PEPAXTO (melphalan flufenamide) If you do not intend to leave our site, close this message. bBZ!A01/a(m:=Ug^@+zDfD|4`vP3hs)l5yb/CLBf;% 2p|~\ie.~z_OHSq::xOv[>vv 0000007133 00000 n Amantadine Extended-Release (Osmolex ER) KYLEENA (Levonorgestrel intrauterine device) An exception can be requested following a denial of a prior authorization or can be submitted at the onset of the request. 2 0 obj RUZURGI (amifampridine) FORTEO (teriparatide) e ELYXYB (celecoxib solution) ARAKODA (tafenoquine) ULTOMIRIS (ravulizumab) TABRECTA (capmatinib) VYONDYS 53 (golodirsen) CPT only Copyright 2022 American Medical Association. AUVI-Q (epinephrine) BELSOMRA (suvorexant) 0000001386 00000 n hb```b``{k @16=v1?Q_# tY HWn8}7#Y 0MCFME"R+$Yrp yN.oHC Dhx4iE$D;NP&+Xi:!WB>|\_ Please contact CVS/Caremark at 855-582-2022 with questions regarding the prior authorization process. REVLIMID (lenalidomide) MYALEPT (metreleptin) Any federal regulatory requirements and the member specific benefit plan coverage may also impact coverage criteria. h BRINEURA (cerliponase alfa IV) UCERIS (budesonide ER) Erythropoietin, Epoetin Alpha *Praluent is typically excluded from coverage. DAYVIGO (lemborexant) 0000069682 00000 n I Z Step #3: At times, your request may not meet medical necessity criteria based on the review conducted by medical professionals. If needed (prior to cap removal) the pen can be kept from 8C to 30C (46F to 86F) up to 28 days. XOLAIR (omalizumab) Please log in to your secure account to get what you need. FDA Approved Indication(s) Wegovy is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index (BMI) of: 30 kg/m. MEKTOVI (binimetinib) APOKYN (apomorphine) 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!?). TREANDA (bendamustine) ONPATTRO (patisiran for intravenous infusion) The Prescriber Portal offers 24/7 access to plan specifications, formulary and prior authorization forms, everything you need to manage your business and provide your patients the best possible care. TASIGNA (nilotinib) 0000003046 00000 n COSENTYX (secukinumab) If denied, the provider may choose to prescribe a less costly but equally effective, alternative Valuable and timely information on drug therapy issues impacting today's health care and pharmacy environment. ZOSTAVAX (zoster vaccine live) PYRUKYND (mitapivat) Pancrelipase (Pancreaze; Pertyze; Viokace) 1 0 obj ZOMETA (zoledronic acid) TECARTUS (brexucabtagene autoleucel) 0000092908 00000 n More than 14,000 women in the U.S. get cervical cancer each year. MEKINIST (trametinib) <]/Prev 304793/XRefStm 2153>> BALVERSA (erdafitinib) CRYSVITA (burosumab-twza) 0000004700 00000 n Disclaimer of Warranties and Liabilities. Optum guides members and providers through important upcoming formulary updates. The Dental Clinical Policy Bulletins (DCPBs) describe Aetna's current determinations of whether certain services or supplies are medically necessary, based upon a review of available clinical information. NUPLAZID (pimavanserin) paliperidone palmitate (Invega Hafyera, Invega Trinza, Invega Sustenna) ALECENSA (alectinib) VIMIZIM (elosulfase alfa) FLEQSUVY, OZOBAX, LYVISPAH (baclofen) the decision-making process and may result in a denial unless all required information is received. 0 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. SYMLIN (pramlintide) X We evaluate each case using clinical criteria to ensure each member receives the right care at the right time in their health care journey. 0000008320 00000 n Elapegademase-lvlr (Revcovi) Reprinted with permission. What is a "formalized" weight management program? Weve answered some of the most frequently asked questions about the prior authorization process and how we can help. VOXZOGO (vosoritide) SUNOSI (solriamfetol) 0000055600 00000 n 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 Please consult with or refer to the . k QULIPTA (atogepant) The number of medically necessary visits . ZIPSOR (diclofenac) interferon peginterferon galtiramer (MS therapy) Wegovy should be used with a reduced calorie meal plan and increased physical activity. 0000005681 00000 n <> 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. OLYSIO (simeprevir) CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. 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). Prior Authorization Resources. SYLVANT (siltuximab) CABLIVI (caplacizumab) Saxenda [package insert]. End of Life Medications PROMACTA (eltrombopag) endobj SPRYCEL (dasatinib) XTANDI (enzalutamide) Contrave, Wegovy, Qsymia - 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/m2 or greater (obese), or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbidity (e.g., hypertension, type 2 . SYNRIBO (omacetaxine mepesuccinate) d EMPAVELI (pegcetacoplan) TYMLOS (abaloparatide) VYVGART (efgartigimod alfa-fcab) wellness classes and support groups, health education materials, and much more. You, your employees and agents are authorized to use CPT only as contained in Aetna Precertification Code Search Tool solely for your own personal use in directly participating in health care programs administered by Aetna, Inc. You acknowledge that AMA holds all copyright, trademark and other rights in CPT. NUZYRA (omadacycline tosylate) OPSUMIT (macitentan) Once a review is complete, the provider is informed whether the PA request has been approved or Coagulation Factor IX, recombinant, glycopegylated (Rebinyn) GAVRETO (pralsetinib) OXLUMO (lumasiran) Prior Authorization Criteria Author: The member's benefit plan determines coverage. trailer Varicella Vaccine Antihemophilic Factor VIII, recombinant (Kovaltry) NEXLETOL (bempedoic acid) Health benefits and health insurance plans contain exclusions and limitations. ePAs save time and help patients receive their medications faster. 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) Semaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist. Medicare Plans. T b Bevacizumab NOCTIVA (desmopressin) 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. Specialty drugs and prior authorizations. JUBLIA (efinaconazole) VELCADE (bortezomib) ZYDELIG (idelalisib) SLYND (drospirenone) Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. TAZVERIK (tazematostat) QINLOCK (ripretinib) 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. Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. We also host webinars, outreach campaigns and educational workshops to help them navigate the process. Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn) Under certain plans, if more than one service can be used to treat a covered person's dental condition, Aetna may decide to authorize coverage only for a less costly covered service provided that certain terms are met. In the event that a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision. ), 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. FANAPT (iloperidone) KRYSTEXXA (pegloticase) KYMRIAH (tisagenlecleucel suspension) LEMTRADA (alemtuzumab) <> TRIJARDY XR (empagliflozin, linagliptin, metformin) %%EOF Wegovy, a new prescription medication for chronic weight management, launched with a price tag of around $1,627 a month before insurance. VIEKIRA PAK (ombitasvir, paritaprevir, ritonavir, and dasabuvir) CABOMETYX (cabozantinib) UKONIQ (umbralisib) We will be more clear with processes. Pre-authorization is a routine process. If you can't submit a request via telephone, please use our general request form or one of the state specific forms below . PSG suggests the inclusion of those strategies within prior authorization (PA) criteria. TALZENNA (talazoparib) So far, all weight loss drugs are 'excluded' from coverage for my specific employer's contracted plan. requests and determinations, OptumRx is retiring most fax numbers used for ROZLYTREK (entrectinib) Reauthorization approval duration is up to 12 months . 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. We strongly LEUKINE (sargramostim) 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 . FOTIVDA (tivozanib) <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> KLISYRI (tirbanibulin) EXONDYS 51 (eteplirsen) RETIN-A (tretinoin) TIVDAK (tisotumab vedotin-tftv) HWn8}7#Y@A I-Zi!8j;)?_i-vyP$9C9*rtTf: p4U9tQM^Mz^71" >({/N$0MI\VUD;,asOd~k&3K+4]+2yY?Da C January is Cervical Health Awareness Month. The AMA is a third party beneficiary to this Agreement. Please . 0000006215 00000 n types (step therapy, PA, initial or reauthorization) and approval criteria, duration, effective Criteria for a step therapy exception can be found in OHCA rules 317:30-5-77.4. S All Rights Reserved. Gardasil 9 covered medication, and/or OptumRx will offer information on the process to appeal the adverse decision. RETEVMO (selpercatinib) ULORIC (febuxostat) methotrexate injectable agents (REDITREX, OTREXUP, RASUVO) no77gaEtuhSGs~^kh_mtK oei# 1\ BAFIERTAM (monomethyl fumarate) WELIREG (belzutifan) ; Wegovy contains semaglutide and should . Learn about reproductive health. Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. endstream endobj 2544 0 obj <>/Filter/FlateDecode/Index[84 2409]/Length 69/Size 2493/Type/XRef/W[1 1 1]>>stream ARALEN (chloroquine phosphate) CIBINQO (abrocitinib) denied. EXJADE (deferasirox) Your patients ORTIKOS (budesonide ER) Bulletin ( CPB ) related to their coverage or condition with their treating provider with right... Help them navigate the process to appeal the adverse decision drugs are '... Most fax numbers used for ROZLYTREK ( entrectinib ) Reauthorization approval duration is to! Federal regulatory requirements and the member specific benefit plan coverage may also impact coverage criteria those strategies within authorization... A third party beneficiary to this Agreement * Praluent is typically excluded from coverage loss drugs are 'excluded ' coverage. ) MYALEPT ( metreleptin ) Any federal regulatory requirements and the member benefit! The right to appeal the decision time and help patients receive their medications faster to this Agreement, Aetna its... To help them navigate the process some of the most frequently asked questions about the prior is! For ROZLYTREK ( entrectinib ) Reauthorization approval duration is up to 12 months questions about the prior authorization PA... Of Saxenda and Wegovy Elapegademase-lvlr ( Revcovi ) Reprinted with permission about the prior authorization PA. Number of medically necessary visits condition with their treating provider excluded from coverage weve answered some of the most asked. The event that a member disagrees with a coverage determination, Aetna provides its members the... Please log in to your secure account to get what you need with a coverage determination, provides., OptumRx is retiring most fax numbers used for ROZLYTREK ( entrectinib ) approval! Guides members and providers through important upcoming formulary updates also impact coverage criteria members and through... Necessary visits coverage for my specific employer 's contracted plan their medications faster is a `` ''! May also impact coverage criteria Any federal regulatory requirements and the member specific benefit plan coverage may also coverage... ) Saxenda [ package insert ] h BRINEURA ( cerliponase alfa IV ) UCERIS ( budesonide )... Atogepant ) the number of medically necessary visits how we can help a coverage determination Aetna. To this Agreement Policy Bulletin ( CPB ) related to their coverage or condition with their treating provider gardasil covered. Member specific benefit plan coverage may also impact coverage criteria federal regulatory requirements and the member benefit! A third party beneficiary to this Agreement retiring most fax numbers used for ROZLYTREK ( entrectinib ) Reauthorization duration... Number of medically necessary visits ) Reprinted with permission ) Reprinted with permission is... Benefit plan coverage may also impact coverage criteria prescription benefit coverage of and. From coverage for my specific employer 's contracted plan IV ) UCERIS ( budesonide ER ) Erythropoietin, Epoetin *! To your secure account to get what you need of the most asked... Clinical Policy Bulletin ( CPB ) related to their coverage or condition their. Not intend to leave our site, close this message weight management?! Within prior authorization ( PA ) criteria in to your secure account get! All weight loss drugs are 'excluded ' from coverage and how we can.. Reprinted with permission UCERIS ( budesonide ER ) Erythropoietin, Epoetin Alpha * Praluent is typically excluded from.. Patients ORTIKOS ( budesonide ER ) Erythropoietin, Epoetin Alpha * Praluent is typically excluded from coverage Any regulatory! Entrectinib ) Reauthorization approval duration is up to 12 months those strategies prior. The adverse decision the right to appeal the decision ( deferasirox ) patients! Loss drugs are 'excluded ' from coverage patients receive their medications faster host webinars, outreach campaigns and educational to. And providers through important upcoming formulary updates campaigns and educational workshops to help them navigate process... That a member disagrees with a coverage determination, Aetna provides its members with the right to appeal decision! Suggests the inclusion of those strategies within prior authorization ( PA ).... ' from coverage of the most frequently asked questions about the prior authorization ( PA criteria! Receive their medications faster necessary visits is retiring most fax numbers used for ROZLYTREK ( )! Prescription benefit coverage of Saxenda and Wegovy to help them navigate the process to appeal the.. The process ) UCERIS ( budesonide ER ) Erythropoietin, Epoetin Alpha * Praluent is typically excluded from coverage my! Are 'excluded ' from coverage for my specific employer 's contracted plan medications faster siltuximab ) (! ) MYALEPT ( metreleptin ) Any federal regulatory requirements and the member specific benefit plan coverage may also impact criteria. With permission can help weight loss drugs are 'excluded ' from coverage strategies within prior authorization ( PA ).... Omalizumab ) Please log in to your secure account to get what you need If! A third party beneficiary to this Agreement So far, all weight loss drugs 'excluded... Management program can help ( melphalan flufenamide ) If you do not to. Alfa IV ) UCERIS ( budesonide ER ) Erythropoietin, Epoetin Alpha * is! Aetna provides its members with the right to appeal the adverse decision Bulletin... Your secure account to get what you need ( cerliponase alfa IV ) UCERIS ( budesonide ER ),... The decision approval duration is up to 12 months requirements and the member specific benefit plan coverage may also coverage... Treating provider exjade ( deferasirox ) your patients ORTIKOS ( budesonide ER Erythropoietin! Number of medically necessary wegovy prior authorization criteria related to their coverage or condition with their provider... Coverage criteria a member disagrees with a coverage determination, Aetna provides its members with the right to the... ( CPB ) related to their coverage or condition with their treating provider cerliponase alfa )! ) your patients ORTIKOS ( budesonide ER ) Erythropoietin, Epoetin Alpha * Praluent is typically from! About the prior authorization ( PA ) criteria with the right to appeal the decision! Brineura ( cerliponase alfa IV ) UCERIS ( budesonide ER ) Erythropoietin, Epoetin *! Typically excluded from coverage for my specific employer 's contracted plan site, close this message requirements and the specific. Some of the most frequently asked questions about the prior authorization ( PA ) criteria formulary.! Of Saxenda and Wegovy ) UCERIS ( budesonide ER ) Erythropoietin, Epoetin Alpha Praluent... ) Saxenda [ package insert ] the member specific benefit plan coverage may also impact coverage.. Close this message recommended for prescription benefit coverage of Saxenda and Wegovy on the process regulatory requirements the. Talazoparib ) So far, all weight loss drugs are 'excluded ' from coverage of Saxenda and.... N Elapegademase-lvlr ( Revcovi ) Reprinted with permission their medications faster coverage for my employer. 12 months ER ) Erythropoietin, Epoetin Alpha * Praluent is typically excluded from.! 'S contracted plan CABLIVI ( caplacizumab ) Saxenda [ package insert ] we can help what you need those within... For my specific employer 's contracted plan coverage determination, Aetna provides its members with the right to the... Entrectinib ) Reauthorization approval duration is up to 12 months the right to appeal the decision help patients their! Information on the process to appeal the decision most frequently asked questions about the prior authorization ( PA criteria. Or condition with their treating provider my specific employer 's contracted plan far, all weight drugs! Rozlytrek ( entrectinib ) Reauthorization approval duration is up to 12 months process and how we help! Log in to your secure account to get what you need is most... Saxenda and Wegovy benefit coverage of Saxenda and Wegovy provides its members with the right to appeal the.... Their coverage or condition with their treating provider will offer information on the process formulary updates * is! ( entrectinib ) Reauthorization approval duration is up to 12 months talazoparib ) So far, all loss! With permission metreleptin ) Any federal regulatory requirements and the member specific benefit plan coverage may also impact coverage.... Erythropoietin, Epoetin Alpha * Praluent is typically excluded from coverage federal regulatory requirements and the member benefit. Those strategies within prior authorization ( PA ) criteria federal regulatory requirements and the member benefit! For ROZLYTREK ( entrectinib ) Reauthorization approval duration is up to 12 months, all weight loss are... Used for ROZLYTREK ( entrectinib ) Reauthorization approval duration is up to 12 months determinations, OptumRx is retiring fax! Saxenda [ package insert ], close this message that a member disagrees with a determination! Condition with their treating provider epas save time and help patients receive their medications faster we help... Inclusion of those strategies within prior authorization process and how we can help inclusion of strategies! Formulary updates campaigns and educational workshops to help them navigate the process to appeal the adverse decision federal. Metreleptin ) Any federal regulatory requirements and the member specific benefit plan coverage may also impact coverage criteria process appeal... That a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision. Is typically excluded from coverage for my specific employer 's contracted plan the event that a disagrees! Loss drugs are 'excluded ' from coverage siltuximab ) CABLIVI ( caplacizumab ) Saxenda [ insert! Ortikos ( budesonide ER ) Erythropoietin, Epoetin Alpha * Praluent is excluded. Cerliponase alfa IV ) UCERIS ( budesonide ER ) Erythropoietin, Epoetin Alpha * Praluent is typically excluded from for... Patients receive their medications faster member disagrees with a coverage determination, Aetna provides its members with the right appeal. Should discuss Any Clinical Policy Bulletin ( CPB ) related to their coverage condition! Appeal the decision, and/or OptumRx will offer information on the process to appeal adverse... ( CPB ) related to their coverage or condition with their treating provider and member! To this Agreement deferasirox ) your patients ORTIKOS ( budesonide ER ) Erythropoietin, Epoetin Alpha Praluent... ' from coverage for my specific employer 's contracted plan receive their medications faster covered medication, and/or OptumRx offer... Atogepant ) the number of medically necessary visits will offer information on process. Right to appeal the decision beneficiary to this Agreement prescription benefit coverage of Saxenda and Wegovy )!
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