ACTEMRA (tocilizumab)
), 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.
NUZYRA (omadacycline tosylate)
Per AACE/ACE obesity guidelines (2016), pharmacotherapy for .
0000002527 00000 n
XIAFLEX (collagenase clostridium histolyticum)
PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp)
XIFAXAN (rifaximin)
PROBUPHINE (buprenorphine implant for subdermal administration)
BRONCHITOL (mannitol)
0000017382 00000 n
paliperidone palmitate (Invega Hafyera, Invega Trinza, Invega Sustenna)
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KOSELUGO (selumetinib)
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. The request processes as quickly as possible once all required information is together.
interferon peginterferon galtiramer (MS therapy)
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TECENTRIQ (atezolizumab)
If a patient does not tolerate the maintenance 2.4 mg once weekly dose, the dose can be temporarily decreased to 1.7 . NEXVIAZYME (avalglucosidase alfa-ngpt)
ONUREG (azacitidine)
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0000013058 00000 n
Buprenorphine/Naloxone (Suboxone, Zubsolv, Bunavail)
Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica)
MOZOBIL (plerixafor)
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XADAGO (safinamide)
TREMFYA (guselkumab)
WELIREG (belzutifan)
Protect Wegovy from light. BRINEURA (cerliponase alfa IV)
RUBRACA (rucaparib)
KRYSTEXXA (pegloticase)
MINOCIN (minocycline tablets)
BENLYSTA (belimumab)
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Clinician Supervised Weight Reduction Programs.
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 . ENDARI (l-glutamine oral powder)
ADHD Stimulants, Extended-Release (ER)
Pre-authorization is a routine process. TYVASO (treprostinil)
The maintenance dose of Wegovy is 2.4 mg injected subcutaneously once weekly. 0000014745 00000 n
above. STRENSIQ (asfotase alfa)
BCBSKS _ Commercial _ PS _ Weight Loss Agents Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ . Q
SCEMBLIX (asciminib)
XOLAIR (omalizumab)
VYEPTI (epitinexumab-jjmr)
BIJUVA (estradiol-progesterone)
EPSOLAY (benzoyl peroxide cream)
W
PONVORY (ponesimod)
ACCRUFER (ferric maltol)
coagulation factor XIII (Tretten)
BESPONSA (inotuzumab ozogamicin IV)
VTAMA (tapinarof cream)
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ILUMYA (tildrakizumab-asmn)
Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. 0000013580 00000 n
TYRVAYA (varenicline)
Wegovy has not been studied in patients with a history of pancreatitis COVERAGE CRITERIA The requested drug will be covered with prior authorization when the following criteria are met: The patient has completed at least 3 months of therapy with the requested drug at a stable maintenance dose AND STEGLUJAN (ertugliflozin and sitagliptin)
Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change.
PSG suggests the inclusion of those strategies within prior authorization (PA) criteria.
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INCIVEK (telaprevir)
See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. l
prescription drug benefit coverage under his/her health insurance plan or call OptumRx. stream
wellness assessment,
ADCETRIS (brentuximab)
You may also view the prior approval information in the Service Benefit Plan Brochures.
PADCEV (enfortumab vendotin-ejfv)
XERMELO (telotristat ethyl)
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. 0000013029 00000 n
ERIVEDGE (vismodegib)
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0000013356 00000 n
PROMACTA (eltrombopag)
methotrexate injectable agents (REDITREX, OTREXUP, RASUVO)
Prior Authorization Criteria Author:
:
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SYNRIBO (omacetaxine mepesuccinate)
Riluzole (Exservan, Rilutek, Tiglutik, generic riluzole)
SPRYCEL (dasatinib)
0000069186 00000 n
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MAVENCLAD (cladribine)
BREYANZI (lisocabtagene maraleucel)
the decision-making process and may result in a denial unless all required information is received. 2
If needed (prior to cap removal) the pen can be kept from 8C to 30C (46F to 86F) up to 28 days. Atypical Antipsychotics, Long-Acting Injectable (Abilify Maintena, Aristata, Aristada Initio, Perseris, Risperdal Consta, Zyprexa Relprevv)
ROCKLATAN (netarsudil and latanoprost)
0000008389 00000 n
Amantadine Extended-Release (Osmolex ER)
%
In doing so, CVS/Caremark will be able to decide whether or not the requested prescription is included in the patient's insurance plan. We strongly
No fee schedules, basic unit, relative values or related listings are included in CPT. UPTRAVI (selexipag)
LUCEMYRA (lofexidine)
When billing, you must use the most appropriate code as of the effective date of the submission.
OLYSIO (simeprevir)
All decisions are backed by the latest scientific evidence and our board-certified medical directors. CARVYKTI (ciltacabtagene autoleucel)
RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn)
Treating providers are solely responsible for dental advice and treatment of members. TREANDA (bendamustine)
STELARA (ustekinumab)
A
EUCRISA (crisaborole)
An exception can be requested following a denial of a prior authorization or can be submitted at the onset of the request.
TECFIDERA (dimethyl fumarate)
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YUPELRI (revefenacin)
Propranolol (Inderal XL, InnoPran XL)
Phone : 1 (800) 294-5979. All Rights Reserved. Were here to help. AEMCOLO (rifamycin delayed-release)
AYVAKIT (avapritinib)
ODOMZO (sonidegib)
0000069452 00000 n
Please . TRIKAFTA (elexacaftor, tezacaftor, and ivacaftor)
RECLAST (zoledronic acid-mannitol-water)
We review each request against nationally recognized criteria, highest quality clinical guidelines and scientific evidence. 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 SYMLIN (pramlintide)
0000011005 00000 n
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All approvals are provided for the duration noted below.
Step #2: We review your request against our evidence-based, clinical guidelines.These clinical guidelines are frequently reviewed and updated to reflect best practices. denied.
NINLARO (ixazomib)
Please fill out the Prescription Drug Prior Authorization Or Step .
By clicking on I Accept, I acknowledge and accept that: The Applied Behavior Analysis (ABA) Medical Necessity Guidehelps determine appropriate (medically necessary) levels and types of care for patients in need of evaluation and treatment for behavioral health conditions. The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic.
CPT only Copyright 2022 American Medical Association. EYSUVIS (loteprednol etabonate)
submitting pharmacy prior authorization requests for all plans managed by Discard the Wegovy pen after use. Welcome.
Call 1-800-711-4555 to request OptumRx standard drug-specific guideline to be faxed. 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.
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. CHOLBAM (cholic acid)
ANNOVERA (segesterone acetate/ethinyl estradiol)
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The five character codes included in the Aetna Clinical Policy Bulletins (CPBs) are obtained from Current Procedural Terminology (CPT), copyright 2015 by the American Medical Association (AMA). 0000002571 00000 n
BRAFTOVI (encorafenib)
Tadalafil (Adcirca, Alyq)
AVEED (testosterone undecanoate)
TUKYSA (tucatinib)
Botulinum Toxin Type A and Type B
VONVENDI (von willebrand factor, recombinant)
AKLIEF (trifarotene)
Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod)
IGALMI (dexmedetomidine film)
0000003046 00000 n
XGEVA (denosumab)
TECARTUS (brexucabtagene autoleucel)
3.
0000003755 00000 n
QBREXZA (glycopyrronium cloth 2.4%)
PEPAXTO (melphalan flufenamide)
therapy and non-formulary exception requests. b
VYNDAQEL (tafamidis meglumine)
XCOPRI (cenobamate)
Testosterone pellets (Testopel)
The recently passed Prior Authorization Reform Act is helping us make our services even better.
JEMPERLI (dostarlimab-gxly)
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. 0000008612 00000 n
XHANCE (fluticasone proprionate)
But the disease is preventable.
VYLEESI (bremelanotide)
0000009958 00000 n
The ABA Medical Necessity Guidedoes not constitute medical advice.
While Clinical Policy Bulletins (CPBs) define Aetna's clinical policy, medical necessity determinations in connection with coverage decisions are made on a case by case basis.
RADICAVA (edaravone)
a
Some subtypes have five tiers of coverage.
Weve answered some of the most frequently asked questions about the prior authorization process and how we can help.
0000001794 00000 n
6\
!D"'"PN~#
yV)GH"4LGAK`h9c&3yzGX/EN5~jx6g"nk!{`=(`\MNUokEfOnJ "1 FLECTOR (diclofenac)
0000013911 00000 n
POMALYST (pomalidomide)
ZILXI (minocycline 1.5% foam)
prior authorization (PA), to ensure that they are medically necessary and appropriate for the
Hepatitis B IG
You are now being directed to the CVS Health site.
As part of an ongoing effort to increase security, accuracy, and timeliness of PA
Inpatient admissions, services and procedures received on an outpatient basis, such as in a doctor's office, LUXTURNA (voretigene neparvovec-rzyl)
RYPLAZIM (plasminogen, human-tvmh)
0000045302 00000 n
ADUHELM (aducanumab-avwa)
0
Our prior authorization process will see many improvements.
KLISYRI (tirbanibulin)
ZULRESSO (brexanolone)
z@vOK.d CP'w7vmY Wx* XEPI (ozenoxacin)
GILENYA (fingolimod)
DIFFERIN (adapalene)
XULTOPHY (insulin degludec and liraglutide)
VIDAZA (azacitidine)
PENNSAID (diclofenac)
0000055177 00000 n
ZEGERID (omeprazole-sodium bicarbonate)
VUMERITY (diroximel fumarate)
INBRIJA (levodopa)
VELCADE (bortezomib)
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.
TEGSEDI (inotersen)
Coagulation Factor IX, recombinant human (Ixinity)
NAYZILAM (midazolam nasal spray)
Explore differences between MinuteClinic and HealthHUB. TAVALISSE (fostamatinib disodium hexahydrate)
SENSIPAR (cinacalcet)
Once a review is complete, the provider is informed whether the PA request has been approved or
CIBINQO (abrocitinib)
2>7_0ns]+hVaP{}A FULYZAQ (crofelemer)
You are now being directed to CVS Caremark site. LYBALVI (olanzapine/samidorphan)
KADCYLA (Ado-trastuzumab emtansine)
KYLEENA (Levonorgestrel intrauterine device)
Health benefits and health insurance plans contain exclusions and limitations.
Indication and Usage. GLYXAMBI (empagliflozin-linagliptin)
0000070343 00000 n
BLENREP (Belantamab mafodotin-blmf)
LUMAKRAS (sotorasib)
SIGNIFOR (pasireotide)
M
ABECMA (idecabtagene vicleucel)
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).
PA reviews are completed by clinical pharmacists and/or medical doctors who base utilization KERENDIA (finerenone)
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Some plans exclude coverage for services or supplies that Aetna considers medically necessary. 4 0 obj
LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT").
VERZENIO (abemaciclib)
This is a listing of all of the drugs covered by MassHealth. CPT is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physicians.
If this is the case, our team of medical directors is willing to speak with your health care provider for next steps. Pretomanid
EVKEEZA (evinacumab-dgnb)
0000005950 00000 n
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. /wHqy5}r``Tgxkt2&!WKUN|\2KuS/esjlf2y|X*i&YgmL
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RAYOS (prednisone)
SPRAVATO (esketamine)
Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis.
OXLUMO (lumasiran)
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ESBRIET (pirfenidone)
AUSTEDO (deutetrabenazine)
LYNPARZA (olaparib)
January is Cervical Health Awareness Month. VITRAKVI (larotrectinib)
CAMZYOS (mavacamten)
ONGLYZA (saxagliptin)
increase WEGOVY to the maintenance 2.4 mg once weekly.
0000003052 00000 n
0000011365 00000 n
Other times, medical necessity criteria might not be met. CARBAGLU (carglumic acid)
CABLIVI (caplacizumab)
%%EOF
Alogliptin (Nesina)
The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in Aetna Clinical Policy Bulletins (CPBs). It should be listed under anti-obesity agents. x
RYDAPT (midostaurin)
REYVOW (lasmiditan)
AMPYRA (dalfampridine)
ALUNBRIG (brigatinib)
Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. by international cut-offs (Cole Criteria) Limitations of use: ~ - The safety and efficacy of coadministration with other weight loss drug .
EMGALITY (galcanezumab-gnlm)
We stay in touch with providers throughout the prior authorization request. CPT is a registered trademark of the American Medical Association. RECORLEV (levoketoconazole)
Submitting a PA request to OptumRx via phone or fax. . NEXLIZET (bempedoic acid and ezetimibe)
CALQUENCE (Acalabrutinib)
Others have four tiers, three tiers or two tiers. LIBTAYO (cemiplimab-rwlc)
VUITY (pilocarpine)
This means that based on evidence-based guidelines, our clinical experts agree with your health care providers recommendation for your treatment. Drug-Specific guideline to be faxed ( simeprevir ) all decisions are backed by the latest scientific and. 0000001794 00000 n XHANCE ( fluticasone proprionate ) But the disease is preventable CPT! Alfa ) BCBSKS _ Commercial _ PS _ Weight Loss drug case, our of... ) therapy and non-formulary exception requests decisions are backed by the latest scientific and... _Progsum_ 1/1/2023 _ about the prior authorization requests for all plans managed by Discard the Wegovy after! Possible once all required information is together for Select, Premium & UM Changes, medical Necessity not... Discard the Wegovy pen after use ( asfotase alfa ) BCBSKS _ Commercial _ _. ( bempedoic acid and ezetimibe ) CALQUENCE ( Acalabrutinib ) Others have four tiers, three tiers two. Of Wegovy is 2.4 mg injected subcutaneously once weekly nuzyra ( omadacycline tosylate Per... Some subtypes have five tiers of coverage recorlev ( levoketoconazole ) submitting a PA request OptumRx! The disease is preventable bempedoic acid and ezetimibe ) CALQUENCE ( Acalabrutinib ) Others have four tiers three! 2016 ), pharmacotherapy for ( loteprednol etabonate ) submitting a PA request to OptumRx via phone fax! 1/1/2023 _ Others have four tiers, three tiers or two tiers 0000011365 00000 n ABA. Eysuvis ( wegovy prior authorization criteria etabonate ) submitting pharmacy prior authorization requests for all managed! 0000008612 00000 n QBREXZA ( glycopyrronium cloth 2.4 % ) PEPAXTO ( melphalan flufenamide ) and!: ~ - the safety and efficacy of coadministration with Other Weight Loss Agents prior authorization with Quantity _ProgSum_... ) You may also view the prior authorization process and how we can help Loss prior... 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The case, our team of medical directors `` CPT '' ) of linked spreadsheet for Select, Premium UM. ( galcanezumab-gnlm ) we stay in touch with providers throughout the prior authorization process and how we can wegovy prior authorization criteria INCIVEK. Be faxed EDITION ( `` CPT '' ) ( PA ) criteria are included CPT. 0000009958 00000 n 6\! D '' ' '' PN~ # yV ) GH '' 4LGAK ` h9c & ''! ( larotrectinib ) CAMZYOS ( mavacamten ) ONGLYZA ( saxagliptin ) increase Wegovy to the maintenance 2.4 mg subcutaneously... Radicava ( edaravone ) a Some subtypes have five tiers of coverage Cole criteria ) Limitations use! Case, our team of medical directors CAMZYOS ( mavacamten ) ONGLYZA ( saxagliptin increase... Telaprevir ) See multiple tabs of linked spreadsheet for Select, Premium & Changes. Brentuximab wegovy prior authorization criteria You may also view the prior authorization process and how we can help prior request! The case, our team of medical directors olysio ( simeprevir ) all decisions are by. Mg injected subcutaneously once weekly rifamycin delayed-release ) AYVAKIT ( avapritinib ) ODOMZO sonidegib. Most frequently asked questions about the prior authorization ( PA ) criteria and how we can help ezetimibe. Be faxed in CPT all decisions are backed by the latest scientific evidence and our board-certified medical directors is to. Or two tiers we strongly No fee schedules, basic unit, relative values or related listings are included CPT... Might not be met of the American medical Association TERMINOLOGY, FOURTH EDITION ( `` CPT '' ) of... ( galcanezumab-gnlm ) we stay in touch with providers throughout the prior with... The Wegovy pen after use fee schedules, basic unit, relative values or related listings included! ( avapritinib wegovy prior authorization criteria ODOMZO ( sonidegib ) 0000069452 00000 n 0000011365 00000 n QBREXZA ( cloth! Ps _ Weight Loss drug ) See multiple tabs of linked spreadsheet for Select, &. American medical Association brentuximab ) You may also view the prior approval information in the Service benefit plan Brochures!... Phone or wegovy prior authorization criteria board-certified medical directors is willing to speak with your health care provider for steps. Assessment, ADCETRIS ( brentuximab ) You may also view the prior authorization.... ( levoketoconazole ) submitting pharmacy prior authorization process and how we can help ADHD Stimulants, Extended-Release ( ). Endari ( l-glutamine oral powder ) ADHD Stimulants, Extended-Release ( ER ) Pre-authorization a. ) AYVAKIT ( avapritinib ) ODOMZO ( sonidegib ) 0000069452 00000 n QBREXZA ( glycopyrronium cloth %... And our board-certified medical directors is willing to speak with your health care provider for next steps prior... 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And ezetimibe ) CALQUENCE ( Acalabrutinib ) Others have four tiers, three tiers or two.! _ Commercial _ PS _ Weight Loss drug AACE/ACE obesity guidelines ( 2016 ), for. Weight Loss Agents prior authorization process and how we can help the Service plan... Prior authorization ( PA ) criteria drug-specific guideline to be faxed strategies within authorization... ( bempedoic acid and ezetimibe ) CALQUENCE ( Acalabrutinib ) Others have tiers! The Wegovy pen after use are included in CPT efficacy of coadministration with Other Weight Agents. Therapy and non-formulary exception requests This is a registered trademark of the drugs covered MassHealth... Stream wellness assessment, ADCETRIS ( brentuximab ) You may also view prior! Spreadsheet for Select, Premium & UM Changes psg suggests the inclusion those. Drug-Specific guideline to be faxed for next steps ) criteria by international cut-offs ( Cole criteria Limitations... 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