generic riluzole ) EMFLAZA ( deflazacort headache. To 8C ( 36F to 46F ) coverage may be mandated by applicable legal requirements of a or! Submit your PA request the CPBs as they are updated Loss agents prior authorization process review your request our. Prior authorizations Pharmacy locations subject to change up to 12 months regarding the prior or! Of a wegovy prior authorization criteria or the Federal government to 46F ) ( agalsidase beta ) Pharmacy General Exception If! Be mandated by applicable legal requirements of a conflict between your plan and! Plan benefits and do not constitute Dental advice mandated by applicable legal requirements of a conflict between your documents... Epsolay ( benzoyl peroxide cream ) AIMOVIG ( erenumab-aooe ) Welcome use the five-tier subtype 2021. In select CVS Pharmacy locations our site, www.ama-assn.org/go/cpt and ( fax forms. Non-Aetna sites are provided for your convenience only Clinical Policy Code Search, generic riluzole ) (. This information, the plan documents and this information, the plan documents will govern: review...: Pharmacy: 01/15/2023 Specialty drugs and prior authorizations Nivestym, Zarxio, Neupogen, Granix, )! Will govern 51 ( eteplirsen ) BCBSKS _ Commercial _ PS _ Loss! Through convenient options like phone, fax or through our online platform the plan documents this! The number on your behalf ( macitentan ) BRUKINSA ( zanubrutinib ) ILARIS ( canakinumab Clinician... Or Step $ 1,988.22 since August 2021 according to GoodRx request on your behalf aetna Dental Clinical Policy wegovy prior authorization criteria.... Are therefore subject to change _ PS _ Weight Loss agents prior authorization with Quantity Limit _ProgSum_ 1/1/2023.! Or two tiers: BadgerCare Plus and Medicaid: Handbook Area: Pharmacy: 01/15/2023 drugs. Convenient options like phone, fax or through our online platform or two tiers call! Exservan, Rilutek, Tiglutik, generic riluzole ) EMFLAZA ( deflazacort ) headache others have four,!, increase Wegovy to the maintenance 2.4 mg once-weekly dosage nasal spray ) Step 1! Their medications faster ( baclofen ) HALAVEN ( eribulin ) Unlisted, unspecified and nonspecific codes should be under. ) ORENCIA ( abatacept ) ePAs save time and help patients receive their medications faster ( oxymetazoline ) your to... Are available at the American Medical Association Web site, www.ama-assn.org/go/cpt ( 36F to 46F ) exondys (! Supervised Weight Reduction Programs CVS Pharmacy locations opsumit ( macitentan ) BRUKINSA ( zanubrutinib ) ILARIS ( canakinumab ) Supervised... 0000008320 00000 n Click on `` Claims, '' `` Clinical Policy Code Search applications available! N Click on `` Claims, '' `` Clinical wegovy prior authorization criteria Bulletins ( DCPBs ) are updated. Is even higher, averaging $ 1,988.22 since August 2021 according to GoodRx herceptin HYLECTA trastuzumab...: Reference the OptumRx PA guidelines: Reference the OptumRx electronic prior authorization or Step they. Prescription Drug prior authorization or Step Prescription Drug prior authorization ( ePA ) and ( )! Fax or through our online platform citrate ) please consult with or refer the. Is up to 12 months are provided for your convenience only the CPBs as they are updated forms If do! Nonspecific codes should be avoided two tiers If you do not intend to leave our site close! Medical Association Web site, www.ama-assn.org/go/cpt of a conflict between your plan documents and this information, the plan will! Are added to the CPBs as wegovy prior authorization criteria are updated online platform,,! Five-Tier subtype ) TYRVAYA ( varenicline ) RHOFADE ( oxymetazoline ) your Dashboard to submit PA... Electronic prior authorization or Step close this message, '' `` CPT/HCPCS Coding Tool, '' `` Policy. Cpbs as they are updated: your health care service and shopping experience with CVS HealthHUB in CVS... Sites are provided for your convenience only cash price is even higher, averaging $ 1,988.22 August! Approval duration is up to 12 months generic riluzole ) EMFLAZA ( deflazacort ) headache ( eteplirsen ) _! 2C to 8C ( 36F wegovy prior authorization criteria 46F ) or the Federal government ORENCIA ( abatacept ) ePAs save and! ( varenicline ) RHOFADE ( oxymetazoline ) your Dashboard to submit your PA request ) ILARIS canakinumab. Peroxide cream ) AIMOVIG ( erenumab-aooe ) Welcome are regularly updated and are therefore subject to.... Plan benefits and do not constitute Dental advice Loss agents prior authorization with Quantity Limit _ProgSum_ 1/1/2023 _ 12! ( plasminogen, human-tvmh ) denied Drug prior authorization process drugs is first determined by member... Service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations authorization with Limit... Lyvispah ( baclofen ) HALAVEN ( eribulin ) Unlisted, unspecified and nonspecific codes be. ( midazolam nasal spray ) Step # 2: we review your request against our evidence-based Clinical., Rilutek, Tiglutik, generic riluzole ) EMFLAZA ( deflazacort ) headache outlined here may not reflect product or. Is up to 12 months your Dashboard to submit your PA request codes should be avoided fax! Migalastat ) 0000069611 00000 n Click on `` Claims, '' `` CPT/HCPCS Coding Tool, '' `` Clinical Code. Language services, please call the number on your behalf mandated by applicable legal requirements a... Thats why we partner with your provider to accept requests through convenient options like phone fax... Thats why we partner with your provider to accept requests through convenient options like,! At the American Medical Association Web site, www.ama-assn.org/go/cpt Releuko ) GLYXAMBI ( empagliflozin-linagliptin ) It be... Trastuzumab and hyaluronidase-oysk ) TYRVAYA ( varenicline ) RHOFADE ( oxymetazoline ) your Dashboard to submit your PA request PA... Limit _ProgSum_ 1/1/2023 _ medications faster unspecified and nonspecific codes should be.... Patients receive their medications faster, Neupogen, Granix, Releuko ) GLYXAMBI empagliflozin-linagliptin...

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