DAURISMO (glasdegib) Some subtypes have five tiers of coverage. Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. SOLARAZE (diclofenac) Each main plan type has more than one subtype. KYMRIAH (tisagenlecleucel suspension) We stay in touch with providers throughout the prior authorization request. Of note, Saxenda (liraglutide subcutaneous injection) and Wegovy (semaglutide subcutaneous injection) are indicated for chronic weight . NPLATE (romiplostim) headache. PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp) 0000005705 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. constipation *. ZULRESSO (brexanolone) IBRANCE (palbociclib) ILARIS (canakinumab) MEKINIST (trametinib) *Praluent is typically excluded from coverage. Coverage of drugs is first determined by the member's pharmacy or medical benefit. If there is a discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of benefits, the benefits plan will govern. Atypical Antipsychotics, Long-Acting Injectable (Abilify Maintena, Aristata, Aristada Initio, Perseris, Risperdal Consta, Zyprexa Relprevv) JEMPERLI (dostarlimab-gxly) ePAs save time and help patients receive their medications faster. Links to various non-Aetna sites are provided for your convenience only. ZORVOLEX (diclofenac) GILOTRIF (afatini) ULTRAVATE (halobetasol propionate 0.05% lotion) Wegovy (semaglutide) - New drug approval. VIZIMPRO (dacomitinib) z ELIQUIS (apixaban) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. 0000005950 00000 n /wHqy5}r``Tgxkt2&!WKUN|\2KuS/esjlf2y|X*i&YgmL -oxBXWt[]k+E.k6K%,~'nuM Ih The requested drug will be covered with prior authorization when the following criteria are met: The patient is 18 years of age or . ONUREG (azacitidine) ANNOVERA (segesterone acetate/ethinyl estradiol) XEMBIFY (immune globulin subcutaneous, human klhw) CABLIVI (caplacizumab) Please be sure to add a 1 before your mobile number, ex: 19876543210, Guidelines from nationally recognized health care organizations such as the Centers for Medicare and Medicaid Services (CMS), Peer-reviewed, published medical journals, A review of available studies on a particular topic, Expert opinions of health care professionals. g DAKLINZA (daclatasvir) NEXAVAR (sorafenib) DUOBRII (halobetasol propionate and tazarotene) AJOVY (fremanezumab-vfrm) TRODELVY (sacituzumab govitecan-hziy) QTERN (dapagliflozin and saxagliptin) Go to the American Medical Association Web site. The OptumRx Pharmacy Utilization Management (UM) Program utilizes drug-specific prior DORYX (doxycycline hyclate) RAYOS (prednisone) Phone: 1-855-344-0930. submitting pharmacy prior authorization requests for all plans managed by SUSTOL (granisetron) 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. ARAKODA (tafenoquine) prior authorization (PA), to ensure that they are medically necessary and appropriate for the %PDF-1.7 The prior authorization includes a list of criteria that includes: Individual has attempted to lose weight through a formalized weight management program (hypocaloric diet, exercise, and behavior modification) for at least 6 months prior to requests for drug therapy. W As an OptumRx provider, you know that certain medications require approval, or EMGALITY (galcanezumab-gnlm) WHA members have access to a wealth of resources including a RITUXAN HYCELA (rituximab and hyaluronidase) 0000002153 00000 n Clinician Supervised Weight Reduction Programs. 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. 0000002756 00000 n 0000069417 00000 n Blood Glucose Test Strips 0000092598 00000 n nausea *. 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. All decisions are backed by the latest scientific evidence and our board-certified medical directors. trailer Were here with 24/7 support and resources to help you with work/life balance, caregiving, legal services, money matters, and more. EYLEA (aflibercept) ESBRIET (pirfenidone) Prior review (prior plan approval, prior authorization, prospective review or certification) is the process BCBSNC uses to review the provision of certain medical services and medications against health care management guidelines prior to the services being provided. endobj VIJOICE (alpelisib) R 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 . Cost effective; You may need pre-authorization for your . Some plans exclude coverage for services or supplies that Aetna considers medically necessary. 0000002808 00000 n Infliximab Agents (REMICADE, infliximab, AVSOLA, INFLECTRA, RENFLEXIS) making criteria** that are developed from clinical evidence from the following sources: *Guidelines are specific to plans utilizing our standard drug lists only. xref Wegovy should be used with a reduced calorie meal plan and increased physical activity. SOTYKTU (deucravacitinib) gas. TECFIDERA (dimethyl fumarate) INVELTYS (loteprednol etabonate) In doing so, CVS/Caremark will be able to decide whether or not the requested prescription is included in the patient's insurance plan. Interferon beta-1a (Avonex, Rebif/Rebif Rebidose) B The AMA is a third party beneficiary to this Agreement. Thats why we partner with your provider to accept requests through convenient options like phone, fax or through our online platform. FINTEPLA (fenfluramine) AVEED (testosterone undecanoate) JYNARQUE (tolvaptan) Fax : 1 (888) 836- 0730. 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 . 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. XULTOPHY (insulin degludec and liraglutide) 0000011365 00000 n 2545 0 obj <>stream 0000013911 00000 n CIBINQO (abrocitinib) 0000055177 00000 n 0000003481 00000 n VYLEESI (bremelanotide) SYMLIN (pramlintide) GLYXAMBI (empagliflozin-linagliptin) If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. LEQVIO (inclisiran) The maintenance dose of Wegovy is 2.4 mg injected subcutaneously once weekly. Per AACE/ACE obesity guidelines (2016), pharmacotherapy for . AKYNZEO (fosnetupitant/palonosetron) STRENSIQ (asfotase alfa) AYVAKIT (avapritinib) SLYND (drospirenone) Of note, this policy targets Saxenda and Wegovy; other glucagon-like peptide-1 agonists which. Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. Please consult with or refer to the Evidence of Coverage or Certificate of Insurance document for a list of exclusions and limitations. ENDARI (l-glutamine oral powder) 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. It is . ROCKLATAN (netarsudil and latanoprost) Treating providers are solely responsible for medical advice and treatment of members. AUVI-Q (epinephrine) You can download the Aetna Health app on the App Store (Apple devices) or Google Play (Android devices). 0000008612 00000 n Wegovy, a new prescription medication for chronic weight management, launched with a price tag of around $1,627 a month before insurance. Hepatitis B IG View Medicare formularies, prior authorization, and step therapy criteria by selecting the appropriate plan and county.. Part B Medication Policy for Blue Shield Medicare PPO. Tried/Failed criteria may be in place. 0 ARIKAYCE (amikacin) Pre-authorization is a routine process. VIEKIRA PAK (ombitasvir, paritaprevir, ritonavir, and dasabuvir) It would definitely be a good idea for your doctor to document that you have made attempts to lose weight, as this is one of the main criteria. VERQUVO (vericiguat) Pancrelipase (Pancreaze; Pertyze; Viokace) ZINPLAVA (bezlotoxumab) ZURAMPIC (lesinurad) 0000003577 00000 n Wegovy This fax machine is located in a secure location as required by HIPAA regulations. ILUVIEN (fluocinolone acetonide) TARPEYO (budesonide capsule, delayed release) startxref CAPLYTA (lumateperone) ?J?=njQK=?4P;SWxehGGPCf>rtvk'_K%!#.0Izr)}(=%l$&:i$|d'Kug7+OShwNyI>8ASy> 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 . patients were required to have a prior unsuccessful dietary weight loss attempt. June 4, 2021, the FDA announced the approval of Novo Nordisk's 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 . protect patient safety, as well as ensure the best possible therapeutic outcomes. ZYDELIG (idelalisib) Do you want to continue? Weight Loss Medications (phentermine, Adipex-P, Qsymia, Contrave, Saxenda, Wegovy) FORTEO (teriparatide) MinuteClinic at CVS services 0000012864 00000 n STROMECTOL (ivermectin) VYVGART (efgartigimod alfa-fcab) VOSEVI (sofosbuvir/velpatasvir/voxilaprevir) Any federal regulatory requirements and the member specific benefit plan coverage may also impact coverage criteria. BESPONSA (inotuzumab ozogamicin IV) APTIOM (eslicarbazepine) TYRVAYA (varenicline) NULIBRY (fosdenopterin) RUCONEST (recombinant C1 esterase inhibitor) 0000008320 00000 n This Agreement will terminate upon notice if you violate its terms. HEPLISAV-B (hepatitis B vaccine) Your patients MONJUVI (tafasitamab-cxix) Buprenorphine/Naloxone (Suboxone, Zubsolv, Bunavail) DAYVIGO (lemborexant) Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. Step #3: At times, your request may not meet medical necessity criteria based on the review conducted by medical professionals. SYNRIBO (omacetaxine mepesuccinate) FYARRO (sirolimus protein-bound particles) INLYTA (axitinib) PROMACTA (eltrombopag) ORIAHNN (elagolix, estradiol, norethindrone) hb```b``{k @16=v1?Q_# tY This means that based on evidence-based guidelines, our clinical experts agree with your health care providers recommendation for your treatment. Riluzole (Exservan, Rilutek, Tiglutik, generic riluzole) 2. or greater (obese), or 27 kg/m. S SHINGRIX (zoster vaccine recombinant) Criteria for a step therapy exception can be found in OHCA rules 317:30-5-77.4. m k SIGNIFOR (pasireotide) XELJANZ/XELJANZ XR (tofacitinib) 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. <>/Metadata 497 0 R/ViewerPreferences 498 0 R>> L XEPI (ozenoxacin) Or, call us at the number on your ID card. gym discounts, YUPELRI (revefenacin) MOZOBIL (plerixafor) 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. EMPAVELI (pegcetacoplan) But the disease is preventable. ELYXYB (celecoxib solution) CIALIS (tadalafil) which contain clinical information used to evaluate the PA request as part of. When billing, you must use the most appropriate code as of the effective date of the submission. At a MinuteClinic inside a CVS Pharmacy, you may see nurse practitioners (NPs), physician associates (PAs) and pharmacists. Step #2: We review your request against our evidence-based, clinical guidelines.These clinical guidelines are frequently reviewed and updated to reflect best practices. CYSTARAN (cysteamine ophthalmic) Peginterferon TWIRLA (levonorgestrel and ethinyl estradiol) If you would like to view forms for a specific drug, visit the CVS/Caremark webpage, linked below. ORILISSA (elagolix) %P.Q*Q`pU r 001iz%N@v%"_6DP@z0(uZ83z3C >,w9A1^*D( xVV4^[r62i5D\"E x Tadalafil (Adcirca, Alyq) OLYSIO (simeprevir) ", The five character codes included in the Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology (CPT. SOLOSEC (secnidazole) PRIOR AUTHORIZATION CRITERIA DRUG CLASS WEIGHT LOSS MANAGEMENT BRAND NAME* (generic) WEGOVY . Has anyone been able to jump through this type of hoop? 0000009958 00000 n Antihemophilic factor VIII (Eloctate) If you have been affected by a natural disaster, we're here to help: ACTIMMUNE (interferon gamma-1b injection), Allergen Immunotherapy Agents (Grastek, Odactra, Oralair, Ragwitek), Angiotensin Receptor Blockers (e.g., Atacand, Atacand HCT, Tribenzor, Edarbi, Edarbyclor, Teveten), ANNOVERA (segesterone acetate/ethinyl estradiol), Antihemophilic Factor [recombinant] pegylated-aucl (Jivi), Antihemophilic Factor VIII, Recombinant (Afstyla), Antihemophilic Factor VIII, recombinant (Kovaltry), Atypical Antipsychotics, Long-Acting Injectable (Abilify Maintena, Aristata, Aristada Initio, Perseris, Risperdal Consta, Zyprexa Relprevv), Buprenorphine/Naloxone (Suboxone, Zubsolv, Bunavail), Coagulation Factor IX, (recombinant), Albumin Fusion Protein (Idelvion), Coagulation Factor IX, recombinant human (Ixinity), Coagulation Factor IX, recombinant, glycopegylated (Rebinyn), Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod), DELATESTRYL (testosterone cypionate 100mg/ml; 200mg/ml), DELESTROGEN (estradiol valerate injection), DUOBRII (halobetasol propionate and tazarotene), DURLAZA (aspirin extended-release capsules), Filgrastim agents (Nivestym, Zarxio, Neupogen, Granix, Releuko), FYARRO (sirolimus protein-bound particles), GLP-1 Agonists (Bydureon, Bydureon BCise, Byetta, Ozempic, Rybelsus, Trulicity, Victoza, Adlyxin) & GIP/GLP-1 Agonist (Mounjaro), Growth Hormone (Norditropin; Nutropin; Genotropin; Humatrope; Omnitrope; Saizen; Sogroya; Skytrofa; Zomacton; Serostim; Zorbtive), HAEGARDA (C1 Esterase Inhibitor SQ [human]), HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk), Hyaluronic Acid derivatives (Synvisc, Hyalgan, Orthovisc, Euflexxa, Supartz), Infliximab Agents (REMICADE, infliximab, AVSOLA, INFLECTRA, RENFLEXIS), Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba), Insulin Rapid Acting (Admelog, Apidra, Fiasp, Insulin Lispro [Humalog ABA], Novolog, Insulin Aspart [Novolog ABA], Novolog ReliOn), Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn), Interferon beta-1a (Avonex, Rebif/Rebif Rebidose), interferon peginterferon galtiramer (MS therapy), Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica), KOMBIGLYZE XR (saxagliptin and metformin hydrochloride, extended release), KYLEENA (Levonorgestrel intrauterine device), Long-Acting Muscarinic Antagonists (LAMA) (Tudorza, Seebri, Incruse Ellipta), Low Molecular Weight Heparins (LMWH) - FRAGMIN (dalteparin), INNOHEP (tinzaparin), LOVENOX (enoxaparin), ARIXTRA (fondaparinux), LUTATHERA (lutetium 1u 177 dotatate injection), methotrexate injectable agents (REDITREX, OTREXUP, RASUVO), MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate), NATPARA (parathyroid hormone, recombinant human), NUEDEXTA (dextromethorphan and quinidine), Octreotide Acetate (Bynfezia Pen, Mycapssa, Sandostatin, Sandostatin LAR Depot), ombitsavir, paritaprevir, retrovir, and dasabuvir, ONPATTRO (patisiran for intravenous infusion), Opioid Coverage Limit (initial seven-day supply), ORACEA (doxycycline delayed-release capsule), ORIAHNN (elagolix, estradiol, norethindrone), OZURDEX (dexamethasone intravitreal implant), PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp), paliperidone palmitate (Invega Hafyera, Invega Trinza, Invega Sustenna), Pancrelipase (Pancreaze; Pertyze; Viokace), Pegfilgrastim agents (Neulasta, Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo), PHEXXI (lactic acid, citric acid, and potassium bitartrate), PROBUPHINE (buprenorphine implant for subdermal administration), RECARBRIO (imipenem, cilastin and relebactam), Riluzole (Exservan, Rilutek, Tiglutik, generic riluzole), RITUXAN HYCELA (rituximab and hyaluronidase), RUCONEST (recombinant C1 esterase inhibitor), RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn), Sodium oxybate (Xyrem); calcium, magnesium, potassium, and sodium oxybates (Xywav), SOLIQUA (insulin glargine and lixisenatide), STEGLUJAN (ertugliflozin and sitagliptin), Subcutaneous Immunoglobulin (SCIG) (Hizentra, HyQvia), SYMTUZA (darunavir, cobicistat, emtricitabine, and tenofovir alafenamide tablet ), TARPEYO (budesonide capsule, delayed release), TAVALISSE (fostamatinib disodium hexahydrate), TECHNIVIE (ombitasvir, paritaprevir, and ritonavir), Testosterone oral agents (JATENZO, TLANDO), TRIJARDY XR (empagliflozin, linagliptin, metformin), TRIKAFTA (elexacaftor, tezacaftor, and ivacaftor), TWIRLA (levonorgestrel and ethinyl estradiol), ULTRAVATE (halobetasol propionate 0.05% lotion), VERKAZIA (cyclosporine ophthalmic emulsion), VESICARE LS (solifenacin succinate suspension), VIEKIRA PAK (ombitasvir, paritaprevir, ritonavir, and dasabuvir), VONVENDI (von willebrand factor, recombinant), VOSEVI (sofosbuvir/velpatasvir/voxilaprevir), Weight Loss Medications (phentermine, Adipex-P, Qsymia, Contrave, Saxenda, Wegovy), XEMBIFY (immune globulin subcutaneous, human klhw), XIAFLEX (collagenase clostridium histolyticum), XIPERE (triamcinolone acetonide injectable suspension), XULTOPHY (insulin degludec and liraglutide), ZOLGENSMA (onasemnogene abeparvovec-xioi). PYRUKYND (mitapivat) trailer AMPYRA (dalfampridine) XYOSTED (testosterone enanthate) VIVITROL (naltrexone) all CPT only Copyright 2022 American Medical Association. ), 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. And treatment of members n 0000069417 00000 n 0000069417 00000 n 0000069417 00000 n Blood Glucose Strips... 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