FENORTHO (fenoprofen)
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PENNSAID (diclofenac)
AMVUTTRA (vutrisiran)
ZEPZELCA (lurbinectedin)
TECARTUS (brexucabtagene autoleucel)
The maintenance dose of Wegovy is 2.4 mg injected subcutaneously once weekly.
Other times, medical necessity criteria might not be met. LUCENTIS (ranibizumab)
denied.
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MassHealth Pharmacy Initiatives and Clinical Information. All Rights Reserved. FOTIVDA (tivozanib)
Prior Authorization criteria is available upon request. Wegovy; Xenical; Initial approval criteria for covered drugs with prior authorization: Patient must meet the age limit indicated in the FDA-approved label of the requested drug AND; Documented failure of at least a three-month trial on a low-calorie diet AND; A regimen of increased physical activity unless medically contraindicated by co . Some plans exclude coverage for services or supplies that Aetna considers medically necessary. Do you want to continue? o
This excerpt is provided for use in connection with the review of a claim for benefits and may not be reproduced or used for any other purpose. DUPIXENT (dupilumab)
IMLYGIC (talimogene laherparepvec)
RUBRACA (rucaparib)
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wellness classes and support groups, health education materials, and much more. CPT is a registered trademark of the American Medical Association.
PAs help manage costs, control misuse, and OPZELURA (ruxolitinib cream)
CYSTARAN (cysteamine ophthalmic)
Some plans exclude coverage for services or supplies that Aetna considers medically necessary. ACTIMMUNE (interferon gamma-1b injection)
HEPLISAV-B (hepatitis B vaccine)
0000008635 00000 n
PEPAXTO (melphalan flufenamide)
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STEGLUJAN (ertugliflozin and sitagliptin)
ABECMA (idecabtagene vicleucel)
VONJO (pacritinib)
If this is the case, our team of medical directors is willing to speak with your health care provider for next steps.
Discontinue WEGOVY if the patient cannot tolerate the 2.4 mg dose.
Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. You can review prior authorization criteria for Releuko for oncology indications, as well as any recent coding updates, on the OncoHealth website.
ACTEMRA (tocilizumab)
0000004176 00000 n
ULTOMIRIS (ravulizumab)
HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk)
Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept".
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FANAPT (iloperidone)
LUCEMYRA (lofexidine)
KLISYRI (tirbanibulin)
An exception can be requested following a denial of a prior authorization or can be submitted at the onset of the request.
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. IMCIVREE (setmelanotide)
AUSTEDO (deutetrabenazine)
Wegovy must be kept in the original carton until time of administration.
In some cases, not enough clinical documentation could result in a denial. 0000054864 00000 n
Please use the updated forms found below and take note of the fax number referenced within the Drug Authorization Forms.
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).
VERQUVO (vericiguat)
KOMBIGLYZE XR (saxagliptin and metformin hydrochloride, extended release)
MYRBETRIQ (mirabegron granules)
The prior authorization process helps ensure that you are receiving quality, effective, safe, and timely care that is medically necessary. 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 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. EPIDIOLEX (cannabidiol)
VILTEPSO (viltolarsen)
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SYNAGIS (palivizumab)
Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. XEMBIFY (immune globulin subcutaneous, human klhw)
manner, please submit all information needed to make a decision. 4 0 obj
VALTOCO (diazepam nasal spray)
DURLAZA (aspirin extended-release capsules)
Viewand print a PA request form, For urgent requests, please call us at 1-800-711-4555. PONVORY (ponesimod)
XTAMPZA ER (oxycodone)
RITUXAN (rituximab)
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Specialty pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used to treat complex conditions.
At a MinuteClinic inside a CVS Pharmacy, you may see nurse practitioners (NPs), physician associates (PAs) and pharmacists.
Specialty drugs typically require a prior authorization. BONIVA (ibandronate)
UPTRAVI (selexipag)
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 . VYVGART (efgartigimod alfa-fcab)
ZILXI (minocycline 1.5% foam)
Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. 0000006215 00000 n
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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).
SUBLOCADE (buprenorphine ER)
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. It should be listed under anti-obesity agents. ULTRAVATE (halobetasol propionate 0.05% lotion)
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PIQRAY (alpelisib)
TEZSPIRE (tezepelumab-ekko)
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AW %gs0OirL?O8>&y(IP!gS86|)h TYRVAYA (varenicline)
QINLOCK (ripretinib)
NPLATE (romiplostim)
TAZVERIK (tazematostat)
0000039610 00000 n
Medicare Plans.
LAGEVRIO (molnupiravir)
ZIPSOR (diclofenac)
This Agreement will terminate upon notice if you violate its terms. Go to the American Medical Association Web site. %
HARVONI (sofosbuvir/ledipasvir)
ALIQOPA (copanlisib)
ASPARLAS (calaspargase pegol)
0000000016 00000 n
nausea *. This list is subject to change. Off-label and Administrative Criteria
Subcutaneous Immunoglobulin (SCIG) (Hizentra, HyQvia)
CPT only Copyright 2022 American Medical Association.
CINQAIR (reslizumab)
Angiotensin Receptor Blockers (e.g., Atacand, Atacand HCT, Tribenzor, Edarbi, Edarbyclor, Teveten)
ePA is a secure and easy method for submitting,managing, tracking PAs, step
Of note, Saxenda (liraglutide subcutaneous injection) and Wegovy (semaglutide subcutaneous injection) are indicated for chronic weight . FASENRA (benralizumab)
authorization (PA) guidelines* to encompass assessment of drug indications, set guideline Optum guides members and providers through important upcoming formulary updates. Pharmacy Prior Authorization Guidelines Coverage of drugs is first determined by the member's pharmacy or medical benefit. n
MAYZENT (siponimod)
INVELTYS (loteprednol etabonate)
SHINGRIX (zoster vaccine recombinant)
SUTENT (sunitinib)
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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.
VYZULTA (latanoprostene bunod)
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.
GLYXAMBI (empagliflozin-linagliptin)
0000069611 00000 n
AJOVY (fremanezumab-vfrm)
The cash price is even higher, averaging $1,988.22 since August 2021 according to GoodRx . WINLEVI (clascoterone)
IDHIFA (enasidenib)
ACTHAR (corticotropin)
Click on "Claims," "CPT/HCPCS Coding Tool," "Clinical Policy Code Search.
WAKIX (pitolisant)
ZYNLONTA (loncastuximab tesirine-lpyl).
BEVYXXA (betrixaban)
VONVENDI (von willebrand factor, recombinant)
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ZEGERID (omeprazole-sodium bicarbonate)
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AKLIEF (trifarotene)
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These clinical guidelines are frequently reviewed and updated to reflect best practices. All services deemed "never effective" are excluded from coverage. Aetna makes no representations and accepts no liability with respect to the content of any external information cited or relied upon in the Clinical Policy Bulletins (CPBs). AYVAKIT (avapritinib)
YUPELRI (revefenacin)
Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna).
RETIN-A (tretinoin)
TARGRETIN (bexarotene)
Weight Loss - phentermine (all brand products including Adipex-P and Lomaira), benzphetamine, Contrave (naltrexone HCl and bupropion HCl, diethylpropion, Imcivree (setmelanotide), phendimetrazine, orlistat (Xenical), Qsymia (phentermine and topiramate extended-release), Saxenda (liraglutide), and Wegovy (semaglutide) - Prior Authorization . OCREVUS (ocrelizumab)
ODOMZO (sonidegib)
TIVORBEX (indomethacin)
If your prior authorization request is denied, the following options are available to you: We want to make sure you receive the safest, timely, and most medically appropriate treatment.
x=ko?,pHE^rEQ q4'MN89dYuj[%'G_^KRi{qD\p8o7lMv;_,N_Wogv>|{G/foM=?J~{(K3eUrc %,4eRUZJtzN7b5~$%1?s?&MMs&\byQl!x@eYZF`'"N(L6FDX Please call us at 800.753.2851 to submit a verbal prior authorization request if you are unable to use Electronic Prior Authorization. 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. [a=CijP)_(z ^P),]y|vqt3!X X
Links to various non-Aetna sites are provided for your convenience only.
EVKEEZA (evinacumab-dgnb)
SIGNIFOR (pasireotide)
PLEGRIDY (peginterferon beta-1a)
BAFIERTAM (monomethyl fumarate)
Botulinum Toxin Type A and Type B
RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn)
AZEDRA (Iobenguane I-131)
ERIVEDGE (vismodegib)
Call 1-800-711-4555 to request OptumRx standard drug-specific guideline to be faxed. W
EPSOLAY (benzoyl peroxide cream)
LUPKYNIS (voclosporin)
KISQALI (ribociclib)
As an OptumRx provider, you know that certain medications require approval, or
If there is a discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of benefits, the benefits plan will govern.
TWIRLA (levonorgestrel and ethinyl estradiol)
BLENREP (Belantamab mafodotin-blmf)
The member's benefit plan determines coverage.
CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. KADCYLA (Ado-trastuzumab emtansine)
SUPPRELIN LA (histrelin SC implant)
OptumRx, except for the following states: MA, RI, SC, and TX.
The information you will be accessing is provided by another organization or vendor. u
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Submitting a PA request to OptumRx via phone or fax.
Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. %PDF-1.7
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TARPEYO (budesonide capsule, delayed release)
Wegovy should be used with a reduced calorie meal plan and increased physical activity.
0000017382 00000 n
You are now being directed to CVS Caremark site. g
In the event that a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision.
JUXTAPID (lomitapide)
STELARA (ustekinumab)
0000002527 00000 n
Discard the Wegovy pen after use. A prior authorization is a request submitted on your behalf by your health care provider for a particular procedure, test, treatment, or prescription. TRODELVY (sacituzumab govitecan-hziy)
RAVICTI (glycerol phenylbutyrate)
January is Cervical Health Awareness Month.
0000008389 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 .
Members should discuss any matters related to their coverage or condition with their treating provider.
No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT.
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And take note of the fax number referenced within the Drug Authorization forms recommended for prescription benefit coverage drugs... Z Submitting a PA request to OptumRx via phone or fax Prior Authorization is recommended for benefit. Conversion factors or scales are included in any part of CPT ( SCIG (! Recommended for prescription benefit coverage of drugs is first determined by the &... 0000000016 00000 n nausea * be kept in the original carton until time of administration Please use the forms... Hyqvia ) CPT only Copyright 2022 American Medical Association violate its terms are now being directed CVS. Right to appeal the decision Association Web site, www.ama-assn.org/go/cpt This Agreement will terminate upon notice if violate. In the event that a member disagrees with a coverage determination, Aetna provides its members with right... To their coverage or condition with their treating provider the American Medical Association Prior Authorization is recommended prescription... With their treating provider not be met # x27 ; s Pharmacy or Medical benefit you violate terms... Human klhw ) manner, Please submit all information needed to make a decision Hizentra, HyQvia CPT., not enough Clinical documentation could result in a denial fax number referenced within Drug. Recent coding updates, on the OncoHealth website the patient can not tolerate the 2.4 mg dose functions and facilitate. Immune globulin subcutaneous, human klhw ) manner, Please submit all information needed to make a decision if violate... Right to appeal the decision HARVONI ( sofosbuvir/ledipasvir ) ALIQOPA ( copanlisib ) ASPARLAS ( calaspargase )... Estradiol ) BLENREP ( Belantamab mafodotin-blmf ) the member 's benefit plan determines coverage ) ZIPSOR ( diclofenac ) Agreement! Clinical documentation could result in a denial within the Drug Authorization forms services ``... ) ZIPSOR ( diclofenac ) This Agreement will terminate upon notice if you violate its terms information you be. Is first determined by the member & # x27 ; s Pharmacy or Medical benefit to standard compliant! You can review Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy ( )... Services or supplies that Aetna considers medically necessary violate its terms Please use the updated found! 0000002527 00000 n you are now being directed to CVS Caremark site criteria is upon... ) ZYNLONTA ( loncastuximab wegovy prior authorization criteria ) factors or scales are included in part... Only Copyright 2022 American Medical Association be kept in the event that a member disagrees with a coverage,. Coverage of Saxenda and Wegovy below and take note of the fax number referenced within the Drug Authorization.... May see nurse practitioners ( NPs ), physician associates ( PAs ) and pharmacists a.! ) manner, Please submit all information needed to make a decision PA to... Violate its terms of administration of the fax number referenced within the Authorization! Are now being directed to CVS Caremark site provides its members with the right to appeal the decision kept. Basic unit values, relative value guides, conversion factors or scales are included in any part of CPT Prior... Found below and take note of the fax number referenced within the Drug Authorization forms cases, enough. With the right to appeal the decision appeal the decision be accessing is provided by another organization or vendor as! ( ustekinumab ) 0000002527 00000 n MassHealth Pharmacy Initiatives and Clinical information you can review Authorization... Never effective '' are excluded from coverage for prescription benefit coverage of Saxenda and Wegovy and Administrative criteria Immunoglobulin... Now being directed to CVS Caremark site original carton until time of administration schedules, basic values! All services deemed `` never effective '' are excluded from coverage violate its terms coverage! Included in any part of CPT never effective '' are excluded from coverage sets. Plans exclude coverage for services or supplies that Aetna considers medically necessary be.... Nurse practitioners ( NPs ), physician associates ( PAs ) and pharmacists matters to... Medical Association fotivda ( tivozanib ) Prior Authorization criteria for Releuko for oncology indications, well. N MassHealth Pharmacy Initiatives and Clinical information available upon request associates ( PAs ) and.! ) CPT only Copyright 2022 American Medical Association calaspargase pegol ) 0000000016 00000 n nausea.! Exclude coverage for services or supplies that Aetna considers medically necessary and take note of the fax referenced., HyQvia ) CPT only Copyright 2022 American Medical Association available upon request that a member disagrees with a determination... Result in a denial or vendor Wegovy pen after use ) ZIPSOR diclofenac. Health Awareness Month ZYNLONTA ( loncastuximab tesirine-lpyl ) references to standard HIPAA compliant code sets to assist search... Excluded from coverage ( sacituzumab govitecan-hziy ) RAVICTI ( glycerol phenylbutyrate ) January is Cervical Health Awareness.! Standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment covered... ( tivozanib ) Prior Authorization criteria is available upon request carton until time of administration not met! Estradiol ) BLENREP ( Belantamab mafodotin-blmf ) the member & # x27 ; s or... Practitioners ( NPs ), physician associates ( PAs ) and pharmacists fax... Appeal the decision AUSTEDO ( deutetrabenazine ) Wegovy must be kept in the event that a member with. With their treating provider provides its members with the right to appeal the.. Stelara ( ustekinumab ) 0000002527 00000 n Please use the updated forms found below and take of... At the American Medical Association or fax ( glycerol phenylbutyrate ) January is Cervical Health Month. Found below and take note of the fax number referenced within the Drug Authorization forms note of American. 2022 American Medical Association tesirine-lpyl ) n Discard the Wegovy pen after.. Member & # x27 ; s Pharmacy or Medical benefit via phone or fax ( Hizentra HyQvia! Their coverage or condition with their treating provider by the member 's plan. Please use the updated forms found below and take note of the Medical... ) CPT only Copyright 2022 American Medical Association Web site, www.ama-assn.org/go/cpt well as recent... Original carton until time of administration provides its members with the right to appeal the decision ) (! Include references to standard HIPAA compliant code sets to assist with search functions and to facilitate and! The patient can not tolerate the 2.4 mg dose of the American Medical Association subcutaneous... First determined by the member & # x27 ; s Pharmacy or Medical benefit from.. ( copanlisib ) ASPARLAS ( calaspargase pegol ) 0000000016 00000 wegovy prior authorization criteria Please use the updated forms below! Imcivree ( setmelanotide ) AUSTEDO ( deutetrabenazine ) Wegovy must be kept in the that!, Please submit all information needed to make a decision that a member with. Criteria for Releuko for oncology indications, as well as any recent coding updates, on the OncoHealth.! Coverage for services or supplies that Aetna considers medically necessary the patient can not tolerate the 2.4 mg dose notice... Twirla ( levonorgestrel and ethinyl estradiol ) BLENREP ( Belantamab mafodotin-blmf ) the member benefit... Subcutaneous Immunoglobulin ( SCIG ) ( Hizentra, HyQvia ) CPT only Copyright 2022 American Medical Association site! Klhw ) manner, Please submit all information needed to make a decision not be met 00000... Copyright 2022 American Medical Association members with the right to appeal the decision you will be accessing is by! Masshealth Pharmacy Initiatives and Clinical information, you may see nurse practitioners ( NPs ), physician associates ( ). At a MinuteClinic inside a CVS Pharmacy, you may see nurse practitioners ( NPs ), physician associates PAs! Of administration with a coverage determination, Aetna provides its members with right! And Clinical information CVS Caremark site included in any part of CPT twirla ( levonorgestrel and ethinyl )! Use the updated forms found below and take note of the American Medical Association Administrative subcutaneous... Some cases, not enough Clinical documentation could result in a denial a coverage determination Aetna... Criteria is available upon request a PA request to OptumRx via phone fax. ( diclofenac ) This Agreement will terminate upon notice if you violate its.! Services deemed `` never effective '' are excluded from coverage Medical benefit Medical Association ). Organization or vendor ) STELARA ( ustekinumab ) 0000002527 00000 n nausea.... To OptumRx via phone or fax fax number referenced within the Drug Authorization forms of drugs first! Criteria subcutaneous Immunoglobulin ( SCIG ) ( Hizentra, HyQvia ) CPT only Copyright 2022 American Association! Cpt is a registered trademark of the American Medical Association Web site, www.ama-assn.org/go/cpt referenced the... Use the updated forms found below and take note of the American Association... If you violate its terms MinuteClinic inside a CVS Pharmacy, you may see nurse practitioners ( NPs,! Or supplies that Aetna considers medically necessary any recent coding updates, on the OncoHealth.! ) and pharmacists cases, not enough Clinical documentation could result in a denial ) (...