CIALIS (tadalafil) Prior Authorization Resources. 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. 0000008389 00000 n LAGEVRIO (molnupiravir) PIQRAY (alpelisib) XTAMPZA ER (oxycodone) BOSULIF (bosutinib) Erythropoietin, Epoetin Alpha ADLARITY (donepezil hydrochloride patch) ISTURISA (osilodrostat) endstream endobj 403 0 obj <>stream 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. TALZENNA (talazoparib) z Pretomanid REBLOZYL (luspatercept) BYLVAY (odevixibat) ROCKLATAN (netarsudil and latanoprost) MAVENCLAD (cladribine) Under certain plans, if more than one service can be used to treat a covered person's dental condition, Aetna may decide to authorize coverage only for a less costly covered service provided that certain terms are met. 0000005705 00000 n XERMELO (telotristat ethyl) 0000001416 00000 n Wegovy should be used with a reduced calorie meal plan and increased physical activity. 3 0 obj ELZONRIS (tagraxofusp) VARUBI (rolapitant) The recently passed Prior Authorization Reform Act is helping us make our services even better. COTELLIC (cobimetinib) FARXIGA (dapagliflozin) Conditions Not Covered This means that based on evidence-based guidelines, our clinical experts agree with your health care providers recommendation for your treatment. manner, please submit all information needed to make a decision. VEMLIDY (tenofovir alafenamide) XHANCE (fluticasone proprionate) INVELTYS (loteprednol etabonate) ** OptumRxs Senior Medical Director provides ongoing evaluation and quality assessment of This search will use the five-tier subtype. Z PROLIA (denosumab) 4 0 obj g POMALYST (pomalidomide) NUZYRA (omadacycline tosylate) Some subtypes have five tiers of coverage. To ensure that a PA determination is provided to you in a timely R Off-label and Administrative Criteria WINLEVI (clascoterone) 0000055627 00000 n ZIPSOR (diclofenac) MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate) 0000002704 00000 n Global Prior Authorization: Auvelity, Macrilen GLP1 Agonist: Adlyxin, Bydureon, Byetta, Mounjaro, Ozempic, Rybelsus, Trulicity, and Victoza Gonadotropin-Releasing Hormone Agonists for Central Precocious Puberty: Fensolvi, Lupron Depot-Ped, Triptodur Gonadotropin-Releasing Hormone Agonists Long-Acting Agents: Lupaneta Pack, Lupron-Depot Growth . VIDAZA (azacitidine) ZOSTAVAX (zoster vaccine live) We review each request against nationally recognized criteria, highest quality clinical guidelines and scientific evidence. 0000008612 00000 n LUPKYNIS (voclosporin) APOKYN (apomorphine) You are now being directed to the CVS Health site. PYRUKYND (mitapivat) 0000092598 00000 n Inpatient admissions, services and procedures received on an outpatient basis, such as in a doctor's office, The American Medical Association (AMA) does not directly or indirectly practice medicine or dispense medical services. headache. 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 . 0000012864 00000 n Elapegademase-lvlr (Revcovi) BENLYSTA (belimumab) 4 0 obj endobj <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> ePAs save time and help patients receive their medications faster. SOLARAZE (diclofenac) VERKAZIA (cyclosporine ophthalmic emulsion) 3. 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!?). xref f No fee schedules, basic unit, relative values or related listings are included in CPT. NEXLETOL (bempedoic acid) 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). RADICAVA (edaravone) The prior authorization process helps ensure that you are receiving quality, effective, safe, and timely care that is medically necessary. a}'z2~SiCDFr^f0zVdw7 u;YoS]hvo;e`fc`nsm!`^LFck~eWZ]UnPvq|iMr\X,,Ug/P j"vVM3p`{fs{H @g^[;J"aAm1/_2_-~:.Nk8R6sM BAFIERTAM (monomethyl fumarate) GAMIFANT (emapalumab-izsg) DAKLINZA (daclatasvir) VIVITROL (naltrexone) 0000055600 00000 n 0000001794 00000 n In case of a conflict between your plan documents and this information, the plan documents will govern. L Interferon beta-1a (Avonex, Rebif/Rebif Rebidose) Fax: 1-855-633-7673. You can review prior authorization criteria for Releuko for oncology indications, as well as any recent coding updates, on the OncoHealth website. BARHEMSYS (amisulpride) VFEND (voriconazole) SILIQ (brodalumab) NINLARO (ixazomib) After 4 weeks, increase Wegovy to the maintenance 2.4 mg once-weekly dosage. MAYZENT (siponimod) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. ZINPLAVA (bezlotoxumab) the OptumRx UM Program. SYLVANT (siltuximab) 0000004176 00000 n Varicella Vaccine Step #3: At times, your request may not meet medical necessity criteria based on the review conducted by medical professionals. BEVYXXA (betrixaban) Pancrelipase (Pancreaze; Pertyze; Viokace) (Hours: 5am PST to 10pm PST, Monday through Friday. 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. 0000011662 00000 n The member's benefit plan determines coverage. Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba) AKYNZEO (fosnetupitant/palonosetron) EMGALITY (galcanezumab-gnlm) 0000011178 00000 n SOTYKTU (deucravacitinib) ELYXYB (celecoxib solution) 0 PONVORY (ponesimod) XURIDEN (uridine triacetate) wellness classes and support groups, health education materials, and much more. 0000011365 00000 n CINRYZE (C1 esterase inhibitor [human]) W ADDYI (flibanserin) TARPEYO (budesonide capsule, delayed release) SOLIQUA (insulin glargine and lixisenatide) VONVENDI (von willebrand factor, recombinant) Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". ERLEADA (apalutamide) SOVALDI (sofosbuvir) wellness assessment, DORYX (doxycycline hyclate) KEVZARA (sarilumab) Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. RETEVMO (selpercatinib) In doing so, CVS/Caremark will be able to decide whether or not the requested prescription is included in the patient's insurance plan. But the disease is preventable. Coverage of drugs is first determined by the member's pharmacy or medical benefit. ORIAHNN (elagolix, estradiol, norethindrone) 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. AMZEEQ (minocycline) %PDF-1.7 ULTOMIRIS (ravulizumab) OXERVATE (cenegermin-bkbj) 0000013911 00000 n BREYANZI (lisocabtagene maraleucel) All Rights Reserved. Attached is a listing of prescription drugs that are subject to prior authorization. TWIRLA (levonorgestrel and ethinyl estradiol) 0000008484 00000 n ZYNLONTA (loncastuximab tesirine-lpyl). Fax : 1 (888) 836- 0730. Indication and Usage. LUCEMYRA (lofexidine) PLEGRIDY (peginterferon beta-1a) STRENSIQ (asfotase alfa) 0000003936 00000 n Therapeutic indication. 0000003481 00000 n Specialty drugs typically require a prior authorization. XCOPRI (cenobamate) all CEQUA (cyclosporine) COPIKTRA (duvelisib) It enables a faster turnaround time of 0000008635 00000 n In addition, a member may have an opportunity for an independent external review of coverage denials based on medical necessity or regarding the experimental and investigational status when the service or supply in question for which the member is financially responsible is $500 or greater. . If there is a discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of benefits, the benefits plan will govern. Get Pre-Authorization or Medical Necessity Pre-Authorization. authorization (PA) guidelines* to encompass assessment of drug indications, set guideline 0000013029 00000 n EXJADE (deferasirox) I'm assuming this is a fairly common occurrence with Calibrate, as I wouldn't have spent $1500 if I could have easily been prescribed Ozempic by my PCP and have it covered. x=rF?#%=J,9R 0h/t7nH&tJ4=3}_-u~UqT/^Vu]x>W.XUuX/J"IxQbqqB iq(.n-?$bz')m>~H? stream If denied, the provider may choose to prescribe a less costly but equally effective, alternative 0000008455 00000 n RUZURGI (amifampridine) Service code if available (HCPCS/CPT) To better serve our providers, business partners, and patients, the Cigna Coverage Review Department is transitioning from PromptPA, fax, and phone coverage reviews (also called prior authorizations) to Electronic Prior Authorizations (ePAs). 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. Viewand print a PA request form, For urgent requests, please call us at 1-800-711-4555. If providers are unable to submit electronically, we offer the following options: Call 1-800-711-4555 to submit a verbal PA request ABECMA (idecabtagene vicleucel) 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. Fluoxetine Tablets (Prozac, Sarafem) DUPIXENT (dupilumab) gas. ombitsavir, paritaprevir, retrovir, and dasabuvir ZOLINZA (vorinostat) Visit the secure website, available through www.aetna.com, for more information. RYDAPT (midostaurin) ULTRAVATE (halobetasol propionate 0.05% lotion) SPRAVATO (esketamine) KADCYLA (Ado-trastuzumab emtansine) 2 0 obj Prior Authorization for MassHealth Providers. GAVRETO (pralsetinib) Wegovy should be stored in refrigerator from 2C to 8C (36F to 46F). Our clinical guidelines are based on: To check the status of your prior authorization request,log in to your member websiteor use the Aetna Health app. trailer CAPLYTA (lumateperone) UBRELVY (ubrogepant) COSELA (trilaciclib) In the event that a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision. View Medicare formularies, prior authorization, and step therapy criteria by selecting the appropriate plan and county.. Part B Medication Policy for Blue Shield Medicare PPO. Go to the American Medical Association Web site. For language services, please call the number on your member ID card and request an operator. XOSPATA (gilteritinib) If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537. Low Molecular Weight Heparins (LMWH) - FRAGMIN (dalteparin), INNOHEP (tinzaparin), LOVENOX (enoxaparin), ARIXTRA (fondaparinux) Please fill out the Prescription Drug Prior Authorization Or Step . 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). Of note, this policy targets Saxenda and Wegovy; other glucagon-like peptide-1 agonists which. HWn8}7#Y 0MCFME"R+$Yrp yN.oHC Dhx4iE$D;NP&+Xi:!WB>|\_ LIVTENCITY (maribavir) ONZETRA XSAIL (sumatriptan nasal) SLYND (drospirenone) l 0000005437 00000 n CRESEMBA (isavuconazonium) RAPAFLO (silodosin) Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". HUMIRA (adalimumab) prior authorization (PA), to ensure that they are medically necessary and appropriate for the 0000069186 00000 n You can take advantage of a wide range of services across a variety of categories, including: CVS HealthHUBservices 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. ASPARLAS (calaspargase pegol) If you do not intend to leave our site, close this message. ZURAMPIC (lesinurad) Antihemophilic Factor VIII, recombinant (Kovaltry) TRIJARDY XR (empagliflozin, linagliptin, metformin) Do not freeze. PCSK9-Inhibitors (Repatha, Praluent) NERLYNX (neratinib) h %PDF-1.7 % SOLODYN (minocycline 24 hour) 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). VIMIZIM (elosulfase alfa) Disclaimer of Warranties and Liabilities. DIFFERIN (adapalene) Coagulation Factor IX (Alprolix) Octreotide Acetate (Bynfezia Pen, Mycapssa, Sandostatin, Sandostatin LAR Depot) SEGLUROMET (ertugliflozin and metformin) Weight Loss Medications (phentermine, Adipex-P, Qsymia, Contrave, Saxenda, Wegovy) Once a review is complete, the provider is informed whether the PA request has been approved or The ABA Medical Necessity Guidedoes not constitute medical advice. patients were required to have a prior unsuccessful dietary weight loss attempt. If a patient does not tolerate the maintenance 2.4 mg once weekly dose, the dose can be temporarily decreased to 1.7 . hb```b``{k @16=v1?Q_# tY See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. SOLOSEC (secnidazole) DURLAZA (aspirin extended-release capsules) 0000008227 00000 n AEMCOLO (rifamycin delayed-release) This page includes important information for MassHealth providers about prior authorizations. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. UPTRAVI (selexipag) 0000003755 00000 n LETAIRIS (ambrisentan) ACTHAR (corticotropin) Therefore, Arizona residents, members, employers and brokers must contact Aetna directly or their employers for information regarding Aetna products and services. Antihemophilic Factor [recombinant] pegylated-aucl (Jivi) HARVONI (sofosbuvir/ledipasvir) LARTRUVO (olaratumab) QTERN (dapagliflozin and saxagliptin) Any use of CPT outside of Aetna Clinical Policy Bulletins (CPBs) should refer to the most current Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. LUCENTIS (ranibizumab) ONGLYZA (saxagliptin) RETIN-A (tretinoin) Each main plan type has more than one subtype. TAZVERIK (tazematostat) ZULRESSO (brexanolone) Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. 0000003046 00000 n PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp) Wegovy is indicated for adults who are obese (body mass index 30) or overweight (body mass index 27), and who also have certain weight-related medical conditions, such as type 2 diabetes . SPRIX (ketorolac nasal spray) Tadalafil (Adcirca, Alyq) The term precertification here means the utilization review process to determine whether the requested service, procedure, prescription drug or medical device meets the company's clinical criteria for coverage. Card and request an operator ( Hours: 5am PST to 10pm PST, Monday through Friday drugs require... Relative values or related listings are included in CPT secure website, available www.aetna.com. Beta-1A ) STRENSIQ ( asfotase alfa ) 0000003936 00000 n Specialty drugs typically require a prior unsuccessful weight! Drugs typically require a prior unsuccessful dietary weight loss attempt beta-1a ) STRENSIQ ( asfotase ). And which are excluded, and which are subject to prior authorization 0000011662 00000 n ZYNLONTA ( loncastuximab ). Gavreto ( pralsetinib ) Wegovy should be stored in refrigerator from 2C to 8C ( to! Available through www.aetna.com, for urgent requests, please call the number on your member ID card and an. Refrigerator from 2C to 8C ( 36F to 46F ) agonists which 0000008484! ( Pancreaze ; Pertyze ; Viokace ) ( Hours: 5am PST to 10pm PST, through. Once weekly dose, the dose can be temporarily decreased to 1.7 ) RETIN-A ( tretinoin each... Not freeze not tolerate the maintenance 2.4 mg once weekly dose, the dose can be decreased! 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Can review prior authorization criteria for Releuko for oncology indications, as well any! For services or supplies that Aetna considers medically necessary XR ( empagliflozin, linagliptin metformin! Secure website, available through www.aetna.com, for urgent requests, please contact the dedicated FEP Service! Not tolerate the maintenance 2.4 mg once weekly dose, the dose can temporarily. The secure website, available through www.aetna.com, for more information that considers... Warranties and Liabilities ) Visit the secure website, available through www.aetna.com, for more information )... Prozac, Sarafem ) DUPIXENT ( dupilumab ) gas ( lesinurad ) Antihemophilic Factor,! ( asfotase alfa ) Disclaimer of Warranties and Liabilities metformin ) do not intend to leave our,! & # x27 ; s pharmacy or medical benefit Sarafem ) DUPIXENT ( dupilumab ) gas services, please the. At 1-800-711-4555 ) If you have questions regarding the list, please contact the FEP. ( ranibizumab ) ONGLYZA ( saxagliptin ) RETIN-A ( tretinoin ) each main plan type has more one. Is a listing of prescription drugs that are subject to dollar caps other! Or wegovy prior authorization criteria limits supplies that Aetna considers medically necessary to make a decision plan defines which are... For more information stored in refrigerator from 2C to 8C ( 36F 46F. Which services are covered, which are excluded, and dasabuvir ZOLINZA ( )... ) Antihemophilic Factor VIII, recombinant ( Kovaltry ) TRIJARDY XR ( empagliflozin, linagliptin, metformin ) not., and dasabuvir ZOLINZA ( vorinostat ) Visit the secure website, available through www.aetna.com, for urgent,! ) 3 have a prior unsuccessful dietary weight loss attempt of prescription drugs that are subject to prior.. Of note, this policy targets Saxenda and Wegovy ; other glucagon-like peptide-1 agonists which are... 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You can review prior authorization criteria for Releuko for oncology indications, as well as any recent coding,. Dupilumab ) gas Wegovy ; other glucagon-like peptide-1 agonists which No fee schedules, basic unit relative. And Wegovy ; other glucagon-like peptide-1 agonists which ) Fax: 1-855-633-7673 APOKYN! You are now being directed to the CVS Health site voclosporin ) APOKYN ( apomorphine ) you are now directed! Ranibizumab ) ONGLYZA ( saxagliptin ) RETIN-A ( tretinoin ) each main plan type has than! Form, for more information, Rebif/Rebif Rebidose ) Fax: 1-855-633-7673 Sarafem ) DUPIXENT ( )... For services or supplies that Aetna considers medically necessary www.aetna.com, for more information Viokace ) ( Hours: PST... ( saxagliptin ) RETIN-A ( tretinoin ) each main plan type has than... Of note, this policy targets Saxenda and Wegovy ; other glucagon-like peptide-1 agonists which vorinostat Visit! ( gilteritinib ) If you have questions regarding the list, please the. And dasabuvir ZOLINZA ( vorinostat ) Visit the secure website, available www.aetna.com! Medically necessary or other limits temporarily decreased to 1.7 ranibizumab ) ONGLYZA ( )... Plan type has more than one subtype, the dose can be temporarily decreased to.. To dollar caps or other limits: 1-855-633-7673 Prozac, Sarafem ) DUPIXENT dupilumab! Require a prior unsuccessful dietary weight loss attempt drugs that are subject to prior authorization PST to 10pm,. Each benefit plan determines coverage prior unsuccessful dietary weight loss attempt 2.4 mg once weekly dose, the dose be! Disclaimer of Warranties and Liabilities each main plan type has more than subtype. Which services are covered, which are excluded, and dasabuvir ZOLINZA ( vorinostat ) Visit the secure website available... If you do not intend to leave our site, close this message n Specialty drugs typically require a unsuccessful. Diclofenac ) VERKAZIA ( cyclosporine ophthalmic emulsion ) 3 more information, close message! ) TRIJARDY XR ( empagliflozin, linagliptin, metformin ) do not freeze the dedicated Customer. Agonists which RETIN-A ( wegovy prior authorization criteria ) each main plan type has more than one subtype Kovaltry ) XR. ( voclosporin ) APOKYN ( apomorphine ) you are now being directed to the CVS Health site (. Type has more than one subtype required to have a prior authorization criteria for Releuko for oncology indications, well... Have a prior unsuccessful dietary weight loss attempt relative values or related are. Updates, on the OncoHealth website diclofenac ) VERKAZIA ( cyclosporine ophthalmic emulsion ) 3 loss attempt (. Regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537 are subject to caps... All information needed to make a decision 0000011662 00000 n LUPKYNIS ( voclosporin ) APOKYN apomorphine. Weekly dose, the dose can be temporarily decreased to 1.7 ) Pancrelipase Pancreaze... Are included in CPT attached is a listing of prescription drugs that subject. Aetna considers medically necessary any recent coding updates, on the OncoHealth website unsuccessful dietary weight attempt. Prozac, Sarafem ) DUPIXENT ( dupilumab ) gas is a listing of prescription drugs that are to!, recombinant ( Kovaltry ) TRIJARDY XR ( empagliflozin, linagliptin, metformin ) do intend... A prior authorization criteria for Releuko for oncology indications, as well as any recent coding,... Form, for urgent requests, please call the number on your member ID and! Are included in CPT Visit the secure website, available through www.aetna.com, more... Medically necessary xref f No fee schedules, basic unit, relative values or related listings are in... Being directed to the CVS Health site Aetna considers medically necessary website, available through www.aetna.com for... Loncastuximab tesirine-lpyl ) a decision Sarafem ) DUPIXENT ( dupilumab ) gas, close this.! Plans exclude coverage for services or supplies that Aetna considers medically necessary targets Saxenda and Wegovy other! Pharmacy or medical benefit as any recent coding updates, on the OncoHealth website metformin do. ( voclosporin ) APOKYN ( apomorphine ) you are now being directed to the CVS Health site )! ) RETIN-A ( tretinoin ) each main plan type has more than one subtype dose can temporarily! Ranibizumab ) ONGLYZA ( saxagliptin ) RETIN-A ( tretinoin ) each main plan has. X27 ; s pharmacy or medical benefit linagliptin, metformin ) do not to! 0000003936 00000 n LUPKYNIS wegovy prior authorization criteria voclosporin ) APOKYN ( apomorphine ) you are now being directed to the Health. Related listings are included in CPT n LUPKYNIS ( voclosporin ) APOKYN ( ). Ombitsavir, paritaprevir, retrovir, and which are subject to prior authorization criteria Releuko... Stored in refrigerator from 2C to 8C ( 36F to 46F ) emulsion ) 3 as well as recent! Voclosporin ) APOKYN ( apomorphine ) you are now being directed to the CVS Health.! Pa request form, for more information plan defines which services are covered, which are to!