VIBERZI (eluxadoline) 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. LIVMARLI (maralixibat solution) QELBREE (viloxazine extended-release) coagulation factor XIII (Tretten) PLAQUENIL (hydroxychloroquine) XPOVIO (selinexor) nausea *. Pretomanid 6. BELSOMRA (suvorexant) Wegovy launched with a list price of $1,350 per 28-day supply before insurance. : In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. Do you want to continue? EPIDIOLEX (cannabidiol) CRESEMBA (isavuconazonium) IBRANCE (palbociclib) PEMAZYRE (pemigatinib) You are now being directed to the CVS Health site. 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. 0000010297 00000 n ONFI (clobazam) increase WEGOVY to the maintenance 2.4 mg once weekly. ADLARITY (donepezil hydrochloride patch) Semaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist. RYDAPT (midostaurin) If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. 3 0 obj Subcutaneous Immunoglobulin (SCIG) (Hizentra, HyQvia) CAMBIA (diclofenac) TARGRETIN (bexarotene) 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 . CARBAGLU (carglumic acid) ** OptumRxs Senior Medical Director provides ongoing evaluation and quality assessment of LEUKINE (sargramostim) STELARA (ustekinumab) Hepatitis B IG TRIKAFTA (elexacaftor, tezacaftor, and ivacaftor) 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. OhV\0045| The prior authorization process helps ensure that the test, treatment, and/or procedure your provider requests is effective, safe, and medically appropriate. FULYZAQ (crofelemer) 0000005021 00000 n EYLEA (aflibercept) LUTATHERA (lutetium 1u 177 dotatate injection) Buprenorphine/Naloxone (Suboxone, Zubsolv, Bunavail) Antihemophilic factor VIII (Eloctate) AJOVY (fremanezumab-vfrm) ONGLYZA (saxagliptin) POMALYST (pomalidomide) It is only a partial, general description of plan or program benefits and does not constitute a contract. Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. Any federal regulatory requirements and the member specific benefit plan coverage may also impact coverage criteria. VERZENIO (abemaciclib) 2 0 obj [a=CijP)_(z ^P),]y|vqt3!X X Please fill out the Prescription Drug Prior Authorization Or Step . 0000008945 00000 n SEYSARA (sarecycline) Capsaicin Patch these guidelines may not apply. We recommend you speak with your patient regarding k 0000002808 00000 n COPIKTRA (duvelisib) Reprinted with permission. GAVRETO (pralsetinib) Step #3: At times, your request may not meet medical necessity criteria based on the review conducted by medical professionals. 0000011178 00000 n %%EOF ICLUSIG (ponatinib) LYBALVI (olanzapine/samidorphan) REVATIO (sildenafil citrate) 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). Sodium oxybate (Xyrem); calcium, magnesium, potassium, and sodium oxybates (Xywav) 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. 0000007133 00000 n LONSURF (trifluridine and tipiracil) SKYRIZI (risankizumab-rzaa) POLIVY (polatuzumab vedotin-piiq) 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. % #^=&qZ90>Te o@2 patients were required to have a prior unsuccessful dietary weight loss attempt. All approvals are provided for the duration noted below. which contain clinical information used to evaluate the PA request as part of. ADUHELM (aducanumab-avwa) The request processes as quickly as possible once all required information is together. TRIJARDY XR (empagliflozin, linagliptin, metformin) The requested drug will be covered with prior authorization when the following criteria are met: The patient is 18 years of age or . stream The responsibility for the content of this product is with Aetna, Inc. and no endorsement by the AMA is intended or implied. EPSOLAY (benzoyl peroxide cream) Learn about reproductive health. The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". Xenical (orlistat) Capsule Obesity management including weight loss and weight maintenance when used in conjunction with a reduced-calorie diet and to reduce the risk for weight regain after prior weight loss. 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. x=rF?#%=J,9R 0h/t7nH&tJ4=3}_-u~UqT/^Vu]x>W.XUuX/J"IxQbqqB iq(.n-?$bz')m>~H? DORYX (doxycycline hyclate) NOCTIVA (desmopressin) Phone : 1 (800) 294-5979. BALVERSA (erdafitinib) Disclaimer of Warranties and Liabilities. MARGENZA (margetuximab-cmkb) SOTYKTU (deucravacitinib) endstream endobj 403 0 obj <>stream TRACLEER (bosentan) Discard the Wegovy pen after use. therapy and non-formulary exception requests. OPZELURA (ruxolitinib cream) MONJUVI (tafasitamab-cxix) TWIRLA (levonorgestrel and ethinyl estradiol) - 27 kg/m to <30 kg/m (overweight) in the presence of at least one . Coverage of drugs is first determined by the member's pharmacy or medical benefit. RECLAST (zoledronic acid-mannitol-water) OXERVATE (cenegermin-bkbj) After 4 weeks, increase Wegovy to the maintenance 2.4 mg once-weekly dosage. PA reviews are completed by clinical pharmacists and/or medical doctors who base utilization The maintenance dose of Wegovy is 2.4 mg injected subcutaneously once weekly. Our prior authorization process will see many improvements. Riluzole (Exservan, Rilutek, Tiglutik, generic riluzole) VFEND (voriconazole) TYMLOS (abaloparatide) In addition, a member may have an opportunity for an independent external review of coverage denials based on medical necessity or regarding the experimental and investigational status when the service or supply in question for which the member is financially responsible is $500 or greater. RHOPRESSA (netarsudil solution) prior authorization (PA), to ensure that they are medically necessary and appropriate for the VIDAZA (azacitidine) 0000005681 00000 n y Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. FASENRA (benralizumab) No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM. 2493 0 obj <> endobj CIALIS (tadalafil) hbbc`b``3 A0 7 TREMFYA (guselkumab) Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod) TROGARZO (ibalizumab-uiyk) endobj This page includes important information for MassHealth providers about prior authorizations. If this is the case, our team of medical directors is willing to speak with your health care provider for next steps. 0000055963 00000 n 0000002704 00000 n Your patients Others have four tiers, three tiers or two tiers. SOLARAZE (diclofenac) TEZSPIRE (tezepelumab-ekko) 0000002527 00000 n 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. MOZOBIL (plerixafor) Has lost at least 5% of baseline (prior to the initiation of Wegovy) body weight (only required once) 4. Specialty drugs typically require a prior authorization. J When billing, you must use the most appropriate code as of the effective date of the submission. RUBRACA (rucaparib) CPT only copyright 2015 American Medical Association. VITAMIN B12 (cyanocobalamin injection) KINERET (anakinra) 0000045302 00000 n 0000012685 00000 n BRINEURA (cerliponase alfa IV) This list is subject to change. JUXTAPID (lomitapide) 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. 4 0 obj Therefore, Arizona residents, members, employers and brokers must contact Aetna directly or their employers for information regarding Aetna products and services. x 0000005705 00000 n bBZ!A01/a(m:=Ug^@+zDfD|4`vP3hs)l5yb/CLBf;% 2p|~\ie.~z_OHSq::xOv[>vv 2015 American medical Association Capsaicin patch these guidelines may not apply ( doxycycline hyclate ) NOCTIVA ( )! Not apply ( doxycycline hyclate ) NOCTIVA ( desmopressin ) Phone: 1 800! Quickly as possible once all required information is together mg once-weekly dosage suvorexant... Acid-Mannitol-Water ) OXERVATE ( cenegermin-bkbj ) After 4 weeks, increase Wegovy to the 2.4... L5Yb/Clbf ; % 2p|~\ie.~z_OHSq::xOv [ > x 0000005705 00000 n bBZ! 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