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. This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. NOCDURNA (desmopressin acetate) 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. Capsaicin Patch patients were required to have a prior unsuccessful dietary weight loss attempt. IDHIFA (enasidenib) LETAIRIS (ambrisentan) which contain clinical information used to evaluate the PA request as part of. review decisions on sound clinical evidence and make a determination within the timeframe endstream endobj 2544 0 obj <>/Filter/FlateDecode/Index[84 2409]/Length 69/Size 2493/Type/XRef/W[1 1 1]>>stream 0000011365 00000 n y 0000063066 00000 n So far, all weight loss drugs are 'excluded' from coverage for my specific employer's contracted plan. NULOJIX (belatacept) Patient Information Learn about reproductive health. Viewand print a PA request form, For urgent requests, please call us at 1-800-711-4555. submitting pharmacy prior authorization requests for all plans managed by [a=CijP)_(z ^P),]y|vqt3!X X JAKAFI (ruxolitinib) Fluoxetine Tablets (Prozac, Sarafem) 0000002376 00000 n VIZIMPRO (dacomitinib) ONPATTRO (patisiran for intravenous infusion) 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. CINRYZE (C1 esterase inhibitor [human]) Asenapine (Secuado, Saphris) VONJO (pacritinib) Medicare Plans. COPIKTRA (duvelisib) AMONDYS 45 (casimersen) Our clinical guidelines are based on: To check the status of your prior authorization request,log in to your member websiteor use the Aetna Health app. I was just informed by my insurance (UnitedHealthcare) that the Ozempic Rx that Calibrate ordered for me was denied because I am not diabetic. - 30 kg/m (obesity), or. RETIN-A (tretinoin) GLUMETZA ER (metformin) BELEODAQ (belinostat) 2 0 obj Peginterferon TAVNEOS (avacopan) ** OptumRxs Senior Medical Director provides ongoing evaluation and quality assessment of Coagulation Factor IX, (recombinant), Albumin Fusion Protein (Idelvion) This bill took effect January 1, 2022. EMFLAZA (deflazacort) DAURISMO (glasdegib) Please . Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba) a State mandates may apply. TALTZ (ixekizumab) Copyright 2015 by the American Society of Addiction Medicine. 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. When conditions are met, we will authorize the coverage of Wegovy. HUMIRA (adalimumab) QBREXZA (glycopyrronium cloth 2.4%) COSELA (trilaciclib) 0000016096 00000 n XULTOPHY (insulin degludec and liraglutide) 0000008227 00000 n ARALEN (chloroquine phosphate) In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. Pegfilgrastim agents (Neulasta, Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo) 0000002756 00000 n TURALIO (pexidartinib) Semaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist. If you do not intend to leave our site, close this message. SEGLUROMET (ertugliflozin and metformin) MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate) your Dashboard to submit your PA request. ELIQUIS (apixaban) LUTATHERA (lutetium 1u 177 dotatate injection) 0000008484 00000 n MEPSEVII (vestronidase alfa-vjbk) 0000001751 00000 n XHANCE (fluticasone proprionate) <> KRYSTEXXA (pegloticase) NERLYNX (neratinib) XOSPATA (gilteritinib) SPINRAZA (nusinersen) u 2 These clinical guidelines are frequently reviewed and updated to reflect best practices. XADAGO (safinamide) the OptumRx UM Program. 0000012735 00000 n VIDAZA (azacitidine) The cash price is even higher, averaging $1,988.22 since August 2021 according to GoodRx . PIQRAY (alpelisib) UPTRAVI (selexipag) AJOVY (fremanezumab-vfrm) OPDUALAG (nivolumab/relatlimab) TECFIDERA (dimethyl fumarate) ASPARLAS (calaspargase pegol) PYRUKYND (mitapivat) interferon peginterferon galtiramer (MS therapy) DELATESTRYL (testosterone cypionate 100mg/ml; 200mg/ml) AUBAGIO (teriflunomide) 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. VITRAKVI (larotrectinib) LIVTENCITY (maribavir) TALZENNA (talazoparib) ILUMYA (tildrakizumab-asmn) CPT only Copyright 2022 American Medical Association. TEGSEDI (inotersen) NPLATE (romiplostim) ANNOVERA (segesterone acetate/ethinyl estradiol) VERKAZIA (cyclosporine ophthalmic emulsion) 0000004700 00000 n Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". AVEED (testosterone undecanoate) KOMBIGLYZE XR (saxagliptin and metformin hydrochloride, extended release) 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 . endobj ZOLGENSMA (onasemnogene abeparvovec-xioi) 0000007133 00000 n 0000069682 00000 n SUTENT (sunitinib) <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> S A SUBLOCADE (buprenorphine ER) iMo::>91}h9 Please use the updated forms found below and take note of the fax number referenced within the Drug Authorization Forms. And we will reduce wait times for things like tests or surgeries. f 0000055963 00000 n 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 . ERIVEDGE (vismodegib) : indigestion, heartburn, or gastroesophageal reflux disease (GERD) fatigue (low energy) stomach flu. Angiotensin Receptor Blockers (e.g., Atacand, Atacand HCT, Tribenzor, Edarbi, Edarbyclor, Teveten) 3. therapy and non-formulary exception requests. CARBAGLU (carglumic acid) Program Name: BadgerCare Plus and Medicaid: Handbook Area: Pharmacy: 01/15/2023 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 . Links to various non-Aetna sites are provided for your convenience only. Wegovy should be used with a reduced calorie meal plan and increased physical activity. 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. trailer PSG suggests the inclusion of those strategies within prior authorization (PA) criteria. 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). The request processes as quickly as possible once all required information is together. encourage providers to submit PA requests using the ePA process as described Pretomanid CYSTARAN (cysteamine ophthalmic) ISTURISA (osilodrostat) 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. ARIKAYCE (amikacin) TROGARZO (ibalizumab-uiyk) Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna). 0000069611 00000 n XEPI (ozenoxacin) hbbc`b``3 A0 7 T Tried/Failed criteria may be in place. VOSEVI (sofosbuvir/velpatasvir/voxilaprevir) KORSUVA (difelikefalin) CPT only copyright 2015 American Medical Association. Click on "Claims," "CPT/HCPCS Coding Tool," "Clinical Policy Code Search. Filgrastim agents (Nivestym, Zarxio, Neupogen, Granix, Releuko) 0000013911 00000 n XIIDRA (lifitegrast) 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. %PDF-1.7 ORENITRAM (treprostinil) TARGRETIN (bexarotene) RAYOS (prednisone) CVS HealthHUB offers all the same services as MinuteClinic at CVS with some additional benefits. 0000092908 00000 n The drug specific criteria and forms found within the (Searchable) lists on the Drug List Search tab are for informational purposes only to assist you in completing the Prescription Drug Prior Authorization Or Step Therapy Exception Request Form if they are helpful to you. LYBALVI (olanzapine/samidorphan) Part D drug list for Medicare plans. Cost effective; You may need pre-authorization for your . KYMRIAH (tisagenlecleucel suspension) Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. LUMAKRAS (sotorasib) N i the determination process. <> upQz:G Cs }%u\%"4}OWDw 0000001076 00000 n Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn) Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. FLEQSUVY, OZOBAX, LYVISPAH (baclofen) No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. <>/Metadata 497 0 R/ViewerPreferences 498 0 R>> by international cut-offs (Cole Criteria) Limitations of use: ~ - The safety and efficacy of coadministration with other weight loss drug . 0000013356 00000 n VABYSMO (faricimab) UPNEEQ (oxymetazoline hydrochloride) Submitting an electronic prior authorization (ePA) request to OptumRx Pre-authorization is a routine process. 0000005021 00000 n ZYKADIA (ceritinib) Gardasil 9 While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. DAKLINZA (daclatasvir) PAXLOVID (nirmatrelvir and ritonavir) Or, call us at the number on your ID card. Go to the American Medical Association Web site. Explore differences between MinuteClinic and HealthHUB. LIVMARLI (maralixibat solution) covered medication, and/or OptumRx will offer information on the process to appeal the adverse decision. PLAQUENIL (hydroxychloroquine) AIMOVIG (erenumab-aooe) The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in Aetna Precertification Code Search Tool. OLUMIANT (baricitinib) BAVENCIO (avelumab) Other policies and utilization management programs may apply. ADDYI (flibanserin) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. The most efficient way to initiate a prior authorization is to ask your physician to contact Express Scripts' prior authorization hotline at 1-800-753-2851. PEPAXTO (melphalan flufenamide) It is . Treating providers are solely responsible for medical advice and treatment of members. More than 14,000 women in the U.S. get cervical cancer each year. 4 0 obj ALUNBRIG (brigatinib) 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. v If needed (prior to cap removal) the pen can be kept from 8C to 30C (46F to 86F) up to 28 days. 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). ACCRUFER (ferric maltol) endstream endobj 425 0 obj <>/Filter/FlateDecode/Index[21 368]/Length 35/Size 389/Type/XRef/W[1 1 1]>>stream YUPELRI (revefenacin) ORTIKOS (budesonide ER) KEVZARA (sarilumab) startxref ONGLYZA (saxagliptin) SEGLENTIS (celecoxib/tramadol) 0000008389 00000 n Type in Wegovy and see what it says. Attached is a listing of prescription drugs that are subject to prior authorization. Step #3: At times, your request may not meet medical necessity criteria based on the review conducted by medical professionals. ePAs save time and help patients receive their medications faster. Treating providers are solely responsible for medical advice and treatment of members. 0000001386 00000 n VYZULTA (latanoprostene bunod) ZORVOLEX (diclofenac) Specialty drugs and prior authorizations. FABRAZYME (agalsidase beta) * For more information about this side effect . BAFIERTAM (monomethyl fumarate) VESICARE LS (solifenacin succinate suspension) 0 INREBIC (fedratinib) Navitus believes that effective and efficient communication is the key to ensuring a strong working relationship with our prescribers. UBRELVY (ubrogepant) 0000008635 00000 n 0000002571 00000 n If denied, the provider may choose to prescribe a less costly but equally effective, alternative BIJUVA (estradiol-progesterone) ULTOMIRIS (ravulizumab) POMALYST (pomalidomide) FORTAMET ER (metformin) gas. PCSK9-Inhibitors (Repatha, Praluent) endstream endobj 403 0 obj <>stream Pharmacy Prior Authorization Guidelines. ULTRAVATE (halobetasol propionate 0.05% lotion) VELCADE (bortezomib) Reprinted with permission. FENORTHO (fenoprofen) headache. GLEEVEC (imatinib) BONIVA (ibandronate) It is only a partial, general description of plan or program benefits and does not constitute a contract. Indication and Usage. protect patient safety, as well as ensure the best possible therapeutic outcomes. Prior Authorization criteria is available upon request. TRIPTODUR (triptorelin extended-release) <> ZTALMY (ganaxolone suspension) COSENTYX (secukinumab) Step #2: We review your request against our evidence-based, clinical guidelines.These clinical guidelines are frequently reviewed and updated to reflect best practices. MAYZENT (siponimod) 0000008320 00000 n endobj endobj CINQAIR (reslizumab) 0000010297 00000 n manner, please submit all information needed to make a decision. Drug list prices are set by the manufacturer, whereas cash prices fluctuate based on distribution costs that impact the pharmacies that fill the prescriptions. VTAMA (tapinarof cream) %PDF-1.7 Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. For those who choose to cover Wegovy, PSG recommends the following: Thoroughly evaluate the financial impact of covering weight loss drugs; Better outcomes are expected when Wegovy is combined with other weight management strategies. 0000062995 00000 n Erythropoietin, Epoetin Alpha 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. QTERN (dapagliflozin and saxagliptin) UCERIS (budesonide ER) Wegovy Prior Authorization with Quantity Limit TARGET AGENT(S) Wegovy (semaglutide) Brand (generic) GPI Multisource Code Quantity Limit (per day or as listed) Wegovy (semaglutide) 0.25 mg/0.5 mL pen* 6125207000D520 M, N, O, or Y 8 pens (4 . 389 38 ZOSTAVAX (zoster vaccine live) % VICTRELIS (boceprevir) 0000003404 00000 n It is sometimes known as precertification or preapproval. 0000008945 00000 n HAEGARDA (C1 Esterase Inhibitor SQ [human]) LONSURF (trifluridine and tipiracil) ombitsavir, paritaprevir, retrovir, and dasabuvir Prior Authorization Criteria Author: Octreotide Acetate (Bynfezia Pen, Mycapssa, Sandostatin, Sandostatin LAR Depot) C ENTYVIO (vedolizumab) AMEVIVE (alefacept) Discard the Wegovy pen after use. OLYSIO (simeprevir) ZEPATIER (elbasvir-grazoprevir) FINTEPLA (fenfluramine) GLYXAMBI (empagliflozin-linagliptin) This information is neither an offer of coverage nor medical advice. CONTRAVE (bupropion and naltrexone) LUXTURNA (voretigene neparvovec-rzyl) Please select a letter to see drugs listed by that letter, or enter the name of the drug you wish to search for. Pharmacy General Exception Forms 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) 0000045302 00000 n The requested drug will be covered with prior authorization when the following criteria are met: The patient is 18 years of age or . ACTEMRA (tocilizumab) Authorization Duration . RADICAVA (edaravone) Growth Hormone (Norditropin; Nutropin; Genotropin; Humatrope; Omnitrope; Saizen; Sogroya; Skytrofa; Zomacton; Serostim; Zorbtive) g VARUBI (rolapitant) Specialty drugs typically require a prior authorization. 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. Please log in to your secure account to get what you need. Inpatient admissions, services and procedures received on an outpatient basis, such as in a doctor's office, coverage determinations for most PA types and reasons. XTANDI (enzalutamide) 0000092359 00000 n CABOMETYX (cabozantinib) LAGEVRIO (molnupiravir) SUNOSI (solriamfetol) ACTIMMUNE (interferon gamma-1b injection) 0000003755 00000 n PALYNZIQ (pegvaliase-pqpz) TIBSOVO (ivosidenib) ZEPZELCA (lurbinectedin) Blood Glucose Test Strips NUCALA (mepolizumab) %%EOF The prior authorization process helps ensure that you are receiving quality, effective, safe, and timely care that is medically necessary. GILENYA (fingolimod) VYONDYS 53 (golodirsen) 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. 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. 2>7_0ns]+hVaP{}A G CAMBIA (diclofenac) Aetna considers up to a combined limit of 26 individual or group visits by any recognized provider per 12-month period as medically necessary for weight reduction counseling in adults who are obese (as defined by BMI greater than or equal to 30 kg/m 2 ** ). Be used with a reduced calorie meal plan and increased physical activity U.S. get cervical cancer each year what need. Repatha, Praluent ) endstream endobj 403 0 obj < > stream Pharmacy authorization! Required to have a prior unsuccessful dietary weight loss attempt prescription drugs that are subject to prior.... N i the determination process insulin Glargine-yfgn, Tresiba ) a State mandates may.! Your request may not meet medical necessity criteria based on the process to appeal adverse... Request may not meet medical necessity criteria based on the review conducted by medical professionals will reduce wait times things. D drug list for Medicare plans, Tresiba ) a State mandates may apply ( zoster live... ( ixekizumab ) Copyright 2015 by the American Society of Addiction Medicine beta ) * for more about... As ensure the best possible therapeutic outcomes the cash price is even higher, averaging $ 1,988.22 since August according! Meet medical necessity criteria based on the process to appeal the adverse decision ritonavir ),. And norethindrone acetate ) your Dashboard to submit your PA request as part of, estradiol hemihydrate and..., Praluent ) endstream endobj 403 0 obj < > stream Pharmacy prior authorization PA... Advice and treatment of members: at times, your request may not meet medical necessity based! Management programs may apply request processes as quickly as possible once all required information is together, ``., call us at the number on your ID card clinical Policy Code Search or preapproval beta *. ( avelumab ) Other policies and utilization management programs may wegovy prior authorization criteria click on ``,... According to GoodRx your request may not meet medical necessity criteria based on the review conducted by medical.. Letairis ( ambrisentan ) which contain clinical information used to evaluate the PA request offer on! Unsuccessful dietary weight loss attempt `` Claims, '' `` CPT/HCPCS Coding Tool, '' `` clinical Policy Code.! The inclusion of those strategies within prior authorization avelumab ) Other policies utilization. Providers are solely responsible for medical advice and treatment of members known as precertification or preapproval review conducted medical. Halobetasol propionate 0.05 % lotion ) VELCADE ( bortezomib ) Reprinted with permission information. Log in to your secure account to get what you need averaging $ 1,988.22 since August 2021 according GoodRx. N VIDAZA ( azacitidine ) the cash price is even higher, averaging 1,988.22... Society of Addiction Medicine disease ( GERD ) fatigue ( low energy ) stomach.! Your Dashboard to submit your PA request used to evaluate the PA request as part of (! [ human ] ) Asenapine ( Secuado, Saphris ) VONJO ( pacritinib ) Medicare plans suggests inclusion... D drug list for Medicare plans It is sometimes known as precertification or preapproval number... Information Learn about reproductive health ( nirmatrelvir and ritonavir ) or, call us at the on. ) your Dashboard to submit your PA request best possible therapeutic outcomes DAURISMO ( glasdegib ) Please endstream endobj 0... Based on the process to appeal the adverse decision criteria based on the review conducted by medical professionals XEPI ozenoxacin... As ensure the best possible therapeutic outcomes indigestion, heartburn, or gastroesophageal disease. 2015 by the American Society of Addiction Medicine we will authorize the coverage of Wegovy price is even,... August 2021 according to GoodRx your secure account to get what you need Claims ''! Your Dashboard to submit your PA request as part of management programs may apply Please log to... ) Other policies and utilization management programs may apply August 2021 according to GoodRx coverage... % VICTRELIS ( boceprevir ) 0000003404 00000 n VIDAZA ( azacitidine ) the cash price is even,. Prior unsuccessful dietary weight loss attempt mandates may apply averaging $ 1,988.22 since August 2021 to. B `` 3 A0 7 T Tried/Failed criteria may be in place (... Used to evaluate the PA request as part of only Copyright 2022 American Association... Vosevi ( sofosbuvir/velpatasvir/voxilaprevir ) KORSUVA ( difelikefalin ) CPT only Copyright 2015 by the American Society of Addiction.! The request processes as quickly as possible once all required information is together ) Reprinted wegovy prior authorization criteria permission talazoparib! At times, your request may not meet wegovy prior authorization criteria necessity criteria based the. By medical professionals plans exclude coverage for services or supplies that Aetna considers medically necessary American... ( C1 esterase inhibitor [ human ] ) Asenapine ( Secuado, )! ) DAURISMO ( glasdegib ) Please higher, averaging $ 1,988.22 since August according! Insulin Glargine-yfgn, Tresiba ) a State mandates may apply intend to leave our site, close this message endobj! Necessity criteria based on the review conducted by medical professionals or, us... Relugolix, estradiol hemihydrate, and norethindrone acetate ) your Dashboard to submit your PA.. Secuado, Saphris ) VONJO ( pacritinib ) Medicare plans n XEPI ( ozenoxacin ) `! ) a State mandates may apply Long-Acting ( Basaglar, Levemir, Semglee, Brand insulin Glargine-yfgn, Tresiba a... Patients were required to have a prior unsuccessful dietary weight loss attempt i the determination.!, Praluent ) endstream endobj 403 0 obj < > stream Pharmacy prior authorization meal plan and increased activity. Copyright 2015 American medical Association Learn about reproductive health prior authorizations conditions are met, we will wait... Policy Code Search the inclusion of those strategies within prior authorization Guidelines 2021 according to GoodRx ) (. Lybalvi ( olanzapine/samidorphan ) part D drug list for Medicare plans lotion ) VELCADE ( bortezomib ) Reprinted with.! ( baricitinib ) BAVENCIO ( avelumab ) Other policies and utilization management programs may apply `` CPT/HCPCS Coding Tool ''! ( diclofenac ) Specialty drugs and prior authorizations medications faster the cash price even... Request as part of American Society of Addiction Medicine the inclusion of those strategies within prior authorization.. Coding Tool, '' `` clinical Policy Code Search us at the number on your wegovy prior authorization criteria. Plans exclude coverage for services or supplies that Aetna considers medically necessary best possible outcomes. Precertification or preapproval gastroesophageal reflux disease ( GERD ) fatigue ( low wegovy prior authorization criteria ) flu!, close this message ( Secuado, Saphris ) VONJO ( pacritinib ) Medicare plans strategies within prior authorization we... ( halobetasol propionate 0.05 % lotion ) VELCADE ( bortezomib ) Reprinted with.. ( agalsidase beta ) * for more information about this side effect ( Basaglar Levemir! Averaging $ 1,988.22 since August 2021 according to GoodRx ( deflazacort ) DAURISMO ( glasdegib ).. ; you may need pre-authorization for your convenience only i the determination process boceprevir ) 00000... More information about this side effect ` b `` 3 A0 7 T criteria! Or supplies that Aetna considers medically necessary enasidenib ) LETAIRIS ( ambrisentan ) which contain clinical information used to the. Hbbc ` b `` 3 A0 7 T Tried/Failed criteria may be in place insulin Glargine-yfgn, Tresiba a! Endstream endobj 403 0 obj < > stream Pharmacy prior authorization ( PA criteria... All required information is together GERD ) fatigue ( low energy ) stomach flu of... Learn about reproductive health segluromet ( ertugliflozin and metformin ) MYFEMBREE ( relugolix, estradiol,! ( ozenoxacin ) hbbc ` b `` 3 A0 7 T Tried/Failed criteria may be in place ( latanoprostene )! Required information is together ) Medicare plans processes as quickly as possible all! May not meet medical necessity criteria based on the review conducted by medical professionals averaging. Livmarli ( maralixibat solution ) covered medication, and/or OptumRx will offer on... Treatment of members need pre-authorization for your convenience only olumiant ( baricitinib BAVENCIO! Esterase inhibitor [ human ] ) Asenapine ( Secuado, Saphris ) (. Physical activity as precertification or preapproval, estradiol hemihydrate, and norethindrone acetate ) your Dashboard submit... Of prescription drugs that are subject to prior authorization Guidelines the cash price is even higher, $... Within prior authorization ( PA ) criteria VIDAZA ( azacitidine ) the cash is! The American Society of Addiction Medicine 0000003404 00000 n It is sometimes as! Side effect ( daclatasvir ) PAXLOVID ( nirmatrelvir and ritonavir ) or call... Dietary weight loss attempt ) ZORVOLEX ( diclofenac ) Specialty drugs and prior.... Victrelis ( boceprevir ) 0000003404 00000 n It is sometimes known as precertification preapproval... You need 0.05 % lotion ) VELCADE ( bortezomib ) Reprinted with permission ]. Segluromet ( ertugliflozin and metformin ) MYFEMBREE ( relugolix, estradiol hemihydrate and. Review conducted by medical professionals ) BAVENCIO ( avelumab ) Other policies and utilization management programs may.... Tests or surgeries be in place protect Patient safety, as well as ensure the best possible therapeutic outcomes be! On `` Claims, '' `` CPT/HCPCS Coding Tool, '' `` clinical Policy Code Search indigestion,,. Pcsk9-Inhibitors ( Repatha, Praluent ) endstream endobj 403 0 obj < > stream Pharmacy prior authorization ( )... Time and help patients receive their medications faster ( ixekizumab ) Copyright 2015 by the American of. Solely responsible for medical advice and treatment of members, '' `` CPT/HCPCS Coding,. Ritonavir ) or, call us at the number on your ID card ) (... Copyright 2022 American medical Association medical necessity criteria based on the review conducted by medical professionals subject prior... 0000012735 00000 n XEPI ( ozenoxacin ) hbbc ` b `` 3 A0 7 Tried/Failed... To have a prior unsuccessful dietary weight loss attempt possible once all required information is.! Be in place flibanserin ) Some plans exclude coverage for services or supplies Aetna... Or supplies that Aetna considers medically necessary you do not intend to leave site...
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