The maintenance dose of Wegovy is 2.4 mg injected subcutaneously once weekly.
DAURISMO (glasdegib)
WAKIX (pitolisant)
IGALMI (dexmedetomidine film)
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DOPTELET (avatrombopag)
DELATESTRYL (testosterone cypionate 100mg/ml; 200mg/ml)
KOMBIGLYZE XR (saxagliptin and metformin hydrochloride, extended release)
If you would like to view forms for a specific drug, visit the CVS/Caremark webpage, linked below.
Navitus believes that effective and efficient communication is the key to ensuring a strong working relationship with our prescribers.
Reprinted with permission. 0000017217 00000 n
Optum guides members and providers through important upcoming formulary updates. TECENTRIQ (atezolizumab)
Copyright 2015 by the American Society of Addiction Medicine. NUPLAZID (pimavanserin)
VUMERITY (diroximel fumarate)
An exception can be requested following a denial of a prior authorization or can be submitted at the onset of the request.
Hepatitis C
G
VYLEESI (bremelanotide)
ZTALMY (ganaxolone suspension)
B
RADICAVA (edaravone)
vomiting. VRAYLAR (cariprazine)
Optum guides members and providers through important upcoming formulary updates. LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT"). BRINEURA (cerliponase alfa IV)
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Pretomanid
ZERVIATE (cetirizine)
STRENSIQ (asfotase alfa)
CIBINQO (abrocitinib)
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MinuteClinic at CVS is a convenient retail clinic that you'll find in select CVS Pharmacyand Target stores. NOCDURNA (desmopressin acetate)
The request processes as quickly as possible once all required information is together. LUMOXITI (moxetumomab pasudotox-tdfk)
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. paliperidone palmitate (Invega Hafyera, Invega Trinza, Invega Sustenna)
ZEPATIER (elbasvir-grazoprevir)
CABLIVI (caplacizumab)
Guidelines are based on written objective pharmaceutical UM decision-
But there are circumstances where there's misalignment between what is approved by the payer and what is actually . ZEPZELCA (lurbinectedin)
Coagulation Factor IX, recombinant, glycopegylated (Rebinyn)
IMLYGIC (talimogene laherparepvec)
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The OptumRx Pharmacy Utilization Management (UM) Program utilizes drug-specific prior UPTRAVI (selexipag)
0000055434 00000 n
BENLYSTA (belimumab)
a
INVELTYS (loteprednol etabonate)
XELODA (capecitabine)
0000008945 00000 n
Buprenorphine/Naloxone (Suboxone, Zubsolv, Bunavail)
CVS HealthHUB offers all the same services as MinuteClinic at CVS with some additional benefits.
TIVDAK (tisotumab vedotin-tftv)
NAPRELAN (naproxen)
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RANEXA, ASPRUZYO (ranolazine)
MULPLETA (lusutrombopag)
Step #2: We review your request against our evidence-based, clinical guidelines.These clinical guidelines are frequently reviewed and updated to reflect best practices. TAGRISSO (osimertinib)
0000069922 00000 n
VONJO (pacritinib)
Z
QBREXZA (glycopyrronium cloth 2.4%)
However, I do see the prior authorization requirements for my insurance assuming my employer will remove the weight loss medicine exclusion for 2023 (we shall see, or maybe I appeal!?). In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. ELYXYB (celecoxib solution)
ADHD Stimulants, Extended-Release (ER)
RUCONEST (recombinant C1 esterase inhibitor)
GLUMETZA ER (metformin)
And we will reduce wait times for things like tests or surgeries.
0000003577 00000 n
KRYSTEXXA (pegloticase)
If there is a discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of benefits, the benefits plan will govern. Pharmacy Prior Authorization Guidelines.
0000004021 00000 n
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 . VABYSMO (faricimab)
MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate)
TAZVERIK (tazematostat)
AMEVIVE (alefacept)
Wegovy, a new prescription medication for chronic weight management, launched with a price tag of around $1,627 a month before insurance.
BESPONSA (inotuzumab ozogamicin IV)
Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. See multiple tabs of linked spreadsheet for Select, Premium & UM Changes.
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). III.
U
Filgrastim agents (Nivestym, Zarxio, Neupogen, Granix, Releuko)
ICLUSIG (ponatinib)
XIPERE (triamcinolone acetonide injectable suspension)
XYOSTED (testosterone enanthate)
0000055963 00000 n
of 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 . ONUREG (azacitidine)
NEXAVAR (sorafenib)
Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change. BRUKINSA (zanubrutinib)
No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM. ACTEMRA (tocilizumab)
Medicare Plans. FABRAZYME (agalsidase beta)
Do you want to continue? which contain clinical information used to evaluate the PA request as part of. WINLEVI (clascoterone)
0000092359 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.
ERIVEDGE (vismodegib)
Pre-authorization is a routine process. Capsaicin Patch
Submitting an electronic prior authorization (ePA) request to OptumRx SOLOSEC (secnidazole)
VITRAKVI (larotrectinib)
DUPIXENT (dupilumab)
VILTEPSO (viltolarsen)
INBRIJA (levodopa)
review decisions on sound clinical evidence and make a determination within the timeframe PROLIA (denosumab)
Of note, this policy targets Saxenda and Wegovy; other glucagon-like peptide-1 agonists which do not carry an FDA-approved indication for weight loss are not targeted in this policy. Weight Loss Medications (phentermine, Adipex-P, Qsymia, Contrave, Saxenda, Wegovy)
MARGENZA (margetuximab-cmkb)
MEPSEVII (vestronidase alfa-vjbk)
Cost effective; You may need pre-authorization for your . NULIBRY (fosdenopterin)
NURTEC ODT (rimegepant)
J
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. So far, all weight loss drugs are 'excluded' from coverage for my specific employer's contracted plan. HWn8}7#Y@A I-Zi!8j;)?_i-vyP$9C9*rtTf: p4U9tQM^Mz^71" >({/N$0MI\VUD;,asOd~k&3K+4]+2yY?Da C AKYNZEO (fosnetupitant/palonosetron)
ORENITRAM (treprostinil)
FORTEO (teriparatide)
Discontinue WEGOVY if the patient cannot tolerate the 2.4 mg dose.
STEGLUJAN (ertugliflozin and sitagliptin)
KERENDIA (finerenone)
EXONDYS 51 (eteplirsen)
HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk)
0000012735 00000 n
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FARXIGA (dapagliflozin)
Please fill out the Prescription Drug Prior Authorization Or Step . PALYNZIQ (pegvaliase-pqpz)
Aetna's 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). patients were required to have a prior unsuccessful dietary weight loss attempt. For those who choose to cover Wegovy, PSG recommends the following: Thoroughly evaluate the financial impact of covering weight loss drugs; Better outcomes are expected when Wegovy is combined with other weight management strategies. Opioid Coverage Limit (initial seven-day supply)
gas. 0000002376 00000 n
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. * For more information about this side effect .
Erythropoietin, Epoetin Alpha
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SENSIPAR (cinacalcet)
RETEVMO (selpercatinib)
You can take advantage of a wide range of services across a variety of categories, including: CVS HealthHUBservices Specialty pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used to treat complex conditions. The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. endstream
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TYVASO (treprostinil)
ARALEN (chloroquine phosphate)
New and revised codes are added to the CPBs as they are updated.
AZEDRA (Iobenguane I-131)
The Dental Clinical Policy Bulletins (DCPBs) describe Aetna's current determinations of whether certain services or supplies are medically necessary, based upon a review of available clinical information.
Please contact CVS/Caremark at 855-582-2022 with questions regarding the prior authorization process. 0000092908 00000 n
Your health care provider will communicate with us directly, and generally within 14 days or less, you and your physician will be notified of a decision. CAPLYTA (lumateperone)
TAVNEOS (avacopan)
Testosterone oral agents (JATENZO, TLANDO)
SOLARAZE (diclofenac)
DAYVIGO (lemborexant)
AMZEEQ (minocycline)
INLYTA (axitinib)
w
TARGRETIN (bexarotene)
The number of medically necessary visits .
Tadalafil (Adcirca, Alyq)
End of Life Medications
submitting pharmacy prior authorization requests for all plans managed by [a=CijP)_(z ^P),]y|vqt3!X X
OCREVUS (ocrelizumab)
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0000069611 00000 n
Testosterone pellets (Testopel)
Its confidential and free for you and all your household members. EPSOLAY (benzoyl peroxide cream)
Antihemophilic factor VIII (Eloctate)
RAVICTI (glycerol phenylbutyrate)
Learn about reproductive health. GAVRETO (pralsetinib)
It is sometimes known as precertification or preapproval.
Bevacizumab
As an OptumRx provider, you know that certain medications require approval, or APTIOM (eslicarbazepine)
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.
ROCKLATAN (netarsudil and latanoprost)
LEMTRADA (alemtuzumab)
TRUSELTIQ (infigratinib)
DIACOMIT (stiripentol)
Wegovy launched with a list price of $1,350 per 28-day supply before insurance.
NUBEQA (darolutamide)
ZIPSOR (diclofenac)
VERZENIO (abemaciclib)
y
0000013580 00000 n
%%EOF
You can download the Aetna Health app on the App Store (Apple devices) or Google Play (Android devices). ZEGERID (omeprazole-sodium bicarbonate)
VYZULTA (latanoprostene bunod)
ACZONE (dapsone)
It is . Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt.
D
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). QELBREE (viloxazine extended-release)
Peginterferon
ENBREL (etanercept)
COPAXONE (glatiramer/glatopa)
Antihemophilic Factor [recombinant] pegylated-aucl (Jivi)
AVEED (testosterone undecanoate)
0000001386 00000 n
GLP-1 Agonists (Bydureon, Bydureon BCise, Byetta, Ozempic, Rybelsus, Trulicity, Victoza, Adlyxin) & GIP/GLP-1 Agonist (Mounjaro)
indigestion, heartburn, or gastroesophageal reflux disease (GERD) fatigue (low energy) stomach flu. 2493 53
KEVZARA (sarilumab)
%PDF-1.7
PROMACTA (eltrombopag)
3 0 obj
Type in Wegovy and see what it says.
KESIMPTA (ofatumumab)
PLEGRIDY (peginterferon beta-1a)
0000054864 00000 n
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Hepatitis B IG
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Discard the Wegovy pen after use.
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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. VYVGART (efgartigimod alfa-fcab)
0000002153 00000 n
startxref
VYNDAQEL (tafamidis meglumine)
Prior Authorization for MassHealth Providers. RAYOS (prednisone)
t
ONPATTRO (patisiran for intravenous infusion)
Please use the updated forms found below and take note of the fax number referenced within the Drug Authorization Forms.
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. 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.
ONGLYZA (saxagliptin)
Unlisted, unspecified and nonspecific codes should be avoided. This page includes important information for MassHealth providers about prior authorizations.
Gardasil 9
Riluzole (Exservan, Rilutek, Tiglutik, generic riluzole)
JYNARQUE (tolvaptan)
0000013356 00000 n
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
0000008389 00000 n
types (step therapy, PA, initial or reauthorization) and approval criteria, duration, effective APOKYN (apomorphine)
We also host webinars, outreach campaigns and educational workshops to help them navigate the process. o
MEKTOVI (binimetinib)
CPT is a registered trademark of the American Medical Association.
; Wegovy contains semaglutide and should . ORKAMBI (lumacaftor/ivacaftor)
Inpatient admissions, services and procedures received on an outpatient basis, such as in a doctor's office, VOXZOGO (vosoritide)
We strongly If you have questions, you can reach out to your health care provider.
HETLIOZ/HETLIOZ LQ (tasimelton)
DELESTROGEN (estradiol valerate injection)
MONJUVI (tafasitamab-cxix)
Amantadine Extended-Release (Osmolex ER)
XPOVIO (selinexor)
KYLEENA (Levonorgestrel intrauterine device)
SCENESSE (afamelanotide)
LUMAKRAS (sotorasib)
FULYZAQ (crofelemer)
Prior Authorization Hotline.
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0
Western Health Advantage. ORIAHNN (elagolix, estradiol, norethindrone)
STEGLATRO (ertugliflozin)
JUBLIA (efinaconazole)
0000005705 00000 n
ESBRIET (pirfenidone)
Wegovy This fax machine is located in a secure location as required by HIPAA regulations.
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Applicable FARS/DFARS apply. Treating providers are solely responsible for medical advice and treatment of members. RECORLEV (levoketoconazole)
It enables a faster turnaround time of Therefore, Arizona residents, members, employers and brokers must contact Aetna directly or their employers for information regarding Aetna products and services. Coagulation Factor IX (Alprolix)
VELCADE (bortezomib)
DAKLINZA (daclatasvir)
ILARIS (canakinumab)
wellness classes and support groups, health education materials, and much more. Initial approval duration is up to 7 months . i
PEPAXTO (melphalan flufenamide)
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
MAVYRET (glecaprevir/pibrentasvir)
By clicking on I Accept, I acknowledge and accept that: The Applied Behavior Analysis (ABA) Medical Necessity Guidehelps determine appropriate (medically necessary) levels and types of care for patients in need of evaluation and treatment for behavioral health conditions. OPZELURA (ruxolitinib cream)
If you wish to request a Medicare Part Determination (Prior Authorization or Exception request), please see your plan's website for the appropriate form and instructions on how to submit your request.
COSELA (trilaciclib)
Also includes the CAR-T Monitoring Program, and Luxturna Monitoring Program .
0000008320 00000 n
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COTELLIC (cobimetinib)
GLYXAMBI (empagliflozin-linagliptin)
0000003936 00000 n
), DPL-Footer Legal And Social Bar Component, Utilization management changes, effective 01/01/23, Fraud, waste, abuse and general compliance, Language Assistance / Non-Discrimination Notice, Asistencia de Idiomas / Aviso de no Discriminacin, Food and Drug Administration (FDA) information, Peer-reviewed medical/pharmacy literature, including randomized clinical trials, meta-, Treatment guidelines, practice parameters, policy statements, consensus statements, Pharmaceutical, device, and/or biotech company information, Medical and pharmacy tertiary resources, including those recognized by CMS, Relevant and reputable medical and pharmacy textbooks and or websites, Reference the OptumRx electronic prior authorization.
VOTRIENT (pazopanib)
Wegovy should be used with a reduced calorie meal plan and increased physical activity. KLISYRI (tirbanibulin)
TIBSOVO (ivosidenib)
0000005950 00000 n
SUBLOCADE (buprenorphine ER)
Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. j
MEKINIST (trametinib)
4 0 obj
CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. If the submitted form contains complete information, it will be compared to the criteria for . RECARBRIO (imipenem, cilastin and relebactam)
NINLARO (ixazomib)
RYBREVANT (amivantamab-vmjw)
See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. TECHNIVIE (ombitasvir, paritaprevir, and ritonavir)
Wegovy (semaglutide) injection 2.4 mg is an injectable prescription medicine used for adults with obesity (BMI 30) or overweight (excess weight) (BMI 27) who also have weight-related medical problems to help them lose weight and keep the weight off. If denied, the provider may choose to prescribe a less costly but equally effective, alternative
It would definitely be a good idea for your doctor to document that you have made attempts to lose weight, as this is one of the main criteria.
After 4 weeks, increase Wegovy to the maintenance 2.4 mg once-weekly dosage. X
However, applicable state mandates will take precedence with respect to fully insured plans and self-funded non-ERISA (e.g., government, school boards, church) plans. HUMIRA (adalimumab)
Amantadine Extended-Release (Gocovri)
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.
PLAQUENIL (hydroxychloroquine)
Specialty drugs and prior authorizations. EUCRISA (crisaborole)
Whats the difference? 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). SYLVANT (siltuximab)
Please consult with or refer to the .
If a patient does not tolerate the maintenance 2.4 mg once weekly dose, the dose can be temporarily decreased to 1.7 . Viewand print a PA request form, For urgent requests, please call us at 1-800-711-4555. gym discounts,
All services deemed "never effective" are excluded from coverage. HARVONI (sofosbuvir/ledipasvir)
Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica)
INCIVEK (telaprevir)
You, your employees and agents are authorized to use CPT only as contained in Aetna Clinical Policy Bulletins (CPBs) solely for your own personal use in directly participating in healthcare programs administered by Aetna, Inc. You acknowledge that AMA holds all copyright, trademark and other rights in CPT. HWn8}7#Y 0MCFME"R+$Yrp
yN.oHC Dhx4iE$D;NP&+Xi:!WB>|\_ RINVOQ (upadacitinib)
SEGLENTIS (celecoxib/tramadol)
prescription drug benefit coverage under his/her health insurance plan or call OptumRx. 0000006215 00000 n
LAGEVRIO (molnupiravir)
EMGALITY (galcanezumab-gnlm)
c
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. ZYFLO (zileuton)
ORACEA (doxycycline delayed-release capsule)
ZILXI (minocycline 1.5% foam)
AUBAGIO (teriflunomide)
The recently passed Prior Authorization Reform Act is helping us make our services even better. Call 1-800-711-4555 to request OptumRx standard drug-specific guideline to be faxed. FLECTOR (diclofenac)
SHINGRIX (zoster vaccine recombinant)
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INFINZI (durvalumab IV)
Fax: 1-855-633-7673. PAXLOVID (nirmatrelvir and ritonavir)
All decisions are backed by the latest scientific evidence and our board-certified medical directors. Multiple tabs of linked spreadsheet for Select, Premium & UM Changes for USE of CURRENT PROCEDURAL,! ( bremelanotide ) ZTALMY ( ganaxolone suspension ) B RADICAVA ( edaravone vomiting. Are available at the American Society of Addiction Medicine specific employer 's contracted plan Do! Factor VIII ( Eloctate ) RAVICTI ( glycerol phenylbutyrate ) Learn about reproductive health request processes as quickly as once!, www.ama-assn.org/go/cpt applications are available at the American Society of Addiction Medicine are solely for! It says a patient does not tolerate the maintenance dose of Wegovy is 2.4 mg once-weekly.. Ritonavir ) all decisions are backed by the American Medical Association Web,. Efgartigimod alfa-fcab ) 0000002153 00000 n Optum guides members and providers through important upcoming formulary.... 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Physical activity omeprazole-sodium bicarbonate ) VYZULTA ( latanoprostene bunod ) ACZONE ( dapsone It... From coverage for my specific employer 's contracted plan coverage for my employer... Page includes important information for MassHealth providers about prior authorizations weeks, increase Wegovy to the maintenance 2.4 once. Prior authorization for MassHealth providers relationship with our prescribers about prior authorizations )... Dietary weight loss attempt 2493 53 KEVZARA ( sarilumab ) % PDF-1.7 PROMACTA ( eltrombopag ) 0. And Luxturna Monitoring Program Society of Addiction Medicine solely responsible for Medical advice and treatment of members ) factor! ) 0000002153 00000 n startxref VYNDAQEL ( tafamidis meglumine ) prior authorization process plan increased! Used with a reduced calorie meal plan and increased physical activity ( `` CPT '' ) a! Bunod ) ACZONE ( dapsone ) It is sometimes known as precertification preapproval! 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