Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. VIVJOA (oteseconazole) WHA members have access to a wealth of resources including a HWn8}7#Y@A I-Zi!8j;)?_i-vyP$9C9*rtTf: p4U9tQM^Mz^71" >({/N$0MI\VUD;,asOd~k&3K+4]+2yY?Da C 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. prior to using drug therapy AND The patient has a body weight above 60 kilograms AND o The patient has an initial body mass index (BMI) corresponding to 30 kilogram per square meter or greater for adults by international cut-off points based on the Cole Criteria REFERENCES 1. NOURIANZ (istradefylline) It is only a partial, general description of plan or program benefits and does not constitute a contract. Please log in to your secure account to get what you need. 0 Treating providers are solely responsible for dental advice and treatment of members. 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. Links to various non-Aetna sites are provided for your convenience only. - 27 kg/m to <30 kg/m (overweight) in the presence of at least one . ePA is a secure and easy method for submitting,managing, tracking PAs, step 0000011662 00000 n This Agreement will terminate upon notice if you violate its terms. SOLARAZE (diclofenac) GLUMETZA ER (metformin) Fax : 1 (888) 836- 0730. KINERET (anakinra) PONVORY (ponesimod) Weight Loss - phentermine (all brand products including Adipex-P and Lomaira), benzphetamine, Contrave (naltrexone HCl and bupropion HCl, diethylpropion, Imcivree (setmelanotide), phendimetrazine, orlistat (Xenical), Qsymia (phentermine and topiramate extended-release), Saxenda (liraglutide), and Wegovy (semaglutide) - Prior Authorization . UPNEEQ (oxymetazoline hydrochloride) Filgrastim agents (Nivestym, Zarxio, Neupogen, Granix, Releuko) In doing so, CVS/Caremark will be able to decide whether or not the requested prescription is included in the patient's insurance plan. 0000005705 00000 n Valuable and timely information on drug therapy issues impacting today's health care and pharmacy environment. coagulation factor XIII (Tretten) ZORVOLEX (diclofenac) But the disease is preventable. %PDF-1.7 % REVATIO (sildenafil citrate) MEKINIST (trametinib) EMGALITY (galcanezumab-gnlm) ERIVEDGE (vismodegib) This means that based on evidence-based guidelines, our clinical experts agree with your health care providers recommendation for your treatment. Off-label and Administrative Criteria SOLIQUA (insulin glargine and lixisenatide) 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. 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. 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.. Wegovy should be used with a reduced calorie meal plan and increased physical activity. Wegovy must be kept in the original carton until time of administration. HETLIOZ/HETLIOZ LQ (tasimelton) Indication and Usage. RECLAST (zoledronic acid-mannitol-water) TRIPTODUR (triptorelin extended-release) When conditions are met, we will authorize the coverage of Wegovy. FDA Approved Indication(s) Wegovy is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index (BMI) of: 30 kg/m. NURTEC ODT (rimegepant) It is sometimes known as precertification or preapproval. 0000010297 00000 n startxref Since Clinical Policy Bulletins (CPBs) 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. Each main plan type has more than one subtype. ONGLYZA (saxagliptin) KOMBIGLYZE XR (saxagliptin and metformin hydrochloride, extended release) dates and more. z ZOMETA (zoledronic acid) FABRAZYME (agalsidase beta) 0000002571 00000 n SHINGRIX (zoster vaccine recombinant) VTAMA (tapinarof cream) 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 RUBRACA (rucaparib) Elapegademase-lvlr (Revcovi) An exception can be requested following a denial of a prior authorization or can be submitted at the onset of the request. GAVRETO (pralsetinib) KORSUVA (difelikefalin) JYNARQUE (tolvaptan) Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn) Infliximab Agents (REMICADE, infliximab, AVSOLA, INFLECTRA, RENFLEXIS) As part of an ongoing effort to increase security, accuracy, and timeliness of PA At a MinuteClinic inside a CVS Pharmacy, you may see nurse practitioners (NPs), physician associates (PAs) and pharmacists. 3 0 obj Botulinum Toxin Type A and Type B 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. Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. FARXIGA (dapagliflozin) MassHealth Pharmacy Initiatives and Clinical Information. ILUVIEN (fluocinolone acetonide) BIJUVA (estradiol-progesterone) XTAMPZA ER (oxycodone) NEXAVAR (sorafenib) 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. Copyright 2015 by the American Society of Addiction Medicine. VOXZOGO (vosoritide) AMVUTTRA (vutrisiran) In the event that a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision. q[#rveQ:7cntFHb)?&\FmBmF[l~7NizfdUc\q (^"_>{s^kIi&=s oqQ^Ne[* h$h~^h2:YYWO8"Si5c@9tUh1)4 prescription drug benefit coverage under his/her health insurance plan or call OptumRx. Were here to help. NEXLETOL (bempedoic acid) Fax complete signed and dated forms to CVS/Caremark at 888-836-0730. Please use the updated forms found below and take note of the fax number referenced within the Drug Authorization Forms. CINQAIR (reslizumab) All Rights Reserved. VERQUVO (vericiguat) EYSUVIS (loteprednol etabonate) AEMCOLO (rifamycin delayed-release) And we will reduce wait times for things like tests or surgeries. CIALIS (tadalafil) bBZ!A01/a(m:=Ug^@+zDfD|4`vP3hs)l5yb/CLBf;% 2p|~\ie.~z_OHSq::xOv[>vv <> HAEGARDA (C1 Esterase Inhibitor SQ [human]) LEQVIO (inclisiran) 0000017217 00000 n constipation *. III. 0000069922 00000 n JEMPERLI (dostarlimab-gxly) CEQUA (cyclosporine) 0000014745 00000 n DAKLINZA (daclatasvir) FENORTHO (fenoprofen) VYZULTA (latanoprostene bunod) 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. ACCRUFER (ferric maltol) EUCRISA (crisaborole) OhV\0045| 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. h ZULRESSO (brexanolone) 0000004021 00000 n BRONCHITOL (mannitol) MEKTOVI (binimetinib) Tadalafil (Adcirca, Alyq) ERLEADA (apalutamide) CARBAGLU (carglumic acid) ILARIS (canakinumab) While Clinical Policy Bulletins (CPBs) define Aetna's clinical policy, medical necessity determinations in connection with coverage decisions are made on a case by case basis. PROBUPHINE (buprenorphine implant for subdermal administration) 2493 0 obj <> endobj SCENESSE (afamelanotide) ALECENSA (alectinib) H l t DUEXIS (ibuprofen and famotidine) STELARA (ustekinumab) XYOSTED (testosterone enanthate) Link to the Concomitant Opioid Benzodiazepine, Pediatric Behavioral Health Medication, Hospital Outpatient Prior Authorization, Opioid and Pain, and Second-Generation (Atypical) Antipsychotic Initiatives. Thats why we partner with your provider to accept requests through convenient options like phone, fax or through our online platform. Riluzole (Exservan, Rilutek, Tiglutik, generic riluzole) % 0000002392 00000 n Authorization will be issued for 12 months. The responsibility for the content of Aetna Clinical Policy Bulletins (CPBs) is with Aetna and no endorsement by the AMA is intended or should be implied. TUKYSA (tucatinib) ADBRY (tralokinumab-ldrm) VALTOCO (diazepam nasal spray) APTIOM (eslicarbazepine) NULIBRY (fosdenopterin) r Therapeutic indication. DIACOMIT (stiripentol) OCREVUS (ocrelizumab) 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. Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. Whats the difference? XTANDI (enzalutamide) iMo::>91}h9 REVLIMID (lenalidomide) FIRDAPSE (amifampridine) PLEGRIDY (peginterferon beta-1a) 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. ePAs save time and help patients receive their medications faster. A prior approval is required for the procedures listed below for both the FEP Standard and Basic Option plan and the FEP Blue Focus plan. SYNRIBO (omacetaxine mepesuccinate) GAMIFANT (emapalumab-izsg) all ADEMPAS (riociguat) Pre-authorization is a routine process. AKYNZEO (fosnetupitant/palonosetron) ! 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