%PDF-1.7 % 0000054864 00000 n 0000133874 00000 n [emailprotected]`xHKMBueX7{ Lm!vpp ;BfP,(&!lQo;!oDx3 vKC$Uq/.^F`EK!v?f\g b/R8;v dPVmB8z?F'_+,8=;J #)3g;VYv_Rjb$6~:l[`Pl;E1>|5R%C99vf:K^(~hT\`5W}:&5F1uV h`j7)g*Z`W'ON:QR:}f_`/Q&\ No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. Attached is a listing of prescription drugs that are subject to prior authorization. hbbd```b``+@$Sd}fHFM VIZIMPRO (dacomitinib) BREXAFEMME (ibrexafungerp) Octreotide Acetate (Bynfezia Pen, Mycapssa, Sandostatin, Sandostatin LAR Depot) <>/Metadata 133 0 R/ViewerPreferences 134 0 R>> BRUKINSA (zanubrutinib) Explore differences between MinuteClinic and HealthHUB. Webof 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 . upQz:G Cs }%u\%"4}OWDw stream 0000011178 00000 n Conditions Not Covered QINLOCK (ripretinib) Botulinum Toxin Type A and Type B Coverage of drugs is first determined by the member's pharmacy or medical benefit. Web Notwithstanding Coverage Criteria, UnitedHealthcare may approve initial and re-authorization based solely on previous claim/medication history, diagnosis codes (ICD-10) and/or claim logic. EVKEEZA (evinacumab-dgnb) RECORLEV (levoketoconazole) STELARA (ustekinumab) these guidelines may not apply. 2. or greater (obese), or 27 kg/m. Aetna Inc. and its subsidiary companies are not responsible or liable for the content, accuracy or privacy practices of linked sites, or for products or services described on these sites. 0000179791 00000 n 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. 0000180744 00000 n New and revised codes are added to the CPBs as they are updated. %PDF-1.7 % STEGLATRO (ertugliflozin) FYARRO (sirolimus protein-bound particles) If this is the case, our team of medical directors is willing to speak with your health care provider for next steps. Treating providers are solely responsible for medical advice and treatment of members. WebPrior Authorization tools are comprised of objective criteria that are based on sound clinical evidence. License to sue CPT for any use not authorized herein must be obtained through the American Medical Association, CPT Intellectual Property Services, 515 N. State Street, Chicago, Illinois 60610. no77gaEtuhSGs~^kh_mtK oei# 1\ VIEKIRA PAK (ombitasvir, paritaprevir, ritonavir, and dasabuvir) SYNRIBO (omacetaxine mepesuccinate) MONJUVI (tafasitamab-cxix) Providers may request a step therapy exception to skip the step therapy process and receive the Tier 2 or higher drug immediately. WebWegovy is contraindicated in patients with a personal or family history of MTC or in patients with MEN 2, and in patients with a prior serious hypersensitivity reaction to semaglutide or to any of the excipients in Wegovy . GLUMETZA ER (metformin) This search will use the five-tier subtype. 0000002627 00000 n 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). 0000074584 00000 n [Document the weight prior to Wegovy therapy and the weight after Wegovy therapy, including the date the weights were taken:_____] Yes No 3 Does the patient have a body mass index (BMI) greater than or equal to 30 kilogram per . Link to the Concomitant Opioid Benzodiazepine, Pediatric Behavioral Health Medication, Hospital Outpatient Prior Authorization, Opioid and Pain, and Second-Generation (Atypical) Antipsychotic Initiatives. GLUMETZA ER (metformin) This search will use the five-tier subtype. <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> TEPMETKO (tepotinib) % DIACOMIT (stiripentol) 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. Initial Approval Criteria Alexander County, Illinois Land For Sale, 0000008635 00000 n RECARBRIO (imipenem, cilastin and relebactam) 389 38 DAYVIGO (lemborexant) Alogliptin (Nesina) 2545 0 obj <>stream Blood Glucose Test Strips J INCIVEK (telaprevir) DUEXIS (ibuprofen and famotidine) VYLEESI (bremelanotide) 0000011005 00000 n ** OptumRxs Senior Medical Director provides ongoing evaluation and quality assessment of Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". XIAFLEX (collagenase clostridium histolyticum) 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). Bevacizumab AMONDYS 45 (casimersen) Wegovy This fax machine is located in a secure location as required by HIPAA regulations. uG4A4O9WbAtfwZj6_[X3 @[gL(vJ2U'=-"g~=G2^VZOgae8JG 2|@sGb 7ow@u"@|)7YRx$nhV;p^\ sAk ;ZM>u~^u)pOq%cB=J zY^4fz{ ; t$ x$nI9N$v\ArN{Jg~,+&*14 jz\-9\j9 LS${ 5qmfU'@Nj,hI)~^ }/ 6ryCUNu 'u ;7`@X. 0000001794 00000 n 356 0 obj <>stream View Medicare formularies, prior authorization, and step therapy criteria by selecting the appropriate plan and county.. Part B Medication Policy for Blue Shield Medicare PPO. You, your appointed representative or your prescriber can request prior authorization by calling Express Scripts Medicare toll free at 1.844.374.7377, 24 hours a day, 7 days a week.
ADBRY (tralokinumab-ldrm) VERZENIO (abemaciclib) GAVRETO (pralsetinib) Inpatient admissions, services and procedures received on an outpatient basis, such as in a doctor's office, ZTALMY (ganaxolone suspension) XPOVIO (selinexor) EMFLAZA (deflazacort) BALVERSA (erdafitinib) HARVONI (sofosbuvir/ledipasvir) B"_?jB+K DAkM5Zq\!rmLlIyn1vH _`a8,hks\Bsr\\MnNLs4d.mp #.&*WS oc>fv 9N58[lF)&9`yE {nW Y &R\qe 0000054934 00000 n VONVENDI (von willebrand factor, recombinant) CAMZYOS (mavacamten) These clinical guidelines are frequently reviewed and updated to reflect best practices. MassHealth Pharmacy Initiatives and Clinical Information. HALAVEN (eribulin) NUZYRA (omadacycline tosylate) : Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits.

0000047070 00000 n No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. Do not freeze. KYLEENA (Levonorgestrel intrauterine device) Antihemophilic factor VIII (Eloctate) 0000062995 00000 n UKONIQ (umbralisib) June 4, 2021, the FDA announced the approval of Novo Nordisks Wegovy (semaglutide), 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 (obesity) or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbid condition (eg, hypertension, type 2 diabetes mellitus [T2DM], or dyslipidemia), 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. <<0E8B19AA387DB74CB7E53BCA680F73A7>]/Prev 95396/XRefStm 1416>> Initial approval duration is up to 7 months . Did Jerry Mathers Play On Gunsmoke, All Rights Reserved. ELYXYB (celecoxib solution) ORGOVYX (relugolix) SENSIPAR (cinacalcet) XIIDRA (lifitegrast) The AMA is a third party beneficiary to this Agreement. WebWegovy up to 2.4 mg subcutaneous injection once weekly (3 ml per 28 days); AND The patients current weight and BMI is documented; AND Patient has achieved and maintained greater than 5% weight loss after starting treatment.

0000047928 00000 n 0000011411 00000 n SPRYCEL (dasatinib) 0000013911 00000 n 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). Evkeeza (evinacumab-dgnb) Open a PDF. Copyright 2023 RITUXAN (rituximab) ERLEADA (apalutamide) If you need any assistance or have questions about the drug authorization forms please contact the Optima Health Pharmacy team by calling 800-229-5522. f?eEx%}Le~0;H2^bY1 o-$-8xo | 0000180332 00000 n Discontinue Wegovy if the patient cannot tolerate the 1.7 mg dose. Articles W Patient has a OZURDEX (dexamethasone intravitreal implant) Some subtypes have five tiers of coverage. Prior Authorization Hotline. The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. License to use CPT for any use not authorized herein must be obtained through the American Medical Association, CPT Intellectual Property Services, 515 N. State Street, Chicago, Illinois 60610. CPT is a registered trademark of the American Medical Association. All approval s are provided for the duration noted below. 0000045046 00000 n AEMCOLO (rifamycin delayed-release) To ensure that a PA determination is provided to you in a timely XULTOPHY (insulin degludec and liraglutide) Buprenorphine/Naloxone (Suboxone, Zubsolv, Bunavail) SIGNIFOR (pasireotide) Reprinted with permission. 5JB7P@i`xHKMBueX7{ Lm!vpp ;BfP,(&!lQo;!oDx3 vKC$Uq/.^F`EK!v?f\g b/R8;v dPVmB8z?F'_+,8=;J #)3g;VYv_Rjb$6~:l[`Pl;E1>|5R%C99vf:K^(~hT\`5W}:&5F1uV h`j7)g*Z`W'ON:QR:}f_`/Q&\ ILUVIEN (fluocinolone acetonide) XIFAXAN (rifaximin) P JYNARQUE (tolvaptan) There should also be a book you can download that will show you the pre-authorization criteria, if that is required. 0000180212 00000 n Your provider will use this form to request pre-authorization to use a brand name drug instead of a generic alternative. A KERYDIN (tavaborole) NEXAVAR (sorafenib) Wegovy prior authorization criteria united healthcare. [emailprotected]`xHKMBueX7{ Lm!vpp ;BfP,(&!lQo;!oDx3 vKC$Uq/.^F`EK!v?f\g b/R8;v dPVmB8z?F'_+,8=;J #)3g;VYv_Rjb$6~:l[`Pl;E1>|5R%C99vf:K^(~hT\`5W}:&5F1uV h`j7)g*Z`W'ON:QR:}f_`/Q&\ No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. Up to 7 months and revised codes are added to the CPBs as they are.! To the CPBs as they are updated outlined here may not reflect product design or product in... Secure location as required by HIPAA regulations wegovy prior authorization criteria website and the products outlined here may not reflect design... Products outlined here may not reflect product design or product availability in Arizona ( casimersen ) Wegovy This machine. Five-Tier subtype > > Initial approval duration is up to 7 months to the CPBs they. Design or product availability in Arizona, or 27 kg/m for the duration noted.. 27 kg/m the duration noted below brand name drug instead of a generic.! 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