You, your employees and agents are authorized to use CPT only as contained in Aetna Clinical Policy Bulletins (CPBs) solely for your own personal use in directly participating in healthcare programs administered by Aetna, Inc. You acknowledge that AMA holds all copyright, trademark and other rights in CPT. It is only a partial, general description of plan or program benefits and does not constitute a contract. STELARA (ustekinumab) OTEZLA (apremilast) - 27 kg/m to <30 kg/m (overweight) in the presence of at least one . ZERVIATE (cetirizine) AUSTEDO (deutetrabenazine) LIVTENCITY (maribavir) Applicable FARS/DFARS apply. CVS HealthHUB offers all the same services as MinuteClinic at CVS with some additional benefits. XELODA (capecitabine) ZOKINVY (lonafarnib) NATPARA (parathyroid hormone, recombinant human) Tadalafil (Adcirca, Alyq) MYRBETRIQ (mirabegron granules) j 0000003755 00000 n PROMACTA (eltrombopag) nausea *. 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. FYARRO (sirolimus protein-bound particles) ePAs save time and help patients receive their medications faster. The maintenance dose of Wegovy is 2.4 mg injected subcutaneously once weekly. which contain clinical information used to evaluate the PA request as part of. VRAYLAR (cariprazine) K VERQUVO (vericiguat) 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. paliperidone palmitate (Invega Hafyera, Invega Trinza, Invega Sustenna) 2'izZLW|zg UZFYqo M( YVuL%x=#mF"8<>Tt 9@%7z oeRa_W(T(y%*KC%KkM"J.\8,M Pre-authorization is a routine process. Call 1-800-711-4555 to request OptumRx standard drug-specific guideline to be faxed. NAYZILAM (midazolam nasal spray) TARPEYO (budesonide capsule, delayed release) 0000005681 00000 n It is . All Rights Reserved. RYPLAZIM (plasminogen, human-tvmh) The request processes as quickly as possible once all required information is together. Were here to help. ARAKODA (tafenoquine) KINERET (anakinra) 0000013029 00000 n Coagulation Factor IX, (recombinant), Albumin Fusion Protein (Idelvion) 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. MULPLETA (lusutrombopag) 0000011005 00000 n Please consult with or refer to the Evidence of Coverage or Certificate of Insurance document for a list of exclusions and limitations. PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp) Its confidential and free for you and all your household members. BELEODAQ (belinostat) INQOVI (decitabine and cedazuridine) W Phone : 1 (800) 294-5979. Inpatient admissions, services and procedures received on an outpatient basis, such as in a doctor's office, Click on "Claims," "CPT/HCPCS Coding Tool," "Clinical Policy Code Search. The information you will be accessing is provided by another organization or vendor. 2>7_0ns]+hVaP{}A GAMIFANT (emapalumab-izsg) GLEEVEC (imatinib) 0000002571 00000 n This Agreement will terminate upon notice if you violate its terms. AUVI-Q (epinephrine) IMCIVREE (setmelanotide) XYOSTED (testosterone enanthate) 0000002756 00000 n endobj Step #1: Your health care provider submits a request on your behalf. 0000070343 00000 n ZYKADIA (ceritinib) SUPPRELIN LA (histrelin SC implant) 0000013911 00000 n It should be listed under anti-obesity agents. RAVICTI (glycerol phenylbutyrate) ** OptumRxs Senior Medical Director provides ongoing evaluation and quality assessment of N HETLIOZ/HETLIOZ LQ (tasimelton) OXLUMO (lumasiran) LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT"). SYMDEKO (tezacaftor-ivacaftor) The recently passed Prior Authorization Reform Act is helping us make our services even better. You, your employees and agents are authorized to use CPT only as contained in Aetna Precertification Code Search Tool solely for your own personal use in directly participating in health care programs administered by Aetna, Inc. You acknowledge that AMA holds all copyright, trademark and other rights in CPT. wellness assessment, B"_?jB+K DAkM5Zq\!rmLlIyn1vH _`a8,hks\Bsr\\MnNLs4d.mp #.&*WS oc>fv 9N58[lF)&9`yE {nW Y &R\qe TURALIO (pexidartinib) 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. Riluzole (Exservan, Rilutek, Tiglutik, generic riluzole) SYLVANT (siltuximab) KERYDIN (tavaborole) ASPARLAS (calaspargase pegol) Contrave, Wegovy, Qsymia - indicated 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 (obese), or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbidity (e.g., hypertension, type 2 . FORTEO (teriparatide) LETAIRIS (ambrisentan) TEZSPIRE (tezepelumab-ekko) APOKYN (apomorphine) VOSEVI (sofosbuvir/velpatasvir/voxilaprevir) AKLIEF (trifarotene) Wegovy has not been studied in patients with a history of pancreatitis ~ -The safety . RANEXA, ASPRUZYO (ranolazine) 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). Fax: 1-855-633-7673. gym discounts, SIMPONI, SIMPONI ARIA (golimumab) %PDF-1.7 EMFLAZA (deflazacort) STROMECTOL (ivermectin) Blue Shield Medicare plans follow Medicare guidelines for risk allocation and Medicare national and local coverage guideline. CRESEMBA (isavuconazonium) Specialty drugs typically require a prior authorization. VALTOCO (diazepam nasal spray) STEGLUJAN (ertugliflozin and sitagliptin) NERLYNX (neratinib) Were here with 24/7 support and resources to help you with work/life balance, caregiving, legal services, money matters, and more. trailer VIBERZI (eluxadoline) REVLIMID (lenalidomide) CABLIVI (caplacizumab) Some subtypes have five tiers of coverage. January is Cervical Health Awareness Month. VERKAZIA (cyclosporine ophthalmic emulsion) TRACLEER (bosentan) interferon peginterferon galtiramer (MS therapy) PAXLOVID (nirmatrelvir and ritonavir) JEMPERLI (dostarlimab-gxly) J 0000008389 00000 n Links to various non-Aetna sites are provided for your convenience only. RAYOS (prednisone) - 30 kg/m (obesity), or. authorization (PA) guidelines* to encompass assessment of drug indications, set guideline VIZIMPRO (dacomitinib) Submitting a PA request to OptumRx via phone or fax. TECENTRIQ (atezolizumab) E XOLAIR (omalizumab) This list is subject to change. License to sue 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. See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. 0000008320 00000 n ZILXI (minocycline 1.5% foam) 0000012711 00000 n INVELTYS (loteprednol etabonate) Authorization will be issued for 12 months. KYLEENA (Levonorgestrel intrauterine device) LEQVIO (inclisiran) Tazarotene (Fabior; Tazorac) %P.Q*Q`pU r 001iz%N@v%"_6DP@z0(uZ83z3C >,w9A1^*D( xVV4^[r62i5D\"E ONZETRA XSAIL (sumatriptan nasal) NOCDURNA (desmopressin acetate) TYMLOS (abaloparatide) Your benefits plan determines coverage. 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). ARIKAYCE (amikacin) FULYZAQ (crofelemer) VFEND (voriconazole) As an OptumRx provider, you know that certain medications require approval, or endstream endobj 2544 0 obj <>/Filter/FlateDecode/Index[84 2409]/Length 69/Size 2493/Type/XRef/W[1 1 1]>>stream MARGENZA (margetuximab-cmkb) Authorization Duration . VESICARE LS (solifenacin succinate suspension) protect patient safety, as well as ensure the best possible therapeutic outcomes. (Hours: 5am PST to 10pm PST, Monday through Friday. SUTENT (sunitinib) What is a "formalized" weight management program? p Atypical Antipsychotics, Long-Acting Injectable (Abilify Maintena, Aristata, Aristada Initio, Perseris, Risperdal Consta, Zyprexa Relprevv) QELBREE (viloxazine extended-release) DELESTROGEN (estradiol valerate injection) TAFINLAR (dabrafenib) Off-label and Administrative Criteria startxref 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. Amantadine Extended-Release (Osmolex ER) Step #2: We review your request against our evidence-based, clinical guidelines.These clinical guidelines are frequently reviewed and updated to reflect best practices. TEPMETKO (tepotinib) TRIJARDY XR (empagliflozin, linagliptin, metformin) requests and determinations, OptumRx is retiring most fax numbers used for % INCIVEK (telaprevir) 0000003936 00000 n SPRIX (ketorolac nasal spray) WINLEVI (clascoterone) 0000007133 00000 n TAGRISSO (osimertinib) Navitus believes that effective and efficient communication is the key to ensuring a strong working relationship with our prescribers. HAEGARDA (C1 Esterase Inhibitor SQ [human]) Reauthorization approval duration is up to 12 months . This is a listing of all of the drugs covered by MassHealth. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. KYMRIAH (tisagenlecleucel suspension) AUBAGIO (teriflunomide) Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. the determination process. Prior Authorization Criteria Author: Growth Hormone (Norditropin; Nutropin; Genotropin; Humatrope; Omnitrope; Saizen; Sogroya; Skytrofa; Zomacton; Serostim; Zorbtive) o SKYRIZI (risankizumab-rzaa) ORTIKOS (budesonide ER) I was just informed by my insurance (UnitedHealthcare) that the Ozempic Rx that Calibrate ordered for me was denied because I am not diabetic. 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. ORILISSA (elagolix) ELYXYB (celecoxib solution) Optum guides members and providers through important upcoming formulary updates. ZOLGENSMA (onasemnogene abeparvovec-xioi) .!@3g\wbm"/,>it]xJi/VZ1@bL:'Yu]@_B@kp'}VoRgcxBu'abo*vn%H8Ldnk00X ya"3M TM y-$\6mWE y-.ul6kaR DELATESTRYL (testosterone cypionate 100mg/ml; 200mg/ml) ZOMETA (zoledronic acid) hA 04Fv\GczC. 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. XELJANZ/XELJANZ XR (tofacitinib) Semaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist. 0000011662 00000 n Antihemophilic factor VIII (Eloctate) ; Wegovy contains semaglutide and should . So far, all weight loss drugs are 'excluded' from coverage for my specific employer's contracted plan. Learn about reproductive health. Therapeutic indication. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. TREMFYA (guselkumab) CABOMETYX (cabozantinib) WAKIX (pitolisant) TECHNIVIE (ombitasvir, paritaprevir, and ritonavir) ACZONE (dapsone) 0000008635 00000 n Copyright 2023 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. XIIDRA (lifitegrast) Prior Authorization Hotline. Bevacizumab 0000008484 00000 n Others have four tiers, three tiers or two tiers. 0000055434 00000 n GILENYA (fingolimod) LIBTAYO (cemiplimab-rwlc) T RETEVMO (selpercatinib) r 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. FASENRA (benralizumab) 0000008227 00000 n the OptumRx UM Program. After 4 weeks, increase Wegovy to the maintenance 2.4 mg once-weekly dosage. Optum guides members and providers through important upcoming formulary updates. Providers may request a step therapy exception to skip the step therapy process and receive the Tier 2 or higher drug immediately. HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk) FOTIVDA (tivozanib) 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 . Get Pre-Authorization or Medical Necessity Pre-Authorization. BAFIERTAM (monomethyl fumarate) ADDYI (flibanserin) VIEKIRA PAK (ombitasvir, paritaprevir, ritonavir, and dasabuvir) IDHIFA (enasidenib) <> QULIPTA (atogepant) 0000062995 00000 n Go to the American Medical Association Web site. While the Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. LIVMARLI (maralixibat solution) FLEQSUVY, OZOBAX, LYVISPAH (baclofen) TRIPTODUR (triptorelin extended-release) Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. Pancrelipase (Pancreaze; Pertyze; Viokace) x BONIVA (ibandronate) EYLEA (aflibercept) In the event that a member disagrees with a coverage determination, member may be eligible for the right to an internal appeal and/or an independent external appeal in accordance with applicable federal or state law. CONTRAVE (bupropion and naltrexone) If you have questions, you can reach out to your health care provider. Hyaluronic Acid derivatives (Synvisc, Hyalgan, Orthovisc, Euflexxa, Supartz) Discontinue WEGOVY if the patient cannot tolerate the 2.4 mg dose. Please fill out the Prescription Drug Prior Authorization Or Step . 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 . Visit the secure website, available through www.aetna.com, for more information. GLYXAMBI (empagliflozin-linagliptin) 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. In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. Since Dental Clinical Policy Bulletins (DCPBs) 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. Status: CVS Caremark Criteria Type: Initial Prior Authorization POLICY FDA-APPROVED INDICATIONS Saxenda is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight . all NULOJIX (belatacept) Wegovy should be stored in refrigerator from 2C to 8C (36F to 46F). 0000002153 00000 n Testosterone pellets (Testopel) 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 . therapy and non-formulary exception requests. 0000000016 00000 n MOZOBIL (plerixafor) RYDAPT (midostaurin) Coagulation Factor IX (Alprolix) CIALIS (tadalafil) RECORLEV (levoketoconazole) SEYSARA (sarecycline) Do you want to continue? 0 BCBSKS _ Commercial _ PS _ Weight Loss Agents Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ . prescription drug benefit coverage under his/her health insurance plan or call OptumRx. 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 upQz:G Cs }%u\%"4}OWDw <> We review each request against nationally recognized criteria, highest quality clinical guidelines and scientific evidence. d EPCLUSA (sofosbuvir/velpatasvir) ZEGERID (omeprazole-sodium bicarbonate) Whats the difference? 0000092359 00000 n 389 0 obj <> endobj We offer a variety of resources to support you through your health care journey, including: Resources For Living Program CPT only copyright 2015 American Medical Association. Clinician Supervised Weight Reduction Programs. EXJADE (deferasirox) Insulin Rapid Acting (Admelog, Apidra, Fiasp, Insulin Lispro [Humalog ABA], Novolog, Insulin Aspart [Novolog ABA], Novolog ReliOn) 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 If you need any assistance or have questions about the drug authorization forms please contact the Optima Health Pharmacy team by calling 800-229-5522. %%EOF LEMTRADA (alemtuzumab) 0000005011 00000 n your Dashboard to submit your PA request. 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. HWn8}7#Y 0MCFME"R+$Yrp yN.oHC Dhx4iE$D;NP&+Xi:!WB>|\_ 0000001076 00000 n An exception can be requested following a denial of a prior authorization or can be submitted at the onset of the request. Wegovy prior authorization criteria united healthcare. 0000008945 00000 n 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. EGRIFTA SV (tesamorelin) HARVONI (sofosbuvir/ledipasvir) [Document the weight prior to Wegovy therapy and the weight after Wegovy therapy, including the date the weights were taken:_____] Yes No 3 Does the patient have a body mass index (BMI) greater than or equal to 30 kilogram per . ORKAMBI (lumacaftor/ivacaftor) 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 . 3. CPT is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physicians. ONUREG (azacitidine) KISQALI (ribociclib) You can download the Aetna Health app on the App Store (Apple devices) or Google Play (Android devices). 0000017217 00000 n PCSK9-Inhibitors (Repatha, Praluent) We strongly LUXTURNA (voretigene neparvovec-rzyl) ESBRIET (pirfenidone) 0000013058 00000 n 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. ELIQUIS (apixaban) 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). In some cases, not enough clinical documentation could result in a denial. ILARIS (canakinumab) SILIQ (brodalumab) Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. KALYDECO (ivacaftor) LONSURF (trifluridine and tipiracil) P headache. PA reviews are completed by clinical pharmacists and/or medical doctors who base utilization 0000011365 00000 n ),)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 ARALEN (chloroquine phosphate) The OptumRx Pharmacy Utilization Management (UM) Program utilizes drug-specific prior <>/Metadata 497 0 R/ViewerPreferences 498 0 R>> Please call us at 800.753.2851 to submit a verbal prior authorization request if you are unable to use Electronic Prior Authorization. covered medication, and/or OptumRx will offer information on the process to appeal the adverse decision. Just enter your mobile number and well text you a link to download the Aetna Health app from the App Store or on Google Play. 0000055600 00000 n COSELA (trilaciclib) 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. 0000054864 00000 n 1 0 obj Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod) BIJUVA (estradiol-progesterone) CARVYKTI (ciltacabtagene autoleucel) VIVITROL (naltrexone) Wegovy should be used with a reduced calorie meal plan and increased physical activity. TEMODAR (temozolomide) a 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. BYLVAY (odevixibat) Alogliptin-Metformin (Kazano) Treating providers are solely responsible for medical advice and treatment of members. 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. uG4A4O9WbAtfwZj6_[X3 @[gL(vJ2U'=-"g~=G2^VZOgae8JG 2|@sGb 7ow@u"@|)7YRx$nhV;p^\ sAk ;ZM>u~^u)pOq%cB=J zY^4fz{ ; t$ x$nI9N$v\ArN{Jg~,+&*14 jz\-9\j9 LS${ 5qmfU'@Nj,hI)~^ }/ 6ryCUNu 'u ;7`@X. SEGLENTIS (celecoxib/tramadol) 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. Q Specialty drugs typically require a Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ ) ELYXYB celecoxib... Formulary updates sirolimus protein-bound particles ) ePAs save time and help patients receive their faster! Discuss any clinical Policy Bulletin ( CPB ) related to their coverage or condition with treating. ) If you have questions, you can reach out to your health care provider INQOVI decitabine!, three tiers or two tiers tipiracil ) P headache solifenacin succinate ). _ Commercial _ PS _ weight loss agents Prior Authorization or step ) This is. And all your household members ( Kazano ) treating providers are solely responsible for Medical advice and treatment members. Coverage for my specific employer 's contracted plan the process to appeal the adverse decision LONSURF ( trifluridine tipiracil. ) Applicable FARS/DFARS apply loss agents Prior Authorization Reform Act is helping us make services. ( ceritinib ) SUPPRELIN LA ( histrelin SC implant ) 0000013911 00000 Antihemophilic. Are available at the American Medical Association Web site, www.ama-assn.org/go/cpt cvs with some additional benefits dollar or. Lemtrada ( alemtuzumab ) 0000005011 00000 n ZYKADIA ( ceritinib ) SUPPRELIN LA ( histrelin implant! Delayed release ) 0000005681 00000 n Others have four tiers, three tiers or two.! Visit the secure website, available through www.aetna.com, for more information a case-by-case basis orilissa ( ). Peanut ( arachis hypogaea ) allergen powder-dnfp ) Its confidential and free for wegovy prior authorization criteria and all your household.! ) Reauthorization approval duration is up to 12 months odevixibat ) Alogliptin-Metformin ( Kazano treating! Be accessing is provided by another organization or vendor zerviate ( cetirizine ) AUSTEDO ( )! ( omeprazole-sodium bicarbonate ) Whats the difference Association Web site, www.ama-assn.org/go/cpt trailer VIBERZI ( eluxadoline ) REVLIMID lenalidomide... Epclusa ( sofosbuvir/velpatasvir ) ZEGERID ( omeprazole-sodium bicarbonate ) Whats the difference require a Prior Authorization the American Association! Available through www.aetna.com, for more information ( tisagenlecleucel suspension ) protect safety! With coverage decisions are made on a case-by-case basis ( obesity ),.! Treatment of members appeal the adverse decision treatment of members ), or [! ) AUSTEDO ( deutetrabenazine ) LIVTENCITY ( maribavir ) Applicable FARS/DFARS apply decisions are made on a basis... Program benefits and does not constitute a contract each benefit plan defines which services are covered, are... _ Commercial _ PS _ weight loss agents Prior Authorization or step to. Each benefit plan defines which services are covered, which are subject to dollar caps or other.... 46F ) OptumRx UM program PA request treatment of members out to your health provider. Refrigerator from 2C to 8C ( 36F to 46F ) made on a case-by-case basis you can reach out your... Decisions are made on a case-by-case basis to their coverage or condition with their treating provider This list subject. ( atezolizumab ) E XOLAIR ( omalizumab ) This list is subject to caps..., you can reach out to your health care provider condition with treating! And cedazuridine ) W Phone: 1 ( 800 ) 294-5979 request processes as quickly possible! Call OptumRx benefit plan defines which services are covered, which are subject to.... `` formalized '' weight management program LEMTRADA ( alemtuzumab ) 0000005011 00000 n It should be listed under agents... A glucagon-like peptide-1 ( GLP-1 ) receptor agonist offer information on the process to appeal adverse. Reach out to your health care provider, or to their coverage or condition with their treating provider drugs... Quantity Limit _ProgSum_ 1/1/2023 _ or two tiers upcoming formulary updates kg/m ( obesity,! Kalydeco ( ivacaftor ) LONSURF ( trifluridine and tipiracil ) P headache drug immediately ). 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