AUVI-Q (epinephrine) But the disease is preventable. NPLATE (romiplostim) I was just informed by my insurance (UnitedHealthcare) that the Ozempic Rx that Calibrate ordered for me was denied because I am not diabetic. An exception can be requested following a denial of a prior authorization or can be submitted at the onset of the request. PROLIA (denosumab) b RECARBRIO (imipenem, cilastin and relebactam) A $25 copay card provided by the manufacturer may help ease the cost but only if . Asenapine (Secuado, Saphris) PENNSAID (diclofenac) KRINTAFEL (tafenoquine) COSENTYX (secukinumab) REVATIO (sildenafil citrate) Welcome. CIALIS (tadalafil) NAPRELAN (naproxen) All decisions are backed by the latest scientific evidence and our board-certified medical directors. SOTYKTU (deucravacitinib) 3 0 obj PLEGRIDY (peginterferon beta-1a) xref U EXJADE (deferasirox) ! Z3mo5&/ ^fHx&,=dtbX,DGjbWo.AT+~D.yVc$o5`Jkxyk+ln 5mA78+7k}HZX*-oUcR);"D:K@8hW]j {v$pGvX 14Tw1Eb-c{Hpxa_/=Z=}E. ", The five character codes included in the Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology (CPT. 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). Specialty drugs typically require a prior authorization. MYRBETRIQ (mirabegron granules) TIVORBEX (indomethacin) Pharmacy Prior Authorization Guidelines. 2>7_0ns]+hVaP{}A NEXAVAR (sorafenib) ORTIKOS (budesonide ER) EYLEA (aflibercept) FLEQSUVY, OZOBAX, LYVISPAH (baclofen) SEGLUROMET (ertugliflozin and metformin) TUKYSA (tucatinib) ILUMYA (tildrakizumab-asmn) B XPOVIO (selinexor) Unlisted, unspecified and nonspecific codes should be avoided. The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. 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 GAVRETO (pralsetinib) SUPPRELIN LA (histrelin SC implant) Link to the Concomitant Opioid Benzodiazepine, Pediatric Behavioral Health Medication, Hospital Outpatient Prior Authorization, Opioid and Pain, and Second-Generation (Atypical) Antipsychotic Initiatives. POMALYST (pomalidomide) 2493 0 obj <> endobj Pretomanid F k PEMAZYRE (pemigatinib) 0000005437 00000 n QELBREE (viloxazine extended-release) EYSUVIS (loteprednol etabonate) PA information for MassHealth providers for both pharmacy and nonpharmacy services. 0000069922 00000 n MEKINIST (trametinib) CEQUA (cyclosporine) INREBIC (fedratinib) 2 0 obj ENBREL (etanercept) Capsaicin Patch 0000013911 00000 n upQz:G Cs }%u\%"4}OWDw FORTAMET ER (metformin) 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 RETEVMO (selpercatinib) ULORIC (febuxostat) XEMBIFY (immune globulin subcutaneous, human klhw) CONTRAVE (bupropion and naltrexone) 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. MULPLETA (lusutrombopag) VIDAZA (azacitidine) It would definitely be a good idea for your doctor to document that you have made attempts to lose weight, as this is one of the main criteria. ZERVIATE (cetirizine) 0000003936 00000 n ZEPATIER (elbasvir-grazoprevir) IMCIVREE (setmelanotide) In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. Please call us at 800.753.2851 to submit a verbal prior authorization request if you are unable to use Electronic Prior Authorization. 0000004700 00000 n If you have been affected by a natural disaster, we're here to help: ACTIMMUNE (interferon gamma-1b injection), Allergen Immunotherapy Agents (Grastek, Odactra, Oralair, Ragwitek), Angiotensin Receptor Blockers (e.g., Atacand, Atacand HCT, Tribenzor, Edarbi, Edarbyclor, Teveten), ANNOVERA (segesterone acetate/ethinyl estradiol), Antihemophilic Factor [recombinant] pegylated-aucl (Jivi), Antihemophilic Factor VIII, Recombinant (Afstyla), Antihemophilic Factor VIII, recombinant (Kovaltry), Atypical Antipsychotics, Long-Acting Injectable (Abilify Maintena, Aristata, Aristada Initio, Perseris, Risperdal Consta, Zyprexa Relprevv), Buprenorphine/Naloxone (Suboxone, Zubsolv, Bunavail), Coagulation Factor IX, (recombinant), Albumin Fusion Protein (Idelvion), Coagulation Factor IX, recombinant human (Ixinity), Coagulation Factor IX, recombinant, glycopegylated (Rebinyn), Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod), DELATESTRYL (testosterone cypionate 100mg/ml; 200mg/ml), DELESTROGEN (estradiol valerate injection), DUOBRII (halobetasol propionate and tazarotene), DURLAZA (aspirin extended-release capsules), Filgrastim agents (Nivestym, Zarxio, Neupogen, Granix, Releuko), FYARRO (sirolimus protein-bound particles), GLP-1 Agonists (Bydureon, Bydureon BCise, Byetta, Ozempic, Rybelsus, Trulicity, Victoza, Adlyxin) & GIP/GLP-1 Agonist (Mounjaro), Growth Hormone (Norditropin; Nutropin; Genotropin; Humatrope; Omnitrope; Saizen; Sogroya; Skytrofa; Zomacton; Serostim; Zorbtive), HAEGARDA (C1 Esterase Inhibitor SQ [human]), HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk), Hyaluronic Acid derivatives (Synvisc, Hyalgan, Orthovisc, Euflexxa, Supartz), Infliximab Agents (REMICADE, infliximab, AVSOLA, INFLECTRA, RENFLEXIS), Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba), Insulin Rapid Acting (Admelog, Apidra, Fiasp, Insulin Lispro [Humalog ABA], Novolog, Insulin Aspart [Novolog ABA], Novolog ReliOn), Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn), Interferon beta-1a (Avonex, Rebif/Rebif Rebidose), interferon peginterferon galtiramer (MS therapy), Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica), KOMBIGLYZE XR (saxagliptin and metformin hydrochloride, extended release), KYLEENA (Levonorgestrel intrauterine device), Long-Acting Muscarinic Antagonists (LAMA) (Tudorza, Seebri, Incruse Ellipta), Low Molecular Weight Heparins (LMWH) - FRAGMIN (dalteparin), INNOHEP (tinzaparin), LOVENOX (enoxaparin), ARIXTRA (fondaparinux), LUTATHERA (lutetium 1u 177 dotatate injection), methotrexate injectable agents (REDITREX, OTREXUP, RASUVO), MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate), NATPARA (parathyroid hormone, recombinant human), NUEDEXTA (dextromethorphan and quinidine), Octreotide Acetate (Bynfezia Pen, Mycapssa, Sandostatin, Sandostatin LAR Depot), ombitsavir, paritaprevir, retrovir, and dasabuvir, ONPATTRO (patisiran for intravenous infusion), Opioid Coverage Limit (initial seven-day supply), ORACEA (doxycycline delayed-release capsule), ORIAHNN (elagolix, estradiol, norethindrone), OZURDEX (dexamethasone intravitreal implant), PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp), paliperidone palmitate (Invega Hafyera, Invega Trinza, Invega Sustenna), Pancrelipase (Pancreaze; Pertyze; Viokace), Pegfilgrastim agents (Neulasta, Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo), PHEXXI (lactic acid, citric acid, and potassium bitartrate), PROBUPHINE (buprenorphine implant for subdermal administration), RECARBRIO (imipenem, cilastin and relebactam), Riluzole (Exservan, Rilutek, Tiglutik, generic riluzole), RITUXAN HYCELA (rituximab and hyaluronidase), RUCONEST (recombinant C1 esterase inhibitor), RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn), Sodium oxybate (Xyrem); calcium, magnesium, potassium, and sodium oxybates (Xywav), SOLIQUA (insulin glargine and lixisenatide), STEGLUJAN (ertugliflozin and sitagliptin), Subcutaneous Immunoglobulin (SCIG) (Hizentra, HyQvia), SYMTUZA (darunavir, cobicistat, emtricitabine, and tenofovir alafenamide tablet ), TARPEYO (budesonide capsule, delayed release), TAVALISSE (fostamatinib disodium hexahydrate), TECHNIVIE (ombitasvir, paritaprevir, and ritonavir), Testosterone oral agents (JATENZO, TLANDO), TRIJARDY XR (empagliflozin, linagliptin, metformin), TRIKAFTA (elexacaftor, tezacaftor, and ivacaftor), TWIRLA (levonorgestrel and ethinyl estradiol), ULTRAVATE (halobetasol propionate 0.05% lotion), VERKAZIA (cyclosporine ophthalmic emulsion), VESICARE LS (solifenacin succinate suspension), VIEKIRA PAK (ombitasvir, paritaprevir, ritonavir, and dasabuvir), VONVENDI (von willebrand factor, recombinant), VOSEVI (sofosbuvir/velpatasvir/voxilaprevir), Weight Loss Medications (phentermine, Adipex-P, Qsymia, Contrave, Saxenda, Wegovy), XEMBIFY (immune globulin subcutaneous, human klhw), XIAFLEX (collagenase clostridium histolyticum), XIPERE (triamcinolone acetonide injectable suspension), XULTOPHY (insulin degludec and liraglutide), ZOLGENSMA (onasemnogene abeparvovec-xioi). MINOCIN (minocycline tablets) Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". FENORTHO (fenoprofen) DOJOLVI (triheptanoin liquid) *Praluent is typically excluded from coverage. ARALEN (chloroquine phosphate) ADLARITY (donepezil hydrochloride patch) endobj 0000001751 00000 n Coagulation Factor IX, (recombinant), Albumin Fusion Protein (Idelvion) 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. Call 1-800-711-4555 to request OptumRx standard drug-specific guideline to be faxed. TYVASO (treprostinil) TWIRLA (levonorgestrel and ethinyl estradiol) 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. Coverage of drugs is first determined by the member's pharmacy or medical benefit. % FINTEPLA (fenfluramine) by international cut-offs (Cole Criteria) Limitations of use: ~ - The safety and efficacy of coadministration with other weight loss drug . 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. 0000011411 00000 n TREANDA (bendamustine) n 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). In the event that a member disagrees with a coverage determination, member may be eligible for the right to an internal appeal and/or an independent external appeal in accordance with applicable federal or state law. endstream endobj 425 0 obj <>/Filter/FlateDecode/Index[21 368]/Length 35/Size 389/Type/XRef/W[1 1 1]>>stream CARVYKTI (ciltacabtagene autoleucel) Type in Wegovy and see what it says. ZOSTAVAX (zoster vaccine live) Phone : 1 (800) 294-5979. Step #1: Your health care provider submits a request on your behalf. hA 04Fv\GczC. Wegovy will be used concomitantly with behavioral modification and a reduced-calorie diet . PEPAXTO (melphalan flufenamide) CPT is a registered trademark of the American Medical Association. The prior authorization process helps ensure that you are receiving quality, effective, safe, and timely care that is medically necessary. Prior Authorization Resources. 0000002704 00000 n TASIGNA (nilotinib) AZEDRA (Iobenguane I-131) ICLUSIG (ponatinib) If a patient does not tolerate the maintenance 2.4 mg once weekly dose, the dose can be temporarily decreased to 1.7 . J NERLYNX (neratinib) Attached is a listing of prescription drugs that are subject to prior authorization. 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. ZYFLO (zileuton) ROZLYTREK (entrectinib) SOLARAZE (diclofenac) XTAMPZA ER (oxycodone) <> PLAQUENIL (hydroxychloroquine) So far, all weight loss drugs are 'excluded' from coverage for my specific employer's contracted plan. 0000002376 00000 n SIMPONI, SIMPONI ARIA (golimumab) TURALIO (pexidartinib) Viewand print a PA request form, For urgent requests, please call us at 1-800-711-4555. Fax: 1-855-633-7673. BARHEMSYS (amisulpride) EVENITY (romosozumab-aqqg) 2545 0 obj <>stream 389 0 obj <> endobj ACTIMMUNE (interferon gamma-1b injection) TROGARZO (ibalizumab-uiyk) ENTYVIO (vedolizumab) AMVUTTRA (vutrisiran) Octreotide Acetate (Bynfezia Pen, Mycapssa, Sandostatin, Sandostatin LAR Depot) denied. VYEPTI (epitinexumab-jjmr) Y 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. You can download the Aetna Health app on the App Store (Apple devices) or Google Play (Android devices). KRYSTEXXA (pegloticase) APOKYN (apomorphine) CALQUENCE (Acalabrutinib) 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. All approvals are provided for the duration noted below. GALAFOLD (migalastat) ORACEA (doxycycline delayed-release capsule) ALUNBRIG (brigatinib) NORTHERA (droxidopa) PALYNZIQ (pegvaliase-pqpz) e <>/Metadata 133 0 R/ViewerPreferences 134 0 R>> ERLEADA (apalutamide) MinuteClinic at CVS is a convenient retail clinic that you'll find in select CVS Pharmacyand Target stores. ANNOVERA (segesterone acetate/ethinyl estradiol) Propranolol (Inderal XL, InnoPran XL) HETLIOZ/HETLIOZ LQ (tasimelton) constipation *. This search will use the five-tier subtype. types (step therapy, PA, initial or reauthorization) and approval criteria, duration, effective Testosterone pellets (Testopel) If patients do not tolerate the maintenance 2.4 mg once-weekly dosage, the dosage can be temporarily decreased to 1.7 mg once weekly, for a maximum of 4 weeks. your Dashboard to submit your PA request. TAFINLAR (dabrafenib) Amantadine Extended-Release (Osmolex ER) 0000012711 00000 n * For more information about this side effect . NOCDURNA (desmopressin acetate) TAZVERIK (tazematostat) Coagulation Factor IX, recombinant, glycopegylated (Rebinyn) ZEGERID (omeprazole-sodium bicarbonate) Riluzole (Exservan, Rilutek, Tiglutik, generic riluzole) GLYXAMBI (empagliflozin-linagliptin) Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change. Prior review (prior plan approval, prior authorization, prospective review or certification) is the process BCBSNC uses to review the provision of certain medical services and medications against health care management guidelines prior to the services being provided. TABRECTA (capmatinib) D ACTHAR (corticotropin) Aetna defines a service as "never effective" when it is not recognized according to professional standards of safety and effectiveness in the United States for diagnosis, care or treatment. ZOLGENSMA (onasemnogene abeparvovec-xioi) You, your employees and agents are authorized to use CPT only as contained in Aetna Clinical Policy Bulletins (CPBs) solely for your own personal use in directly participating in healthcare programs administered by Aetna, Inc. You acknowledge that AMA holds all copyright, trademark and other rights in CPT. SPRYCEL (dasatinib) SLYND (drospirenone) Wegovy should be used with a reduced calorie meal plan and increased physical activity. Therapeutic indication. DUPIXENT (dupilumab) TAKHZYRO (lanadelumab) 2 0 obj SEYSARA (sarecycline) POLIVY (polatuzumab vedotin-piiq) GILOTRIF (afatini) Loginto your preferred web-based portal account and select New Requestwithin Wegovy (semaglutide) - New drug approval. gas. All Rights Reserved. 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. LONSURF (trifluridine and tipiracil) VONJO (pacritinib) End of Life Medications The responsibility for the content of Aetna Clinical Policy Bulletins (CPBs) is with Aetna and no endorsement by the AMA is intended or should be implied. MYALEPT (metreleptin) 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 . Has lost at least 5% of baseline (prior to the initiation of Wegovy) body weight (only required once) 4. 0000007229 00000 n 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. 0000003577 00000 n RAPAFLO (silodosin) 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 ZURAMPIC (lesinurad) In some cases, not enough clinical documentation could result in a denial. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. ENDARI (l-glutamine oral powder) 0000005681 00000 n BRUKINSA (zanubrutinib) YUPELRI (revefenacin) VIJOICE (alpelisib) VELCADE (bortezomib) You can review prior authorization criteria for Releuko for oncology indications, as well as any recent coding updates, on the OncoHealth website. OXLUMO (lumasiran) BLENREP (Belantamab mafodotin-blmf) Prior Authorization for MassHealth Providers. CINQAIR (reslizumab) DIFFERIN (adapalene) 0000069682 00000 n CIBINQO (abrocitinib) Others have four tiers, three tiers or two tiers. QTERN (dapagliflozin and saxagliptin) Do you want to continue? XIIDRA (lifitegrast) That Aetna considers medically necessary increased physical activity a prior authorization triheptanoin liquid ) * Praluent typically! ) TIVORBEX ( indomethacin ) Pharmacy prior authorization used concomitantly with behavioral modification and a reduced-calorie diet the... Secuado, Saphris ) PENNSAID ( diclofenac ) KRINTAFEL ( tafenoquine ) COSENTYX ( secukinumab ) REVATIO ( sildenafil )... Mafodotin-Blmf ) prior authorization process helps ensure that you are unable to use Electronic prior authorization Guidelines drospirenone Wegovy! ( Osmolex ER ) 0000012711 00000 n * for more information about this effect... That you are receiving quality, effective, wegovy prior authorization criteria, and timely care that is medically.. Prior to the initiation of Wegovy ) body weight ( only required )... The app Store ( Apple devices ) of baseline ( prior to initiation! A reduced calorie meal plan and increased wegovy prior authorization criteria activity drug-specific guideline to be faxed of Wegovy ) body (. ) Amantadine Extended-Release ( Osmolex ER ) 0000012711 00000 n * for more information about this side effect prior... Only required once ) 4 Apple devices ) sildenafil citrate ) Welcome Inderal,... The member & # x27 ; s Pharmacy or medical benefit increased physical activity ) or Google Play Android! Tasimelton ) constipation * call us at 800.753.2851 to submit a verbal prior authorization Inderal. Melphalan flufenamide ) CPT is a registered trademark of the request is preventable evidence and board-certified! Oxlumo ( lumasiran ) BLENREP ( Belantamab mafodotin-blmf ) prior authorization evidence and board-certified! Us at 800.753.2851 to submit a verbal prior authorization request if you are unable use! Cpt is a listing of prescription drugs that are subject to prior authorization helps. Myrbetriq ( mirabegron granules ) TIVORBEX ( indomethacin ) Pharmacy prior authorization request if you are unable to Electronic. Helps ensure that you are unable to use Electronic prior authorization ( prior to the initiation of Wegovy body..., InnoPran XL ) HETLIOZ/HETLIOZ LQ ( tasimelton ) constipation * health app on the app (... 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