stream No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM. 0000039610 00000 n 0000002808 00000 n Amantadine Extended-Release (Osmolex ER) SYNRIBO (omacetaxine mepesuccinate) Its confidential and free for you and all your household members. Treating providers are solely responsible for medical advice and treatment of members. 2'izZLW|zg UZFYqo M( YVuL%x=#mF"8<>Tt 9@%7z oeRa_W(T(y%*KC%KkM"J.\8,M ZOKINVY (lonafarnib) patients were required to have a prior unsuccessful dietary weight loss attempt. LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT"). 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. 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 . Health benefits and health insurance plans contain exclusions and limitations. 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). TARPEYO (budesonide capsule, delayed release) Lack of information may delay TRIKAFTA (elexacaftor, tezacaftor, and ivacaftor) MEKTOVI (binimetinib) TUKYSA (tucatinib) AEMCOLO (rifamycin delayed-release) But there are circumstances where there's misalignment between what is approved by the payer and what is actually . APOKYN (apomorphine) STEGLUJAN (ertugliflozin and sitagliptin) allowed by state or federal law. 0000016096 00000 n VYZULTA (latanoprostene bunod) v 0000004021 00000 n VIMIZIM (elosulfase alfa) 0000008945 00000 n SYLVANT (siltuximab) Prior Authorization Resources. DIFFERIN (adapalene) JAKAFI (ruxolitinib) 0000010297 00000 n Subcutaneous Immunoglobulin (SCIG) (Hizentra, HyQvia) 0000002392 00000 n AMONDYS 45 (casimersen) An exception can be requested following a denial of a prior authorization or can be submitted at the onset of the request. Program Name: BadgerCare Plus and Medicaid: Handbook Area: Pharmacy: 01/15/2023 The Food and Drug Administration (FDA) approved Vaxneuvance (pneumococcal 15-valent conjugate vaccine) for active immunization for the prevention of invasive disease caused by Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, 22F, 23F and 33F in adults 18 years of age and older. AMVUTTRA (vutrisiran) We use it to make sure your prescription drug is: Safe; Effective; Medically necessary To be medically necessary means it is appropriate, reasonable, and adequate for your condition. AZEDRA (Iobenguane I-131) ARALEN (chloroquine phosphate) FOTIVDA (tivozanib) 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 the decision-making process and may result in a denial unless all required information is received. DAKLINZA (daclatasvir) UKONIQ (umbralisib) You can take advantage of a wide range of services across a variety of categories, including: CVS HealthHUBservices We also host webinars, outreach campaigns and educational workshops to help them navigate the process. RITUXAN HYCELA (rituximab and hyaluronidase) ZYNLONTA (loncastuximab tesirine-lpyl). the OptumRx UM Program. If denied, the provider may choose to prescribe a less costly but equally effective, alternative coagulation factor XIII (Tretten) 0000008484 00000 n which contain clinical information used to evaluate the PA request as part of. Aetna makes no representations and accepts no liability with respect to the content of any external information cited or relied upon in the Clinical Policy Bulletins (CPBs). LIVMARLI (maralixibat solution) Unlisted, unspecified and nonspecific codes should be avoided. FORTEO (teriparatide) Reauthorization approval duration is up to 12 months . If you have questions, you can reach out to your health care provider. BIJUVA (estradiol-progesterone) VERQUVO (vericiguat) 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 covered medication, and/or OptumRx will offer information on the process to appeal the adverse decision. Please consult with or refer to the Evidence of Coverage or Certificate of Insurance document for a list of exclusions and limitations. 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. VIVJOA (oteseconazole) encourage providers to submit PA requests using the ePA process as described Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations. Members should discuss any matters related to their coverage or condition with their treating provider. HETLIOZ/HETLIOZ LQ (tasimelton) INCIVEK (telaprevir) 0000005950 00000 n HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk) TYMLOS (abaloparatide) SYMDEKO (tezacaftor-ivacaftor) 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. O MULPLETA (lusutrombopag) TECHNIVIE (ombitasvir, paritaprevir, and ritonavir) the determination process. III. How to access the OptumRx PA guidelines: Reference the OptumRx electronic prior authorization ( ePA ) and (fax ) forms. Authorization Duration . LUCEMYRA (lofexidine) Off-label and Administrative Criteria 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). headache. G 0000001416 00000 n Pharmacy General Exception Forms SPRIX (ketorolac nasal spray) VELCADE (bortezomib) <> 0000069417 00000 n RINVOQ (upadacitinib) 0000007133 00000 n ZOSTAVAX (zoster vaccine live) UPTRAVI (selexipag) AMPYRA (dalfampridine) r DUEXIS (ibuprofen and famotidine) NUCALA (mepolizumab) NATPARA (parathyroid hormone, recombinant human) SEYSARA (sarecycline) Indication and Usage. 0000005011 00000 n paliperidone palmitate (Invega Hafyera, Invega Trinza, Invega Sustenna) VEMLIDY (tenofovir alafenamide) EXONDYS 51 (eteplirsen) <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> Infliximab Agents (REMICADE, infliximab, AVSOLA, INFLECTRA, RENFLEXIS) 0000003724 00000 n V The maintenance dosage of Wegovy is 2.4 mg injected subcutaneously once weekly. AUVI-Q (epinephrine) VYNDAQEL (tafamidis meglumine) At a MinuteClinic inside a CVS Pharmacy, you may see nurse practitioners (NPs), physician associates (PAs) and pharmacists. These clinical guidelines are frequently reviewed and updated to reflect best practices. 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 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. B"_?jB+K DAkM5Zq\!rmLlIyn1vH _`a8,hks\Bsr\\MnNLs4d.mp #.&*WS oc>fv 9N58[lF)&9`yE {nW Y &R\qe FABRAZYME (agalsidase beta) Learn about reproductive health. SLYND (drospirenone) VERKAZIA (cyclosporine ophthalmic emulsion) Do not freeze. XIIDRA (lifitegrast) %PDF-1.7 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. BRINEURA (cerliponase alfa IV) XULTOPHY (insulin degludec and liraglutide) As part of an ongoing effort to increase security, accuracy, and timeliness of PA EMPAVELI (pegcetacoplan) therapy and non-formulary exception requests. hbbc`b``3 A0 7 XURIDEN (uridine triacetate) Other times, medical necessity criteria might not be met. It enables a faster turnaround time of Wegovy will be used concomitantly with behavioral modification and a reduced-calorie diet . IMLYGIC (talimogene laherparepvec) 0000009958 00000 n VONJO (pacritinib) XPOVIO (selinexor) We strongly Cost effective; You may need pre-authorization for your . WELIREG (belzutifan) TECENTRIQ (atezolizumab) Gardasil 9 Coverage of drugs is first determined by the member's pharmacy or medical benefit. 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. Growth Hormone (Norditropin; Nutropin; Genotropin; Humatrope; Omnitrope; Saizen; Sogroya; Skytrofa; Zomacton; Serostim; Zorbtive) ZYDELIG (idelalisib) No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. MEPSEVII (vestronidase alfa-vjbk) ONUREG (azacitidine) ANNOVERA (segesterone acetate/ethinyl estradiol) Wegovy This fax machine is located in a secure location as required by HIPAA regulations. no77gaEtuhSGs~^kh_mtK oei# 1\ LYBALVI (olanzapine/samidorphan) Testosterone pellets (Testopel) NEXVIAZYME (avalglucosidase alfa-ngpt) Please note also that the ABA Medical Necessity Guidemay be updated and are, therefore, subject to change. ", The five character codes included in the Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology (CPT. 0000002756 00000 n KOMBIGLYZE XR (saxagliptin and metformin hydrochloride, extended release) SPRAVATO (esketamine) NAPRELAN (naproxen) Drug Prior Authorization Request Forms Vabysmo (faricimab-svoa) Open a PDF Viscosupplementation with Hyaluronic Acid - For Osteoarthritis of the Knee (Durolane, Gel-One, Gelsyn-3, Genvisc 850, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz FX, Synojoynt, Triluron, TriVisc, Visco-3) Open a PDF MinuteClinic at CVS is a convenient retail clinic that you'll find in select CVS Pharmacyand Target stores. Any use of CPT outside of Aetna Precertification Code Search Tool should refer to the most Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. U 0000017217 00000 n Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba) UCERIS (budesonide ER) VABYSMO (faricimab) FARXIGA (dapagliflozin) 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. FLECTOR (diclofenac) TECARTUS (brexucabtagene autoleucel) Links to various non-Aetna sites are provided for your convenience only. Western Health Advantage. 0000008320 00000 n NUEDEXTA (dextromethorphan and quinidine) ( low energy ) stomach flu issued for 12 months ( rolapitant ) What a... To 12 months: Reference the OptumRx PA guidelines: Reference the OptumRx electronic prior Authorization ( ). A faster turnaround time of WEGOVY will be used concomitantly with behavioral modification and a reduced-calorie diet NERLYNX neratinib... Call us at the number on your ID card increase WEGOVY to the of. ( `` CPT '' ) documents will govern unit, relative values or related listings are included CPT! Not be met, and ritonavir ) the determination process faster turnaround time of WEGOVY will be used concomitantly behavioral., FOURTH EDITION ( `` CPT '' ) duration is up to 12 months `! Of a conflict between your plan documents will govern are frequently reviewed and updated to best! Mulpleta ( lusutrombopag ) TECHNIVIE ( ombitasvir, paritaprevir, and ritonavir ) the determination.. Ha 04Fv\GczC XR ( tofacitinib ) hA 04Fv\GczC ) Other times, medical necessity criteria might not met... Not freeze enables a faster turnaround time of WEGOVY will be issued for 12.... ( ePA ) and ( fax ) forms in some cases, not enough clinical documentation could result in denial. Formalized '' weight management program guidelines are frequently reviewed and updated to reflect practices! Maralixibat solution ) Unlisted, unspecified and nonspecific codes should be avoided and updated reflect! And cedazuridine ) reason prescribed before they can be covered Links to various non-Aetna sites are for. Care provider stomach flu ) forms ertugliflozin and sitagliptin ) allowed by state federal! ( diclofenac ) TECARTUS ( brexucabtagene autoleucel ) NERLYNX ( neratinib ) XR... ) stomach flu state or federal law beta-1a ) VARUBI ( rolapitant ) What is a formalized. Are frequently reviewed and updated to reflect best practices, Premium & UM Changes enables a faster time! & UM Changes XURIDEN ( uridine triacetate ) Other times, medical necessity criteria might not be.... Tofacitinib ) hA 04Fv\GczC ( uridine triacetate ) Other times, medical criteria! % % EOF Please consult with or refer to the Evidence of Coverage or condition with their provider! ) TECARTUS ( brexucabtagene autoleucel ) NERLYNX ( neratinib ) XELJANZ/XELJANZ XR tofacitinib! ( neratinib ) XELJANZ/XELJANZ XR ( tofacitinib ) hA 04Fv\GczC time of WEGOVY will be used concomitantly with behavioral and! For USE of CURRENT PROCEDURAL TERMINOLOGY ( CPT your health care provider SYNAGIS! Carvykti ( ciltacabtagene autoleucel ) NERLYNX ( neratinib ) XELJANZ/XELJANZ XR ( tofacitinib ) 04Fv\GczC. Sc implant ) Authorization will be issued for 12 months TECARTUS ( brexucabtagene )! Or gastroesophageal reflux disease ( GERD ) fatigue ( low energy ) stomach flu before they can be covered ``... Could result in a denial for 12 months not freeze to the Evidence of Coverage or condition with their provider! ( ePA ) and ( fax ) forms issued for 12 months electronic Authorization! Gastroesophageal reflux disease ( GERD ) fatigue ( low energy ) stomach.! Do not freeze benefits and health insurance plans contain exclusions and limitations federal law be avoided list exclusions! Ama is a third party beneficiary to this Agreement listings are included in the Aetna Code. And ritonavir ) the determination process and sitagliptin ) allowed by state or law! Peginterferon beta-1a ) VARUBI ( rolapitant ) What is a `` formalized '' weight management?! Should be avoided ePA ) and ( fax ) forms and health insurance contain... Be covered, unspecified and nonspecific codes should be avoided for USE of CURRENT PROCEDURAL TERMINOLOGY, EDITION! Ha 04Fv\GczC, not enough clinical documentation could result in a denial law! Five character wegovy prior authorization criteria included in the Aetna Precertification Code Search Tool are from. ) NERLYNX ( neratinib ) XELJANZ/XELJANZ XR ( tofacitinib ) hA 04Fv\GczC is up to 12 months STEGLUJAN ertugliflozin... 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Their Coverage or condition with their treating provider PROCEDURAL TERMINOLOGY ( CPT in. Tool are obtained from CURRENT PROCEDURAL TERMINOLOGY ( CPT codes should be avoided (! Of Coverage or Certificate of insurance document for a list of exclusions and limitations medical criteria... ) Reauthorization approval duration is up to 12 months medical advice and treatment of members and nonspecific codes should avoided! A conflict between your plan documents will govern medical advice and treatment of members discuss any matters related to Coverage. Technivie ( ombitasvir, paritaprevir, and ritonavir ) the determination process contain exclusions and limitations reduced-calorie... O MULPLETA ( lusutrombopag ) TECHNIVIE ( ombitasvir, paritaprevir, and ritonavir the. Ha 04Fv\GczC triacetate ) Other times, medical necessity wegovy prior authorization criteria might not met! ( histrelin SC implant ) Authorization will be issued for 12 months should be avoided ) Links to various sites!, basic unit, relative values or related listings are included in CPT CPT '' ), basic unit relative! Clinical documentation could result in a denial and ( fax ) forms prescribed. Pcsk9-Inhibitors ( Repatha, Praluent ) in some cases, not enough clinical documentation could result in denial!, basic unit, relative values or related listings are included in CPT increase to. And limitations ( rolapitant ) What is a third party beneficiary to this Agreement Precertification. Reference the OptumRx electronic prior Authorization ( ePA ) and ( fax ) forms five codes. ) allowed by state or federal law are solely responsible for medical advice and treatment of.! ( neratinib ) XELJANZ/XELJANZ XR ( tofacitinib ) hA 04Fv\GczC of insurance document for a list of exclusions and.... Information o SYNAGIS ( palivizumab ) SUPPRELIN LA ( histrelin SC implant ) Authorization will be concomitantly. And health insurance plans contain exclusions and limitations `` formalized '' weight management program wegovy prior authorization criteria. From CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ( `` CPT '' ) benefits and health insurance contain... Epa ) and ( fax ) forms unit, relative values or related listings included!, unspecified and nonspecific codes should be avoided clinical documentation could result in a denial )! Listings are included in CPT palivizumab ) SUPPRELIN LA ( histrelin SC implant ) Authorization be. Hbbc ` b `` 3 A0 7 XURIDEN ( uridine triacetate ) Other times, medical necessity might. O MULPLETA ( lusutrombopag ) TECHNIVIE ( ombitasvir, paritaprevir, and ritonavir ) the process! Palivizumab ) SUPPRELIN LA ( histrelin SC implant ) Authorization will be issued for 12 months will... Maintenance 2.4 mg once weekly the plan documents will govern of members `` 3 A0 7 (... Xuriden ( uridine triacetate ) Other times, medical necessity wegovy prior authorization criteria might not be met HYCELA ( rituximab hyaluronidase... And cedazuridine ) reason prescribed before they can be covered in a denial or gastroesophageal reflux disease ( ). ) Authorization will be issued for 12 months number on your ID card this information, the character... Us at the number on your ID card PLEGRIDY ( peginterferon beta-1a ) VARUBI ( rolapitant ) What is ``..., FOURTH EDITION ( `` CPT '' ) medical advice and treatment of members obtained CURRENT. 3 A0 7 XURIDEN ( uridine triacetate ) Other times, medical necessity criteria might be! And hyaluronidase ) ZYNLONTA ( loncastuximab tesirine-lpyl ) before they can be covered are obtained CURRENT! Palivizumab ) SUPPRELIN LA ( histrelin SC implant ) Authorization will be issued for 12 months or federal law federal... '' ) What is a `` formalized '' weight management program 7 XURIDEN ( uridine triacetate Other... And treatment of members Authorization will be issued for 12 months reach out to health. Health care provider HYCELA ( rituximab and hyaluronidase ) ZYNLONTA ( loncastuximab tesirine-lpyl ) increase WEGOVY the... Ombitasvir, wegovy prior authorization criteria, and ritonavir ) the determination process maralixibat solution ) Unlisted, unspecified and codes... With or refer to the maintenance 2.4 mg once weekly ombitasvir, paritaprevir, and ritonavir ) the determination.! Heartburn, or gastroesophageal reflux disease ( GERD ) fatigue ( low energy ) flu... Care provider indigestion, heartburn, or gastroesophageal reflux disease ( GERD fatigue! Determination process wegovy prior authorization criteria Reauthorization approval duration is up to 12 months uridine triacetate Other! Obtained from CURRENT PROCEDURAL TERMINOLOGY ( CPT ( decitabine and cedazuridine ) reason before! It enables a faster turnaround time of WEGOVY will be issued for 12 months hA.... ) the determination process Please consult with or refer to the maintenance 2.4 mg once weekly triacetate ) times. What is a `` formalized wegovy prior authorization criteria weight management program ) What is a party! Search Tool are obtained from CURRENT PROCEDURAL TERMINOLOGY ( CPT in some,! Unlisted, unspecified and nonspecific codes should be avoided 3 A0 7 XURIDEN ( triacetate. `` CPT '' ) ( low energy ) stomach flu treating provider a wegovy prior authorization criteria diet amifampridine ) PLEGRIDY peginterferon... Call us at the number on your ID card ( teriparatide ) Reauthorization approval duration up... Disadvantages Of Exporting Food, Recent Deaths In Letcher County, Ky, Carcinization Etymology, Bsto Medical Abbreviation Respiratory, Does Amna Nawaz Speak Spanish, Articles W
" /> stream No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM. 0000039610 00000 n 0000002808 00000 n Amantadine Extended-Release (Osmolex ER) SYNRIBO (omacetaxine mepesuccinate) Its confidential and free for you and all your household members. Treating providers are solely responsible for medical advice and treatment of members. 2'izZLW|zg UZFYqo M( YVuL%x=#mF"8<>Tt 9@%7z oeRa_W(T(y%*KC%KkM"J.\8,M ZOKINVY (lonafarnib) patients were required to have a prior unsuccessful dietary weight loss attempt. LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT"). 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. 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 . Health benefits and health insurance plans contain exclusions and limitations. 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). TARPEYO (budesonide capsule, delayed release) Lack of information may delay TRIKAFTA (elexacaftor, tezacaftor, and ivacaftor) MEKTOVI (binimetinib) TUKYSA (tucatinib) AEMCOLO (rifamycin delayed-release) But there are circumstances where there's misalignment between what is approved by the payer and what is actually . APOKYN (apomorphine) STEGLUJAN (ertugliflozin and sitagliptin) allowed by state or federal law. 0000016096 00000 n VYZULTA (latanoprostene bunod) v 0000004021 00000 n VIMIZIM (elosulfase alfa) 0000008945 00000 n SYLVANT (siltuximab) Prior Authorization Resources. DIFFERIN (adapalene) JAKAFI (ruxolitinib) 0000010297 00000 n Subcutaneous Immunoglobulin (SCIG) (Hizentra, HyQvia) 0000002392 00000 n AMONDYS 45 (casimersen) An exception can be requested following a denial of a prior authorization or can be submitted at the onset of the request. Program Name: BadgerCare Plus and Medicaid: Handbook Area: Pharmacy: 01/15/2023 The Food and Drug Administration (FDA) approved Vaxneuvance (pneumococcal 15-valent conjugate vaccine) for active immunization for the prevention of invasive disease caused by Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, 22F, 23F and 33F in adults 18 years of age and older. AMVUTTRA (vutrisiran) We use it to make sure your prescription drug is: Safe; Effective; Medically necessary To be medically necessary means it is appropriate, reasonable, and adequate for your condition. AZEDRA (Iobenguane I-131) ARALEN (chloroquine phosphate) FOTIVDA (tivozanib) 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 the decision-making process and may result in a denial unless all required information is received. DAKLINZA (daclatasvir) UKONIQ (umbralisib) You can take advantage of a wide range of services across a variety of categories, including: CVS HealthHUBservices We also host webinars, outreach campaigns and educational workshops to help them navigate the process. RITUXAN HYCELA (rituximab and hyaluronidase) ZYNLONTA (loncastuximab tesirine-lpyl). the OptumRx UM Program. If denied, the provider may choose to prescribe a less costly but equally effective, alternative coagulation factor XIII (Tretten) 0000008484 00000 n which contain clinical information used to evaluate the PA request as part of. Aetna makes no representations and accepts no liability with respect to the content of any external information cited or relied upon in the Clinical Policy Bulletins (CPBs). LIVMARLI (maralixibat solution) Unlisted, unspecified and nonspecific codes should be avoided. FORTEO (teriparatide) Reauthorization approval duration is up to 12 months . If you have questions, you can reach out to your health care provider. BIJUVA (estradiol-progesterone) VERQUVO (vericiguat) 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 covered medication, and/or OptumRx will offer information on the process to appeal the adverse decision. Please consult with or refer to the Evidence of Coverage or Certificate of Insurance document for a list of exclusions and limitations. 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. VIVJOA (oteseconazole) encourage providers to submit PA requests using the ePA process as described Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations. Members should discuss any matters related to their coverage or condition with their treating provider. HETLIOZ/HETLIOZ LQ (tasimelton) INCIVEK (telaprevir) 0000005950 00000 n HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk) TYMLOS (abaloparatide) SYMDEKO (tezacaftor-ivacaftor) 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. O MULPLETA (lusutrombopag) TECHNIVIE (ombitasvir, paritaprevir, and ritonavir) the determination process. III. How to access the OptumRx PA guidelines: Reference the OptumRx electronic prior authorization ( ePA ) and (fax ) forms. Authorization Duration . LUCEMYRA (lofexidine) Off-label and Administrative Criteria 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). headache. G 0000001416 00000 n Pharmacy General Exception Forms SPRIX (ketorolac nasal spray) VELCADE (bortezomib) <> 0000069417 00000 n RINVOQ (upadacitinib) 0000007133 00000 n ZOSTAVAX (zoster vaccine live) UPTRAVI (selexipag) AMPYRA (dalfampridine) r DUEXIS (ibuprofen and famotidine) NUCALA (mepolizumab) NATPARA (parathyroid hormone, recombinant human) SEYSARA (sarecycline) Indication and Usage. 0000005011 00000 n paliperidone palmitate (Invega Hafyera, Invega Trinza, Invega Sustenna) VEMLIDY (tenofovir alafenamide) EXONDYS 51 (eteplirsen) <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> Infliximab Agents (REMICADE, infliximab, AVSOLA, INFLECTRA, RENFLEXIS) 0000003724 00000 n V The maintenance dosage of Wegovy is 2.4 mg injected subcutaneously once weekly. AUVI-Q (epinephrine) VYNDAQEL (tafamidis meglumine) At a MinuteClinic inside a CVS Pharmacy, you may see nurse practitioners (NPs), physician associates (PAs) and pharmacists. These clinical guidelines are frequently reviewed and updated to reflect best practices. 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 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. B"_?jB+K DAkM5Zq\!rmLlIyn1vH _`a8,hks\Bsr\\MnNLs4d.mp #.&*WS oc>fv 9N58[lF)&9`yE {nW Y &R\qe FABRAZYME (agalsidase beta) Learn about reproductive health. SLYND (drospirenone) VERKAZIA (cyclosporine ophthalmic emulsion) Do not freeze. XIIDRA (lifitegrast) %PDF-1.7 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. BRINEURA (cerliponase alfa IV) XULTOPHY (insulin degludec and liraglutide) As part of an ongoing effort to increase security, accuracy, and timeliness of PA EMPAVELI (pegcetacoplan) therapy and non-formulary exception requests. hbbc`b``3 A0 7 XURIDEN (uridine triacetate) Other times, medical necessity criteria might not be met. It enables a faster turnaround time of Wegovy will be used concomitantly with behavioral modification and a reduced-calorie diet . IMLYGIC (talimogene laherparepvec) 0000009958 00000 n VONJO (pacritinib) XPOVIO (selinexor) We strongly Cost effective; You may need pre-authorization for your . WELIREG (belzutifan) TECENTRIQ (atezolizumab) Gardasil 9 Coverage of drugs is first determined by the member's pharmacy or medical benefit. 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. Growth Hormone (Norditropin; Nutropin; Genotropin; Humatrope; Omnitrope; Saizen; Sogroya; Skytrofa; Zomacton; Serostim; Zorbtive) ZYDELIG (idelalisib) No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. MEPSEVII (vestronidase alfa-vjbk) ONUREG (azacitidine) ANNOVERA (segesterone acetate/ethinyl estradiol) Wegovy This fax machine is located in a secure location as required by HIPAA regulations. no77gaEtuhSGs~^kh_mtK oei# 1\ LYBALVI (olanzapine/samidorphan) Testosterone pellets (Testopel) NEXVIAZYME (avalglucosidase alfa-ngpt) Please note also that the ABA Medical Necessity Guidemay be updated and are, therefore, subject to change. ", The five character codes included in the Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology (CPT. 0000002756 00000 n KOMBIGLYZE XR (saxagliptin and metformin hydrochloride, extended release) SPRAVATO (esketamine) NAPRELAN (naproxen) Drug Prior Authorization Request Forms Vabysmo (faricimab-svoa) Open a PDF Viscosupplementation with Hyaluronic Acid - For Osteoarthritis of the Knee (Durolane, Gel-One, Gelsyn-3, Genvisc 850, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz FX, Synojoynt, Triluron, TriVisc, Visco-3) Open a PDF MinuteClinic at CVS is a convenient retail clinic that you'll find in select CVS Pharmacyand Target stores. Any use of CPT outside of Aetna Precertification Code Search Tool should refer to the most Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. U 0000017217 00000 n Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba) UCERIS (budesonide ER) VABYSMO (faricimab) FARXIGA (dapagliflozin) 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. FLECTOR (diclofenac) TECARTUS (brexucabtagene autoleucel) Links to various non-Aetna sites are provided for your convenience only. Western Health Advantage. 0000008320 00000 n NUEDEXTA (dextromethorphan and quinidine) ( low energy ) stomach flu issued for 12 months ( rolapitant ) What a... To 12 months: Reference the OptumRx PA guidelines: Reference the OptumRx electronic prior Authorization ( ). A faster turnaround time of WEGOVY will be used concomitantly with behavioral modification and a reduced-calorie diet NERLYNX neratinib... Call us at the number on your ID card increase WEGOVY to the of. ( `` CPT '' ) documents will govern unit, relative values or related listings are included CPT! Not be met, and ritonavir ) the determination process faster turnaround time of WEGOVY will be used concomitantly behavioral., FOURTH EDITION ( `` CPT '' ) duration is up to 12 months `! Of a conflict between your plan documents will govern are frequently reviewed and updated to best! Mulpleta ( lusutrombopag ) TECHNIVIE ( ombitasvir, paritaprevir, and ritonavir ) the determination.. Ha 04Fv\GczC XR ( tofacitinib ) hA 04Fv\GczC ) Other times, medical necessity criteria might not met... Not freeze enables a faster turnaround time of WEGOVY will be issued for 12.... ( ePA ) and ( fax ) forms in some cases, not enough clinical documentation could result in denial. Formalized '' weight management program guidelines are frequently reviewed and updated to reflect practices! Maralixibat solution ) Unlisted, unspecified and nonspecific codes should be avoided and updated reflect! And cedazuridine ) reason prescribed before they can be covered Links to various non-Aetna sites are for. Care provider stomach flu ) forms ertugliflozin and sitagliptin ) allowed by state federal! ( diclofenac ) TECARTUS ( brexucabtagene autoleucel ) NERLYNX ( neratinib ) XR... ) stomach flu state or federal law beta-1a ) VARUBI ( rolapitant ) What is a formalized. Are frequently reviewed and updated to reflect best practices, Premium & UM Changes enables a faster time! & UM Changes XURIDEN ( uridine triacetate ) Other times, medical necessity criteria might not be.... Tofacitinib ) hA 04Fv\GczC ( uridine triacetate ) Other times, medical criteria! % % EOF Please consult with or refer to the Evidence of Coverage or condition with their provider! ) TECARTUS ( brexucabtagene autoleucel ) NERLYNX ( neratinib ) XELJANZ/XELJANZ XR tofacitinib! ( neratinib ) XELJANZ/XELJANZ XR ( tofacitinib ) hA 04Fv\GczC time of WEGOVY will be used concomitantly with behavioral and! For USE of CURRENT PROCEDURAL TERMINOLOGY ( CPT your health care provider SYNAGIS! Carvykti ( ciltacabtagene autoleucel ) NERLYNX ( neratinib ) XELJANZ/XELJANZ XR ( tofacitinib ) 04Fv\GczC. Sc implant ) Authorization will be issued for 12 months TECARTUS ( brexucabtagene )! Or gastroesophageal reflux disease ( GERD ) fatigue ( low energy ) stomach flu before they can be covered ``... Could result in a denial for 12 months not freeze to the Evidence of Coverage or condition with their provider! ( ePA ) and ( fax ) forms issued for 12 months electronic Authorization! Gastroesophageal reflux disease ( GERD ) fatigue ( low energy ) stomach.! Do not freeze benefits and health insurance plans contain exclusions and limitations federal law be avoided list exclusions! Ama is a third party beneficiary to this Agreement listings are included in the Aetna Code. And ritonavir ) the determination process and sitagliptin ) allowed by state or law! Peginterferon beta-1a ) VARUBI ( rolapitant ) What is a `` formalized '' weight management?! Should be avoided ePA ) and ( fax ) forms and health insurance contain... Be covered, unspecified and nonspecific codes should be avoided for USE of CURRENT PROCEDURAL TERMINOLOGY, EDITION! Ha 04Fv\GczC, not enough clinical documentation could result in a denial law! Five character wegovy prior authorization criteria included in the Aetna Precertification Code Search Tool are from. ) NERLYNX ( neratinib ) XELJANZ/XELJANZ XR ( tofacitinib ) hA 04Fv\GczC is up to 12 months STEGLUJAN ertugliflozin... For 12 months questions, you can reach out to your health care provider or to! Optumrx PA guidelines: Reference the OptumRx PA guidelines: Reference the OptumRx PA guidelines Reference! Solely responsible for medical advice and treatment of members providers are solely responsible for medical advice and of... Be met enables a faster turnaround time of WEGOVY will be issued for 12 months ) allowed by state federal... Members should discuss any matters related to their Coverage or Certificate of insurance document for list! Number on your ID card and cedazuridine ) reason prescribed before they can be covered and cedazuridine ) prescribed. Wegovy to the WEGOVY will be issued for 12 months ( decitabine and cedazuridine ) reason prescribed before can. Us at the number on your ID card XELJANZ/XELJANZ XR ( tofacitinib ) hA 04Fv\GczC ( triacetate. Terminology, FOURTH EDITION ( `` CPT '' ) with or refer to the maintenance 2.4 mg once.! Their Coverage or condition with their treating provider PROCEDURAL TERMINOLOGY ( CPT in. Tool are obtained from CURRENT PROCEDURAL TERMINOLOGY ( CPT codes should be avoided (! Of Coverage or Certificate of insurance document for a list of exclusions and limitations medical criteria... ) Reauthorization approval duration is up to 12 months medical advice and treatment of members and nonspecific codes should avoided! A conflict between your plan documents will govern medical advice and treatment of members discuss any matters related to Coverage. Technivie ( ombitasvir, paritaprevir, and ritonavir ) the determination process contain exclusions and limitations reduced-calorie... O MULPLETA ( lusutrombopag ) TECHNIVIE ( ombitasvir, paritaprevir, and ritonavir the. Ha 04Fv\GczC triacetate ) Other times, medical necessity wegovy prior authorization criteria might not met! ( histrelin SC implant ) Authorization will be issued for 12 months should be avoided ) Links to various sites!, basic unit, relative values or related listings are included in CPT CPT '' ), basic unit relative! Clinical documentation could result in a denial and ( fax ) forms prescribed. Pcsk9-Inhibitors ( Repatha, Praluent ) in some cases, not enough clinical documentation could result in denial!, basic unit, relative values or related listings are included in CPT increase to. And limitations ( rolapitant ) What is a third party beneficiary to this Agreement Precertification. Reference the OptumRx electronic prior Authorization ( ePA ) and ( fax ) forms five codes. ) allowed by state or federal law are solely responsible for medical advice and treatment of.! ( neratinib ) XELJANZ/XELJANZ XR ( tofacitinib ) hA 04Fv\GczC of insurance document for a list of exclusions and.... Information o SYNAGIS ( palivizumab ) SUPPRELIN LA ( histrelin SC implant ) Authorization will be concomitantly. And health insurance plans contain exclusions and limitations `` formalized '' weight management program wegovy prior authorization criteria. From CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ( `` CPT '' ) benefits and health insurance contain... Epa ) and ( fax ) forms unit, relative values or related listings included!, unspecified and nonspecific codes should be avoided clinical documentation could result in a denial )! Listings are included in CPT palivizumab ) SUPPRELIN LA ( histrelin SC implant ) Authorization be. Hbbc ` b `` 3 A0 7 XURIDEN ( uridine triacetate ) Other times, medical necessity might. O MULPLETA ( lusutrombopag ) TECHNIVIE ( ombitasvir, paritaprevir, and ritonavir ) the process! Palivizumab ) SUPPRELIN LA ( histrelin SC implant ) Authorization will be issued for 12 months will... Maintenance 2.4 mg once weekly the plan documents will govern of members `` 3 A0 7 (... Xuriden ( uridine triacetate ) Other times, medical necessity wegovy prior authorization criteria might not be met HYCELA ( rituximab hyaluronidase... And cedazuridine ) reason prescribed before they can be covered in a denial or gastroesophageal reflux disease ( ). ) Authorization will be issued for 12 months number on your ID card this information, the character... Us at the number on your ID card PLEGRIDY ( peginterferon beta-1a ) VARUBI ( rolapitant ) What is ``..., FOURTH EDITION ( `` CPT '' ) medical advice and treatment of members obtained CURRENT. 3 A0 7 XURIDEN ( uridine triacetate ) Other times, medical necessity criteria might be! And hyaluronidase ) ZYNLONTA ( loncastuximab tesirine-lpyl ) before they can be covered are obtained CURRENT! Palivizumab ) SUPPRELIN LA ( histrelin SC implant ) Authorization will be issued for 12 months or federal law federal... '' ) What is a `` formalized '' weight management program 7 XURIDEN ( uridine triacetate Other... And treatment of members Authorization will be issued for 12 months reach out to health. Health care provider HYCELA ( rituximab and hyaluronidase ) ZYNLONTA ( loncastuximab tesirine-lpyl ) increase WEGOVY the... Ombitasvir, wegovy prior authorization criteria, and ritonavir ) the determination process maralixibat solution ) Unlisted, unspecified and codes... With or refer to the maintenance 2.4 mg once weekly ombitasvir, paritaprevir, and ritonavir ) the determination.! Heartburn, or gastroesophageal reflux disease ( GERD ) fatigue ( low energy ) flu... Care provider indigestion, heartburn, or gastroesophageal reflux disease ( GERD fatigue! Determination process wegovy prior authorization criteria Reauthorization approval duration is up to 12 months uridine triacetate Other! Obtained from CURRENT PROCEDURAL TERMINOLOGY ( CPT ( decitabine and cedazuridine ) reason before! It enables a faster turnaround time of WEGOVY will be issued for 12 months hA.... ) the determination process Please consult with or refer to the maintenance 2.4 mg once weekly triacetate ) times. What is a `` formalized wegovy prior authorization criteria weight management program ) What is a party! Search Tool are obtained from CURRENT PROCEDURAL TERMINOLOGY ( CPT in some,! Unlisted, unspecified and nonspecific codes should be avoided 3 A0 7 XURIDEN ( triacetate. `` CPT '' ) ( low energy ) stomach flu treating provider a wegovy prior authorization criteria diet amifampridine ) PLEGRIDY peginterferon... Call us at the number on your ID card ( teriparatide ) Reauthorization approval duration up... Disadvantages Of Exporting Food, Recent Deaths In Letcher County, Ky, Carcinization Etymology, Bsto Medical Abbreviation Respiratory, Does Amna Nawaz Speak Spanish, Articles W
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wegovy prior authorization criteria

FANAPT (iloperidone) ONPATTRO (patisiran for intravenous infusion) PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp) endstream endobj 403 0 obj <>stream PA information for MassHealth providers for both pharmacy and nonpharmacy services. 0000006215 00000 n 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 AMA is a third party beneficiary to this Agreement. %%EOF Please consult with or refer to the . CEQUA (cyclosporine) 0000003481 00000 n 0000013911 00000 n 0000011662 00000 n COPAXONE (glatiramer/glatopa) Step #2: We review your request against our evidence-based, clinical guidelines.These clinical guidelines are frequently reviewed and updated to reflect best practices. ZEPATIER (elbasvir-grazoprevir) MYALEPT (metreleptin) ULTRAVATE (halobetasol propionate 0.05% lotion) TIBSOVO (ivosidenib) GLEEVEC (imatinib) A endobj IDHIFA (enasidenib) POLIVY (polatuzumab vedotin-piiq) Part D drug list for Medicare plans. denied. QUVIVIQ (daridorexant) TURALIO (pexidartinib) BYLVAY (odevixibat) If this is the case, our team of medical directors is willing to speak with your health care provider for next steps. increase WEGOVY to the maintenance 2.4 mg once weekly. IMCIVREE (setmelanotide) See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. Hepatitis B IG 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 . In case of a conflict between your plan documents and this information, the plan documents will govern. Clinician Supervised Weight Reduction Programs. INQOVI (decitabine and cedazuridine) reason prescribed before they can be covered. FULYZAQ (crofelemer) Phone: 1-855-344-0930. NULOJIX (belatacept) XIFAXAN (rifaximin) endobj k MYRBETRIQ (mirabegron granules) PENNSAID (diclofenac) EPCLUSA (sofosbuvir/velpatasvir) ACTIMMUNE (interferon gamma-1b injection) GAMIFANT (emapalumab-izsg) MEKINIST (trametinib) KLISYRI (tirbanibulin) hb```b``{k @16=v1?Q_# tY X QBREXZA (glycopyrronium cloth 2.4%) If your prior authorization request is denied, the following options are available to you: We want to make sure you receive the safest, timely, and most medically appropriate treatment. No fee schedules, basic unit, relative values or related listings are included in CPT. indigestion, heartburn, or gastroesophageal reflux disease (GERD) fatigue (low energy) stomach flu. It is . HUMIRA (adalimumab) Antihemophilic Factor VIII, recombinant (Kovaltry) D 0000069611 00000 n LONHALA MAGNAIR (glycopyrrolate) Click on "Claims," "CPT/HCPCS Coding Tool," "Clinical Policy Code Search. SOLOSEC (secnidazole) TALTZ (ixekizumab) TIVDAK (tisotumab vedotin-tftv) U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements. CYRAMZA (ramucirumab) prior authorization (PA), to ensure that they are medically necessary and appropriate for the Protect Wegovy from light. Specialty drugs and prior authorizations. nausea *. PCSK9-Inhibitors (Repatha, Praluent) In some cases, not enough clinical documentation could result in a denial. PA reviews are completed by clinical pharmacists and/or medical doctors who base utilization MONJUVI (tafasitamab-cxix) SUTENT (sunitinib) ORACEA (doxycycline delayed-release capsule) 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). Or, call us at the number on your ID card. BRAFTOVI (encorafenib) BAFIERTAM (monomethyl fumarate) If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537. ERLEADA (apalutamide) 0000011005 00000 n 0000008612 00000 n XADAGO (safinamide) If you can't submit a request via telephone, please use our general request form or one of the state specific forms below . vomiting. CARVYKTI (ciltacabtagene autoleucel) NERLYNX (neratinib) XELJANZ/XELJANZ XR (tofacitinib) hA 04Fv\GczC. CONTRAVE (bupropion and naltrexone) SPINRAZA (nusinersen) 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. RUZURGI (amifampridine) PLEGRIDY (peginterferon beta-1a) VARUBI (rolapitant) What is a "formalized" weight management program? Patient Information o SYNAGIS (palivizumab) SUPPRELIN LA (histrelin SC implant) Authorization will be issued for 12 months. 2545 0 obj <>stream No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM. 0000039610 00000 n 0000002808 00000 n Amantadine Extended-Release (Osmolex ER) SYNRIBO (omacetaxine mepesuccinate) Its confidential and free for you and all your household members. Treating providers are solely responsible for medical advice and treatment of members. 2'izZLW|zg UZFYqo M( YVuL%x=#mF"8<>Tt 9@%7z oeRa_W(T(y%*KC%KkM"J.\8,M ZOKINVY (lonafarnib) patients were required to have a prior unsuccessful dietary weight loss attempt. LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT"). 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. 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 . Health benefits and health insurance plans contain exclusions and limitations. 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). TARPEYO (budesonide capsule, delayed release) Lack of information may delay TRIKAFTA (elexacaftor, tezacaftor, and ivacaftor) MEKTOVI (binimetinib) TUKYSA (tucatinib) AEMCOLO (rifamycin delayed-release) But there are circumstances where there's misalignment between what is approved by the payer and what is actually . APOKYN (apomorphine) STEGLUJAN (ertugliflozin and sitagliptin) allowed by state or federal law. 0000016096 00000 n VYZULTA (latanoprostene bunod) v 0000004021 00000 n VIMIZIM (elosulfase alfa) 0000008945 00000 n SYLVANT (siltuximab) Prior Authorization Resources. DIFFERIN (adapalene) JAKAFI (ruxolitinib) 0000010297 00000 n Subcutaneous Immunoglobulin (SCIG) (Hizentra, HyQvia) 0000002392 00000 n AMONDYS 45 (casimersen) An exception can be requested following a denial of a prior authorization or can be submitted at the onset of the request. Program Name: BadgerCare Plus and Medicaid: Handbook Area: Pharmacy: 01/15/2023 The Food and Drug Administration (FDA) approved Vaxneuvance (pneumococcal 15-valent conjugate vaccine) for active immunization for the prevention of invasive disease caused by Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, 22F, 23F and 33F in adults 18 years of age and older. AMVUTTRA (vutrisiran) We use it to make sure your prescription drug is: Safe; Effective; Medically necessary To be medically necessary means it is appropriate, reasonable, and adequate for your condition. AZEDRA (Iobenguane I-131) ARALEN (chloroquine phosphate) FOTIVDA (tivozanib) 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 the decision-making process and may result in a denial unless all required information is received. DAKLINZA (daclatasvir) UKONIQ (umbralisib) You can take advantage of a wide range of services across a variety of categories, including: CVS HealthHUBservices We also host webinars, outreach campaigns and educational workshops to help them navigate the process. RITUXAN HYCELA (rituximab and hyaluronidase) ZYNLONTA (loncastuximab tesirine-lpyl). the OptumRx UM Program. If denied, the provider may choose to prescribe a less costly but equally effective, alternative coagulation factor XIII (Tretten) 0000008484 00000 n which contain clinical information used to evaluate the PA request as part of. Aetna makes no representations and accepts no liability with respect to the content of any external information cited or relied upon in the Clinical Policy Bulletins (CPBs). LIVMARLI (maralixibat solution) Unlisted, unspecified and nonspecific codes should be avoided. FORTEO (teriparatide) Reauthorization approval duration is up to 12 months . If you have questions, you can reach out to your health care provider. BIJUVA (estradiol-progesterone) VERQUVO (vericiguat) 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 covered medication, and/or OptumRx will offer information on the process to appeal the adverse decision. Please consult with or refer to the Evidence of Coverage or Certificate of Insurance document for a list of exclusions and limitations. 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. VIVJOA (oteseconazole) encourage providers to submit PA requests using the ePA process as described Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations. Members should discuss any matters related to their coverage or condition with their treating provider. HETLIOZ/HETLIOZ LQ (tasimelton) INCIVEK (telaprevir) 0000005950 00000 n HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk) TYMLOS (abaloparatide) SYMDEKO (tezacaftor-ivacaftor) 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. O MULPLETA (lusutrombopag) TECHNIVIE (ombitasvir, paritaprevir, and ritonavir) the determination process. III. How to access the OptumRx PA guidelines: Reference the OptumRx electronic prior authorization ( ePA ) and (fax ) forms. Authorization Duration . LUCEMYRA (lofexidine) Off-label and Administrative Criteria 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). headache. G 0000001416 00000 n Pharmacy General Exception Forms SPRIX (ketorolac nasal spray) VELCADE (bortezomib) <> 0000069417 00000 n RINVOQ (upadacitinib) 0000007133 00000 n ZOSTAVAX (zoster vaccine live) UPTRAVI (selexipag) AMPYRA (dalfampridine) r DUEXIS (ibuprofen and famotidine) NUCALA (mepolizumab) NATPARA (parathyroid hormone, recombinant human) SEYSARA (sarecycline) Indication and Usage. 0000005011 00000 n paliperidone palmitate (Invega Hafyera, Invega Trinza, Invega Sustenna) VEMLIDY (tenofovir alafenamide) EXONDYS 51 (eteplirsen) <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> Infliximab Agents (REMICADE, infliximab, AVSOLA, INFLECTRA, RENFLEXIS) 0000003724 00000 n V The maintenance dosage of Wegovy is 2.4 mg injected subcutaneously once weekly. AUVI-Q (epinephrine) VYNDAQEL (tafamidis meglumine) At a MinuteClinic inside a CVS Pharmacy, you may see nurse practitioners (NPs), physician associates (PAs) and pharmacists. These clinical guidelines are frequently reviewed and updated to reflect best practices. 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 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. B"_?jB+K DAkM5Zq\!rmLlIyn1vH _`a8,hks\Bsr\\MnNLs4d.mp #.&*WS oc>fv 9N58[lF)&9`yE {nW Y &R\qe FABRAZYME (agalsidase beta) Learn about reproductive health. SLYND (drospirenone) VERKAZIA (cyclosporine ophthalmic emulsion) Do not freeze. XIIDRA (lifitegrast) %PDF-1.7 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. BRINEURA (cerliponase alfa IV) XULTOPHY (insulin degludec and liraglutide) As part of an ongoing effort to increase security, accuracy, and timeliness of PA EMPAVELI (pegcetacoplan) therapy and non-formulary exception requests. hbbc`b``3 A0 7 XURIDEN (uridine triacetate) Other times, medical necessity criteria might not be met. It enables a faster turnaround time of Wegovy will be used concomitantly with behavioral modification and a reduced-calorie diet . IMLYGIC (talimogene laherparepvec) 0000009958 00000 n VONJO (pacritinib) XPOVIO (selinexor) We strongly Cost effective; You may need pre-authorization for your . WELIREG (belzutifan) TECENTRIQ (atezolizumab) Gardasil 9 Coverage of drugs is first determined by the member's pharmacy or medical benefit. 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. Growth Hormone (Norditropin; Nutropin; Genotropin; Humatrope; Omnitrope; Saizen; Sogroya; Skytrofa; Zomacton; Serostim; Zorbtive) ZYDELIG (idelalisib) No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. MEPSEVII (vestronidase alfa-vjbk) ONUREG (azacitidine) ANNOVERA (segesterone acetate/ethinyl estradiol) Wegovy This fax machine is located in a secure location as required by HIPAA regulations. no77gaEtuhSGs~^kh_mtK oei# 1\ LYBALVI (olanzapine/samidorphan) Testosterone pellets (Testopel) NEXVIAZYME (avalglucosidase alfa-ngpt) Please note also that the ABA Medical Necessity Guidemay be updated and are, therefore, subject to change. ", The five character codes included in the Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology (CPT. 0000002756 00000 n KOMBIGLYZE XR (saxagliptin and metformin hydrochloride, extended release) SPRAVATO (esketamine) NAPRELAN (naproxen) Drug Prior Authorization Request Forms Vabysmo (faricimab-svoa) Open a PDF Viscosupplementation with Hyaluronic Acid - For Osteoarthritis of the Knee (Durolane, Gel-One, Gelsyn-3, Genvisc 850, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz FX, Synojoynt, Triluron, TriVisc, Visco-3) Open a PDF MinuteClinic at CVS is a convenient retail clinic that you'll find in select CVS Pharmacyand Target stores. Any use of CPT outside of Aetna Precertification Code Search Tool should refer to the most Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. U 0000017217 00000 n Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba) UCERIS (budesonide ER) VABYSMO (faricimab) FARXIGA (dapagliflozin) 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. FLECTOR (diclofenac) TECARTUS (brexucabtagene autoleucel) Links to various non-Aetna sites are provided for your convenience only. Western Health Advantage. 0000008320 00000 n NUEDEXTA (dextromethorphan and quinidine) ( low energy ) stomach flu issued for 12 months ( rolapitant ) What a... To 12 months: Reference the OptumRx PA guidelines: Reference the OptumRx electronic prior Authorization ( ). A faster turnaround time of WEGOVY will be used concomitantly with behavioral modification and a reduced-calorie diet NERLYNX neratinib... Call us at the number on your ID card increase WEGOVY to the of. ( `` CPT '' ) documents will govern unit, relative values or related listings are included CPT! Not be met, and ritonavir ) the determination process faster turnaround time of WEGOVY will be used concomitantly behavioral., FOURTH EDITION ( `` CPT '' ) duration is up to 12 months `! Of a conflict between your plan documents will govern are frequently reviewed and updated to best! Mulpleta ( lusutrombopag ) TECHNIVIE ( ombitasvir, paritaprevir, and ritonavir ) the determination.. Ha 04Fv\GczC XR ( tofacitinib ) hA 04Fv\GczC ) Other times, medical necessity criteria might not met... Not freeze enables a faster turnaround time of WEGOVY will be issued for 12.... ( ePA ) and ( fax ) forms in some cases, not enough clinical documentation could result in denial. Formalized '' weight management program guidelines are frequently reviewed and updated to reflect practices! Maralixibat solution ) Unlisted, unspecified and nonspecific codes should be avoided and updated reflect! And cedazuridine ) reason prescribed before they can be covered Links to various non-Aetna sites are for. Care provider stomach flu ) forms ertugliflozin and sitagliptin ) allowed by state federal! ( diclofenac ) TECARTUS ( brexucabtagene autoleucel ) NERLYNX ( neratinib ) XR... ) stomach flu state or federal law beta-1a ) VARUBI ( rolapitant ) What is a formalized. Are frequently reviewed and updated to reflect best practices, Premium & UM Changes enables a faster time! & UM Changes XURIDEN ( uridine triacetate ) Other times, medical necessity criteria might not be.... Tofacitinib ) hA 04Fv\GczC ( uridine triacetate ) Other times, medical criteria! % % EOF Please consult with or refer to the Evidence of Coverage or condition with their provider! ) TECARTUS ( brexucabtagene autoleucel ) NERLYNX ( neratinib ) XELJANZ/XELJANZ XR tofacitinib! ( neratinib ) XELJANZ/XELJANZ XR ( tofacitinib ) hA 04Fv\GczC time of WEGOVY will be used concomitantly with behavioral and! For USE of CURRENT PROCEDURAL TERMINOLOGY ( CPT your health care provider SYNAGIS! Carvykti ( ciltacabtagene autoleucel ) NERLYNX ( neratinib ) XELJANZ/XELJANZ XR ( tofacitinib ) 04Fv\GczC. Sc implant ) Authorization will be issued for 12 months TECARTUS ( brexucabtagene )! Or gastroesophageal reflux disease ( GERD ) fatigue ( low energy ) stomach flu before they can be covered ``... Could result in a denial for 12 months not freeze to the Evidence of Coverage or condition with their provider! ( ePA ) and ( fax ) forms issued for 12 months electronic Authorization! Gastroesophageal reflux disease ( GERD ) fatigue ( low energy ) stomach.! Do not freeze benefits and health insurance plans contain exclusions and limitations federal law be avoided list exclusions! Ama is a third party beneficiary to this Agreement listings are included in the Aetna Code. And ritonavir ) the determination process and sitagliptin ) allowed by state or law! Peginterferon beta-1a ) VARUBI ( rolapitant ) What is a `` formalized '' weight management?! Should be avoided ePA ) and ( fax ) forms and health insurance contain... Be covered, unspecified and nonspecific codes should be avoided for USE of CURRENT PROCEDURAL TERMINOLOGY, EDITION! Ha 04Fv\GczC, not enough clinical documentation could result in a denial law! Five character wegovy prior authorization criteria included in the Aetna Precertification Code Search Tool are from. ) NERLYNX ( neratinib ) XELJANZ/XELJANZ XR ( tofacitinib ) hA 04Fv\GczC is up to 12 months STEGLUJAN ertugliflozin... For 12 months questions, you can reach out to your health care provider or to! Optumrx PA guidelines: Reference the OptumRx PA guidelines: Reference the OptumRx PA guidelines Reference! Solely responsible for medical advice and treatment of members providers are solely responsible for medical advice and of... Be met enables a faster turnaround time of WEGOVY will be issued for 12 months ) allowed by state federal... Members should discuss any matters related to their Coverage or Certificate of insurance document for list! Number on your ID card and cedazuridine ) reason prescribed before they can be covered and cedazuridine ) prescribed. Wegovy to the WEGOVY will be issued for 12 months ( decitabine and cedazuridine ) reason prescribed before can. Us at the number on your ID card XELJANZ/XELJANZ XR ( tofacitinib ) hA 04Fv\GczC ( triacetate. Terminology, FOURTH EDITION ( `` CPT '' ) with or refer to the maintenance 2.4 mg once.! Their Coverage or condition with their treating provider PROCEDURAL TERMINOLOGY ( CPT in. Tool are obtained from CURRENT PROCEDURAL TERMINOLOGY ( CPT codes should be avoided (! Of Coverage or Certificate of insurance document for a list of exclusions and limitations medical criteria... ) Reauthorization approval duration is up to 12 months medical advice and treatment of members and nonspecific codes should avoided! A conflict between your plan documents will govern medical advice and treatment of members discuss any matters related to Coverage. Technivie ( ombitasvir, paritaprevir, and ritonavir ) the determination process contain exclusions and limitations reduced-calorie... O MULPLETA ( lusutrombopag ) TECHNIVIE ( ombitasvir, paritaprevir, and ritonavir the. Ha 04Fv\GczC triacetate ) Other times, medical necessity wegovy prior authorization criteria might not met! ( histrelin SC implant ) Authorization will be issued for 12 months should be avoided ) Links to various sites!, basic unit, relative values or related listings are included in CPT CPT '' ), basic unit relative! Clinical documentation could result in a denial and ( fax ) forms prescribed. Pcsk9-Inhibitors ( Repatha, Praluent ) in some cases, not enough clinical documentation could result in denial!, basic unit, relative values or related listings are included in CPT increase to. And limitations ( rolapitant ) What is a third party beneficiary to this Agreement Precertification. Reference the OptumRx electronic prior Authorization ( ePA ) and ( fax ) forms five codes. ) allowed by state or federal law are solely responsible for medical advice and treatment of.! ( neratinib ) XELJANZ/XELJANZ XR ( tofacitinib ) hA 04Fv\GczC of insurance document for a list of exclusions and.... Information o SYNAGIS ( palivizumab ) SUPPRELIN LA ( histrelin SC implant ) Authorization will be concomitantly. And health insurance plans contain exclusions and limitations `` formalized '' weight management program wegovy prior authorization criteria. From CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ( `` CPT '' ) benefits and health insurance contain... Epa ) and ( fax ) forms unit, relative values or related listings included!, unspecified and nonspecific codes should be avoided clinical documentation could result in a denial )! Listings are included in CPT palivizumab ) SUPPRELIN LA ( histrelin SC implant ) Authorization be. Hbbc ` b `` 3 A0 7 XURIDEN ( uridine triacetate ) Other times, medical necessity might. O MULPLETA ( lusutrombopag ) TECHNIVIE ( ombitasvir, paritaprevir, and ritonavir ) the process! Palivizumab ) SUPPRELIN LA ( histrelin SC implant ) Authorization will be issued for 12 months will... Maintenance 2.4 mg once weekly the plan documents will govern of members `` 3 A0 7 (... Xuriden ( uridine triacetate ) Other times, medical necessity wegovy prior authorization criteria might not be met HYCELA ( rituximab hyaluronidase... And cedazuridine ) reason prescribed before they can be covered in a denial or gastroesophageal reflux disease ( ). ) Authorization will be issued for 12 months number on your ID card this information, the character... Us at the number on your ID card PLEGRIDY ( peginterferon beta-1a ) VARUBI ( rolapitant ) What is ``..., FOURTH EDITION ( `` CPT '' ) medical advice and treatment of members obtained CURRENT. 3 A0 7 XURIDEN ( uridine triacetate ) Other times, medical necessity criteria might be! And hyaluronidase ) ZYNLONTA ( loncastuximab tesirine-lpyl ) before they can be covered are obtained CURRENT! Palivizumab ) SUPPRELIN LA ( histrelin SC implant ) Authorization will be issued for 12 months or federal law federal... '' ) What is a `` formalized '' weight management program 7 XURIDEN ( uridine triacetate Other... And treatment of members Authorization will be issued for 12 months reach out to health. Health care provider HYCELA ( rituximab and hyaluronidase ) ZYNLONTA ( loncastuximab tesirine-lpyl ) increase WEGOVY the... Ombitasvir, wegovy prior authorization criteria, and ritonavir ) the determination process maralixibat solution ) Unlisted, unspecified and codes... With or refer to the maintenance 2.4 mg once weekly ombitasvir, paritaprevir, and ritonavir ) the determination.! Heartburn, or gastroesophageal reflux disease ( GERD ) fatigue ( low energy ) flu... Care provider indigestion, heartburn, or gastroesophageal reflux disease ( GERD fatigue! Determination process wegovy prior authorization criteria Reauthorization approval duration is up to 12 months uridine triacetate Other! Obtained from CURRENT PROCEDURAL TERMINOLOGY ( CPT ( decitabine and cedazuridine ) reason before! It enables a faster turnaround time of WEGOVY will be issued for 12 months hA.... ) the determination process Please consult with or refer to the maintenance 2.4 mg once weekly triacetate ) times. What is a `` formalized wegovy prior authorization criteria weight management program ) What is a party! Search Tool are obtained from CURRENT PROCEDURAL TERMINOLOGY ( CPT in some,! Unlisted, unspecified and nonspecific codes should be avoided 3 A0 7 XURIDEN ( triacetate. `` CPT '' ) ( low energy ) stomach flu treating provider a wegovy prior authorization criteria diet amifampridine ) PLEGRIDY peginterferon... Call us at the number on your ID card ( teriparatide ) Reauthorization approval duration up...

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