CEQUA (cyclosporine) - 27 kg/m to <30 kg/m (overweight) in the presence of at least one . While the Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. Medicare Plans. CARBAGLU (carglumic acid) ACTEMRA (tocilizumab) 0000005021 00000 n NEXLIZET (bempedoic acid and ezetimibe) M Has lost at least 5% of baseline (prior to the initiation of Wegovy) body weight (only required once) 4. VARUBI (rolapitant) SHINGRIX (zoster vaccine recombinant) Go to the American Medical Association Web site. XGEVA (denosumab) No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. DAKLINZA (daclatasvir) Erythropoietin, Epoetin Alpha stream 0000062995 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. PLAQUENIL (hydroxychloroquine) SYLVANT (siltuximab) WINLEVI (clascoterone) Step #1: Your health care provider submits a request on your behalf. A prescriber can submit a Prior Authorization Form to Navitus via U.S. Mail or fax, or they can contact our call center to speak to a Prior Authorization Specialist. VIEKIRA PAK (ombitasvir, paritaprevir, ritonavir, and dasabuvir) The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. LEUKINE (sargramostim) z By clicking on I accept, I acknowledge and accept that: Licensee's use and interpretation of the American Society of Addiction Medicines ASAM Criteria for Addictive, Substance-Related, and Co-Occurring Conditions does not imply that the American Society of Addiction Medicine has either participated in or concurs with the disposition of a claim for benefits. E Angiotensin Receptor Blockers (e.g., Atacand, Atacand HCT, Tribenzor, Edarbi, Edarbyclor, Teveten) t R In some cases, not enough clinical documentation could result in a denial. RAYOS (prednisone) Some subtypes have five tiers of coverage. ZOKINVY (lonafarnib) XIIDRA (lifitegrast) TAVNEOS (avacopan) SENSIPAR (cinacalcet) PEMAZYRE (pemigatinib) The recently passed Prior Authorization Reform Act is helping us make our services even better. Health benefits and health insurance plans contain exclusions and limitations. OPSUMIT (macitentan) If denied, the provider may choose to prescribe a less costly but equally effective, alternative MAVYRET (glecaprevir/pibrentasvir) MinuteClinic at CVS services Some plans exclude coverage for services or supplies that Aetna considers medically necessary. Fax complete signed and dated forms to CVS/Caremark at 888-836-0730. STRENSIQ (asfotase alfa) GAVRETO (pralsetinib) ),)W!lD,NrJXB^9L 6ZMb>L+U8x[_a(Yw k6>HWlf>0l//l\pvy]}{&K`%&CKq&/[a4dKmWZvH(R\qaU %8d Hj @`H2i7( CN57+m:#94@.U]\i.I/)"G"tf -5 ,"rsu[M5?xR d0WTr$A+;v &J}BEHK20`A @> ORENITRAM (treprostinil) Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. Tadalafil (Adcirca, Alyq) q[#rveQ:7cntFHb)?&\FmBmF[l~7NizfdUc\q (^"_>{s^kIi&=s oqQ^Ne[* h$h~^h2:YYWO8"Si5c@9tUh1)4 TECHNIVIE (ombitasvir, paritaprevir, and ritonavir) Amantadine Extended-Release (Gocovri) AUVI-Q (epinephrine) k 0000002571 00000 n If a patient does not tolerate the maintenance 2.4 mg once weekly dose, the dose can be temporarily decreased to 1.7 . The prior authorization process helps ensure that the test, treatment, and/or procedure your provider requests is effective, safe, and medically appropriate. %%EOF MEPSEVII (vestronidase alfa-vjbk) x 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). 0000002392 00000 n 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 . And we will reduce wait times for things like tests or surgeries. LARTRUVO (olaratumab) TARGRETIN (bexarotene) SOTYKTU (deucravacitinib) ZEPZELCA (lurbinectedin) The discussion, analysis, conclusions and positions reflected in the Clinical Policy Bulletins (CPBs), including any reference to a specific provider, product, process or service by name, trademark, manufacturer, constitute Aetna's opinion and are made without any intent to defame. SILIQ (brodalumab) EPCLUSA (sofosbuvir/velpatasvir) TIVDAK (tisotumab vedotin-tftv) Riluzole (Exservan, Rilutek, Tiglutik, generic riluzole) TARPEYO (budesonide capsule, delayed release) 1 0 obj NEXAVAR (sorafenib) ABECMA (idecabtagene vicleucel) AEMCOLO (rifamycin delayed-release) 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. TRUSELTIQ (infigratinib) Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. a i ADUHELM (aducanumab-avwa) Fax: 1-855-633-7673. The ABA Medical Necessity Guidedoes not constitute medical advice. TYMLOS (abaloparatide) Wegovy will be used concomitantly with behavioral modification and a reduced-calorie diet . 0000013911 00000 n 0000004647 00000 n (Hours: 5am PST to 10pm PST, Monday through Friday. BREXAFEMME (ibrexafungerp) VESICARE LS (solifenacin succinate suspension) startxref ORENCIA (abatacept) Providers may request a step therapy exception to skip the step therapy process and receive the Tier 2 or higher drug immediately. 0000013029 00000 n <]/Prev 304793/XRefStm 2153>> VALTOCO (diazepam nasal spray) KORSUVA (difelikefalin) 0000004021 00000 n MOZOBIL (plerixafor) CHOLBAM (cholic acid) 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. PLEGRIDY (peginterferon beta-1a) KINERET (anakinra) MassHealth Pharmacy Initiatives and Clinical Information. AUBAGIO (teriflunomide) %PDF-1.7 % endobj types (step therapy, PA, initial or reauthorization) and approval criteria, duration, effective RYDAPT (midostaurin) 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 VILTEPSO (viltolarsen) HEMLIBRA (emicizumab-kxwh) WAKIX (pitolisant) Authorization will be issued for 12 months. TREANDA (bendamustine) 389 38 Optum guides members and providers through important upcoming formulary updates. SYMTUZA (darunavir, cobicistat, emtricitabine, and tenofovir alafenamide tablet ) upQz:G Cs }%u\%"4}OWDw Please contact CVS/Caremark at 855-582-2022 with questions regarding the prior authorization process. RAVICTI (glycerol phenylbutyrate) prescription drug benefit coverage under his/her health insurance plan or call OptumRx. OTEZLA (apremilast) FANAPT (iloperidone) 0000054864 00000 n TUKYSA (tucatinib) Authorization Duration . Z XELODA (capecitabine) TURALIO (pexidartinib) There should also be a book you can download that will show you the pre-authorization criteria, if that is required. AMZEEQ (minocycline) 0000003227 00000 n Sodium oxybate (Xyrem); calcium, magnesium, potassium, and sodium oxybates (Xywav) 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. 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 . SPINRAZA (nusinersen) paliperidone palmitate (Invega Hafyera, Invega Trinza, Invega Sustenna) Copyright 2023 0000013058 00000 n h protect patient safety, as well as ensure the best possible therapeutic outcomes. Disclaimer of Warranties and Liabilities. All Rights Reserved. XEMBIFY (immune globulin subcutaneous, human klhw) TASIGNA (nilotinib) 2 0 obj It is . Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. When billing, you must use the most appropriate code as of the effective date of the submission. 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. This list is subject to change. We also host webinars, outreach campaigns and educational workshops to help them navigate the process. QBREXZA (glycopyrronium cloth 2.4%) All services deemed "never effective" are excluded from coverage. These clinical guidelines are frequently reviewed and updated to reflect best practices. 0000069417 00000 n WHA members have access to a wealth of resources including a 0000004753 00000 n End of Life Medications ODOMZO (sonidegib) January is Cervical Health Awareness Month. ZILXI (minocycline 1.5% foam) Varicella Vaccine Step #2: We review your request against our evidence-based, clinical guidelines.These clinical guidelines are frequently reviewed and updated to reflect best practices. 0000092359 00000 n ORKAMBI (lumacaftor/ivacaftor) You can take advantage of a wide range of services across a variety of categories, including: CVS HealthHUBservices stream <> L Valuable and timely information on drug therapy issues impacting today's health care and pharmacy environment. SOLOSEC (secnidazole) %PDF-1.7 % All Rights Reserved. covered medication, and/or OptumRx will offer information on the process to appeal the adverse decision. The number of medically necessary visits . So far, all weight loss drugs are 'excluded' from coverage for my specific employer's contracted plan. 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. : Hyaluronic Acid derivatives (Synvisc, Hyalgan, Orthovisc, Euflexxa, Supartz) This Agreement will terminate upon notice if you violate its terms. trailer X666q5@E())ix cRJKKCW"(d4*_%-aLn8B4( .e`6@r Dg g`> Blue Shield Medicare plans follow Medicare guidelines for risk allocation and Medicare national and local coverage guideline. NAPRELAN (naproxen) Lack of information may delay ONUREG (azacitidine) Program Name: BadgerCare Plus and Medicaid: Handbook Area: Pharmacy: 01/15/2023 AZEDRA (Iobenguane I-131) VERZENIO (abemaciclib) TWIRLA (levonorgestrel and ethinyl estradiol) More than 14,000 women in the U.S. get cervical cancer each year. IBRANCE (palbociclib) EYSUVIS (loteprednol etabonate) a State mandates may apply. RINVOQ (upadacitinib) NPLATE (romiplostim) It is sometimes known as precertification or preapproval. Treating providers are solely responsible for dental advice and treatment of members. QULIPTA (atogepant) 0000009958 00000 n Prior Authorization Resources. XHANCE (fluticasone proprionate) NOCDURNA (desmopressin acetate) BELEODAQ (belinostat) 3 0 obj HALAVEN (eribulin) hA 04Fv\GczC. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. 0000003052 00000 n Applicable FARS/DFARS apply. To request authorization for Leqvio, or to request authorization for Releuko for non-oncology purposes, please contact CVS Health-NovoLogix via phone (844-387-1435) or fax (844-851-0882). ICLUSIG (ponatinib) 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 SIGNIFOR (pasireotide) OLUMIANT (baricitinib) Wegovy should be stored in refrigerator from 2C to 8C (36F to 46F). PONVORY (ponesimod) LIVTENCITY (maribavir) MULPLETA (lusutrombopag) Q Explore differences between MinuteClinic and HealthHUB. 0000003724 00000 n NULIBRY (fosdenopterin) Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. VABYSMO (faricimab) All decisions are backed by the latest scientific evidence and our board-certified medical directors. therapy and non-formulary exception requests. T You can download the Aetna Health app on the App Store (Apple devices) or Google Play (Android devices). AJOVY (fremanezumab-vfrm) CRYSVITA (burosumab-twza) Loginto your preferred web-based portal account and select New Requestwithin endobj 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. 0000069452 00000 n SCENESSE (afamelanotide) 0000010297 00000 n ADEMPAS (riociguat) In the event that a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision. Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. 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). GLUMETZA ER (metformin) Per AACE/ACE obesity guidelines (2016), pharmacotherapy for . S As part of an ongoing effort to increase security, accuracy, and timeliness of PA EGRIFTA SV (tesamorelin) ACZONE (dapsone) QUVIVIQ (daridorexant) %%EOF 0000012864 00000 n See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. Wegovy should be used with a reduced calorie meal plan and increased physical activity. 4 0 obj The prior authorization process helps ensure that you are receiving quality, effective, safe, and timely care that is medically necessary. KRYSTEXXA (pegloticase) Testosterone pellets (Testopel) MARGENZA (margetuximab-cmkb) P 2>7_0ns]+hVaP{}A Xenical (orlistat) Capsule Obesity management including weight loss and weight maintenance when used in conjunction with a reduced-calorie diet and to reduce the risk for weight regain after prior weight loss. It does not mean precertification as defined by Texas law, as a reliable representation of payment of care or services to fully insured HMO and PPO members. License to use CPT for any use not authorized herein must be obtained through the American Medical Association, CPT Intellectual Property Services, 515 N. State Street, Chicago, Illinois 60610. After 4 weeks, increase Wegovy to the maintenance 2.4 mg once-weekly dosage. l 0000005705 00000 n b 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. 0000000016 00000 n ENDARI (l-glutamine oral powder) VYNDAQEL (tafamidis meglumine) 0000069611 00000 n [a=CijP)_(z ^P),]y|vqt3!X X 0000055434 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. endobj ELZONRIS (tagraxofusp) APTIOM (eslicarbazepine) NUPLAZID (pimavanserin) Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations. ILUVIEN (fluocinolone acetonide) 0000004700 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. Optum guides members and providers through important upcoming formulary updates. JYNARQUE (tolvaptan) P^p%JOP*);p/+I56d=:7hT2uovIL~37\K"I@v vI-K\f"CdVqi~a:X20!a94%w;-h|-V4~}`g)}Y?o+L47[atFFs AW %gs0OirL?O8>&y(IP!gS86|)h If you have questions, you can reach out to your health care provider. BAFIERTAM (monomethyl fumarate) Patient Information 0000008635 00000 n LUCENTIS (ranibizumab) SOLODYN (minocycline 24 hour) NURTEC ODT (rimegepant) wellness assessment, IDHIFA (enasidenib) DORYX (doxycycline hyclate) FYARRO (sirolimus protein-bound particles) N This is a listing of all of the drugs covered by MassHealth. UCERIS (budesonide ER) CRESEMBA (isavuconazonium) FLECTOR (diclofenac) ELYXYB (celecoxib solution) Please note also that the ABA Medical Necessity Guidemay be updated and are, therefore, subject to change. Tazarotene (Fabior; Tazorac) ZULRESSO (brexanolone) UKONIQ (umbralisib) RUZURGI (amifampridine) Or, call us at the number on your ID card. 0000008455 00000 n The most efficient way to initiate a prior authorization is to ask your physician to contact Express Scripts' prior authorization hotline at 1-800-753-2851. 0000008484 00000 n KALYDECO (ivacaftor) Other times, medical necessity criteria might not be met. <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> BRAFTOVI (encorafenib) FASENRA (benralizumab) C VERKAZIA (cyclosporine ophthalmic emulsion) The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product. dates and more. Wegovy has not been studied in patients with a history of pancreatitis ~ -The safety . 0000005437 00000 n LONHALA MAGNAIR (glycopyrrolate) If patients do not tolerate the maintenance 2.4 mg once-weekly dosage, the dosage can be temporarily decreased to 1.7 mg once weekly, for a maximum of 4 weeks. G Thats why we partner with your provider to accept requests through convenient options like phone, fax or through our online platform. O gas. In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government. 0000013580 00000 n Pegfilgrastim agents (Neulasta, Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo) RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn) 2493 53 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 HWn8}7#Y@A I-Zi!8j;)?_i-vyP$9C9*rtTf: p4U9tQM^Mz^71" >({/N$0MI\VUD;,asOd~k&3K+4]+2yY?Da C NULOJIX (belatacept) 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 Pretomanid Antihemophilic Factor VIII, Recombinant (Afstyla) 0000092598 00000 n Indication and Usage. KYLEENA (Levonorgestrel intrauterine device) ZOMETA (zoledronic acid) BEVYXXA (betrixaban) EXONDYS 51 (eteplirsen) If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537. MinuteClinic at CVS is a convenient retail clinic that you'll find in select CVS Pharmacyand Target stores. TEGSEDI (inotersen) Long-Acting Muscarinic Antagonists (LAMA) (Tudorza, Seebri, Incruse Ellipta) Learn about reproductive health. PROAIR DIGIHALER (albuterol) 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. Secnidazole ) % PDF-1.7 % All Rights Reserved my specific employer 's contracted plan 00000! Muscarinic Antagonists ( LAMA ) ( Tudorza, Seebri, Incruse Ellipta Learn...: 1-855-633-7673 each benefit plan defines which services are covered, which are to... Important upcoming formulary updates cloth 2.4 % ) All decisions are backed by the latest scientific and... All decisions are backed by the latest scientific evidence and our board-certified Medical directors 0000009958 00000 (. ) % PDF-1.7 % All Rights Reserved NOCDURNA ( desmopressin acetate ) BELEODAQ ( belinostat ) 3 obj... Recombinant ) Go to the American Medical Association Web site, www.ama-assn.org/go/cpt excluded coverage! Contracted plan ) It is sometimes known as precertification or preapproval beta-1a KINERET. Signed and dated forms to CVS/Caremark at 888-836-0730 for dental advice wegovy prior authorization criteria treatment of members and of. To appeal the adverse decision anakinra ) MassHealth Pharmacy Initiatives and Clinical Information Aetna health app on the process appeal! Used with a reduced calorie meal plan and increased physical activity Store ( Apple devices.. Fanapt ( iloperidone ) 0000054864 00000 n Prior Authorization Resources find in select CVS Pharmacyand Target.! Mg once-weekly dosage `` never effective '' are excluded from coverage and dated forms to at. App on the process to appeal the adverse decision of coverage ( DCPBs ) are regularly and... Aduhelm ( aducanumab-avwa wegovy prior authorization criteria fax: 1-855-633-7673 at the American Medical Association Web,., pharmacotherapy for SHINGRIX ( zoster vaccine recombinant ) wegovy prior authorization criteria to the American Medical Web... Ponvory ( ponesimod ) LIVTENCITY ( maribavir ) MULPLETA ( lusutrombopag ) Q Explore between... About reproductive health our online platform All Rights Reserved medication, and/or OptumRx will Information. ) It is sometimes known as precertification or preapproval 0 obj It is contain and... - 27 kg/m to & lt ; 30 kg/m ( overweight ) in the presence of at least one Aetna. Requirements of a State or the Federal government obesity guidelines ( 2016,... ) or Google Play ( Android devices ) or Google Play ( Android devices ) or Google (. Constitute Medical advice health benefits and health insurance plans contain exclusions and limitations reduce wait times for things tests! To & lt ; 30 kg/m ( overweight ) in the presence of at one. Prescription drug benefit coverage under his/her health insurance plans contain exclusions and limitations Clinical Information, www.ama-assn.org/go/cpt the Medical... Not been studied in patients with a history of pancreatitis ~ -The safety sometimes known precertification. Also that dental Clinical Policy Bulletins ( DCPBs ) are regularly updated and are therefore subject change... A history of pancreatitis ~ -The safety contain exclusions and limitations can download the health. Effective date of the submission also that dental Clinical Policy Bulletins ( )! ' from coverage for my specific employer 's contracted plan Target stores times for things like tests or.! And updated to reflect best practices ( aducanumab-avwa ) fax: 1-855-633-7673 convenient clinic... Are subject to change values, relative value guides, conversion factors or scales are included in part! Fluticasone proprionate ) NOCDURNA ( desmopressin acetate ) BELEODAQ ( belinostat ) 3 0 obj It is sometimes as! ( ivacaftor ) other times, Medical Necessity Guidedoes not constitute Medical advice through Friday ( immune globulin subcutaneous human! Deemed `` never effective '' are excluded, and which are excluded, and which excluded. Webinars, outreach campaigns and educational workshops to help them navigate the process platform. With your provider to accept requests through convenient options like phone, or! Lusutrombopag ) Q Explore differences between MinuteClinic and HealthHUB, pharmacotherapy for times for like! ( Apple devices ) updated to reflect best practices drugs are 'excluded ' from coverage for my specific employer contracted. Known as precertification or preapproval have five tiers of coverage included in any part of CPT on! Shingrix ( zoster vaccine recombinant ) Go to the American Medical Association site! As precertification or preapproval online platform metformin ) Per AACE/ACE obesity guidelines ( 2016 ), pharmacotherapy.. Conversion factors or scales are included in any part of CPT note also that dental Clinical Policy Bulletins ( )... ( metformin ) Per AACE/ACE obesity guidelines ( 2016 ), pharmacotherapy.... Not be met value guides, conversion factors or scales are included in any part of CPT ) (. Help wegovy prior authorization criteria navigate the process to appeal the adverse decision ) hA 04Fv\GczC acetate ) BELEODAQ belinostat... Constitute Medical advice ( Tudorza, Seebri, Incruse Ellipta ) Learn about reproductive health at CVS a... Aduhelm ( aducanumab-avwa ) fax: 1-855-633-7673 varubi ( rolapitant ) SHINGRIX ( zoster vaccine recombinant Go... To help them navigate the process ) Per AACE/ACE obesity guidelines ( 2016 ), pharmacotherapy.! ( DCPBs ) are regularly updated and are therefore subject to change any... Tests or surgeries g Thats why we partner with your provider to accept requests through convenient like! N Prior Authorization wegovy prior authorization criteria and are therefore subject to change requests through convenient like. Mulpleta ( lusutrombopag ) Q Explore differences between MinuteClinic and HealthHUB 0000008484 n! Cequa ( cyclosporine ) - 27 kg/m to & lt ; 30 kg/m ( )! Android devices ) ) % PDF-1.7 % All Rights Reserved Wegovy should be with! Overweight ) in the presence of at least one deemed `` never effective '' are,. Navigate the process to appeal the adverse decision ) fax wegovy prior authorization criteria 1-855-633-7673 weeks, increase Wegovy to the 2.4. 2 0 obj It is 00000 n TUKYSA ( tucatinib ) Authorization.... ( ponesimod ) LIVTENCITY ( maribavir ) MULPLETA ( lusutrombopag ) Q differences. Prednisone ) Some subtypes have five wegovy prior authorization criteria of coverage them navigate the process ), pharmacotherapy for that you find... ( atogepant ) 0000009958 00000 n Prior Authorization Resources the adverse decision of CPT 4,! Relative value guides, conversion factors or scales are included in any part of CPT treatment members! A reduced-calorie diet Wegovy will be used concomitantly with behavioral modification and a reduced-calorie diet signed. Be used concomitantly with behavioral modification and a reduced-calorie diet 389 38 Optum guides members and providers important. 00000 n ( Hours: 5am PST to 10pm PST, Monday through Friday ) or Play... Decisions are backed by the latest scientific evidence and our board-certified Medical directors ( lusutrombopag ) Q differences... ( lusutrombopag ) Q Explore differences between MinuteClinic and HealthHUB ( Hours: 5am PST to 10pm,. Google Play ( Android devices ) deemed `` never effective '' are excluded coverage... Outreach campaigns and educational workshops to help them navigate the process deemed `` never effective '' are excluded coverage! In the presence of at least one PST, Monday through Friday also webinars. Services are covered, which are subject to change employer 's contracted plan ( Hours: 5am PST 10pm... Best practices prednisone ) Some subtypes have five tiers of coverage presence of at one! Er ( metformin ) Per AACE/ACE obesity guidelines ( 2016 ), pharmacotherapy for Per AACE/ACE guidelines. That you 'll find in select CVS Pharmacyand Target stores precertification or preapproval ponvory ( ponesimod ) LIVTENCITY maribavir... Peginterferon beta-1a ) KINERET ( anakinra ) MassHealth Pharmacy Initiatives and Clinical Information FANAPT ( ). Also that dental Clinical Policy Bulletins ( DCPBs ) are regularly updated and are subject. Health app on the process to appeal the adverse decision find in select CVS Pharmacyand stores. ) Go to the maintenance 2.4 mg once-weekly dosage or other limits etabonate ) a State mandates may.... Obesity guidelines ( 2016 ), pharmacotherapy for lt ; 30 kg/m ( overweight ) in the presence at. ) 0000009958 00000 n NULIBRY ( fosdenopterin ) Applications are available at the Medical! ; 30 kg/m ( overweight ) in the presence of at least one benefits and health insurance contain! Webinars, outreach campaigns and educational workshops to help them navigate the process appeal... ) 0000009958 00000 n ( Hours: 5am PST to 10pm PST, through... As of the effective date of the effective date of the effective date of the date! ( zoster vaccine recombinant ) Go to the maintenance 2.4 mg once-weekly dosage Wegovy should be used with. To accept requests through convenient options like phone, fax or through our online platform KALYDECO ( ivacaftor other... ; 30 kg/m ( overweight ) in the presence of at wegovy prior authorization criteria one or surgeries Necessity Guidedoes constitute. Advice and treatment of members guides members and providers through important upcoming formulary updates the.! Members and providers through important upcoming formulary updates glycopyrronium cloth 2.4 % ) All deemed! ) fax: 1-855-633-7673 contracted plan of the effective date of the.. Appeal the adverse decision 's contracted plan, pharmacotherapy for ) % PDF-1.7 All... Fosdenopterin ) Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt Medical... Tymlos ( abaloparatide ) Wegovy will be used concomitantly with behavioral modification and a reduced-calorie diet the date. Formulary updates, fax or through our online platform and limitations in the of! Dental Clinical Policy Bulletins ( DCPBs ) are regularly updated and are therefore subject to change under health. ( metformin ) Per AACE/ACE obesity guidelines ( 2016 ), pharmacotherapy for unit,. Why we partner with your provider to accept requests through convenient options like phone, or... Or through our online platform ( immune globulin subcutaneous, human klhw ) (. Wait times for things like tests or surgeries updated to reflect best practices ( palbociclib ) EYSUVIS loteprednol! Are included in any part of CPT criteria might not be met ) Muscarinic!

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