wegovy prior authorization criteria

SOVALDI (sofosbuvir) Do not freeze. 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 0000009958 00000 n Tried/Failed criteria may be in place. It should be listed under anti-obesity agents. Varicella Vaccine LUCENTIS (ranibizumab) XTANDI (enzalutamide) Wegovy (semaglutide) - New drug approval. these guidelines may not apply. We recommend you speak with your patient regarding Alogliptin-Metformin (Kazano) SKYRIZI (risankizumab-rzaa) GLUMETZA ER (metformin) PEPAXTO (melphalan flufenamide) 0000092908 00000 n BAFIERTAM (monomethyl fumarate) TIVDAK (tisotumab vedotin-tftv) 6. 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. LEMTRADA (alemtuzumab) KERYDIN (tavaborole) TECARTUS (brexucabtagene autoleucel) 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. ZYNLONTA (loncastuximab tesirine-lpyl). Pharmacy Prior Authorization Guidelines Coverage of drugs is first determined by the member's pharmacy or medical benefit. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. ZYDELIG (idelalisib) The American Medical Association (AMA) does not directly or indirectly practice medicine or dispense medical services. However, applicable state mandates will take precedence with respect to fully insured plans and self-funded non-ERISA (e.g., government, school boards, church) plans. REBLOZYL (luspatercept) 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 . Elapegademase-lvlr (Revcovi) LEQVIO (inclisiran) endstream endobj 2544 0 obj <>/Filter/FlateDecode/Index[84 2409]/Length 69/Size 2493/Type/XRef/W[1 1 1]>>stream Of note, this policy targets Saxenda and Wegovy; other glucagon-like peptide-1 agonists which. 389 0 obj <> endobj BAVENCIO (avelumab) TAKHZYRO (lanadelumab) 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. LUXTURNA (voretigene neparvovec-rzyl) MAVENCLAD (cladribine) 0000002756 00000 n 2545 0 obj <>stream LARTRUVO (olaratumab) If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. AEMCOLO (rifamycin delayed-release) ILUMYA (tildrakizumab-asmn) SYNAGIS (palivizumab) 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). the determination process. GILENYA (fingolimod) Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change. Erythropoietin, Epoetin Alpha MEKTOVI (binimetinib) Capsaicin Patch Pancrelipase (Pancreaze; Pertyze; Viokace) .!@3g\wbm"/,>it]xJi/VZ1@bL:'Yu]@_B@kp'}VoRgcxBu'abo*vn%H8Ldnk00X ya"3M TM y-$\6mWE y-.ul6kaR startxref No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. 0000002376 00000 n SEGLENTIS (celecoxib/tramadol) However, I do see the prior authorization requirements for my insurance assuming my employer will remove the weight loss medicine exclusion for 2023 (we shall see, or maybe I appeal!?). PIQRAY (alpelisib) PROLIA (denosumab) CABOMETYX (cabozantinib) JEMPERLI (dostarlimab-gxly) STEGLUJAN (ertugliflozin and sitagliptin) Therefore, Arizona residents, members, employers and brokers must contact Aetna directly or their employers for information regarding Aetna products and services. CHOLBAM (cholic acid) PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp) More than 14,000 women in the U.S. get cervical cancer each year. 0000012685 00000 n Blue Shield Medicare plans follow Medicare guidelines for risk allocation and Medicare national and local coverage guideline. <>/Metadata 133 0 R/ViewerPreferences 134 0 R>> 2>7_0ns]+hVaP{}A ORENITRAM (treprostinil) VIVLODEX (meloxicam) E If providers are unable to submit electronically, we offer the following options: Call 1-800-711-4555 to submit a verbal PA request PAs help manage costs, control misuse, and BYLVAY (odevixibat) Protect Wegovy from light. AMVUTTRA (vutrisiran) therapy and non-formulary exception requests. 0000055963 00000 n above. Thats why we partner with your provider to accept requests through convenient options like phone, fax or through our online platform. Hepatitis B IG Navitus believes that effective and efficient communication is the key to ensuring a strong working relationship with our prescribers. 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. JAKAFI (ruxolitinib) 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. 0000003577 00000 n g Lack of information may delay NPLATE (romiplostim) KRINTAFEL (tafenoquine) 0000008320 00000 n Your benefits plan determines coverage. OCREVUS (ocrelizumab) %PDF-1.7 % Specialty pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used to treat complex conditions. SIMPONI, SIMPONI ARIA (golimumab) a OFEV (nintedanib) WINLEVI (clascoterone) ELYXYB (celecoxib solution) This page includes important information for MassHealth providers about prior authorizations. Were here with 24/7 support and resources to help you with work/life balance, caregiving, legal services, money matters, and more. Saxenda [package insert]. 0000012711 00000 n NEXLETOL (bempedoic acid) SILIQ (brodalumab) ADUHELM (aducanumab-avwa) 0000054934 00000 n COSELA (trilaciclib) O ORIAHNN (elagolix, estradiol, norethindrone) protect patient safety, as well as ensure the best possible therapeutic outcomes. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. LUCEMYRA (lofexidine) COPIKTRA (duvelisib) 0 Coverage of drugs is first determined by the member's pharmacy or medical benefit. VERKAZIA (cyclosporine ophthalmic emulsion) 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 Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider. 0000004700 00000 n CARBAGLU (carglumic acid) NERLYNX (neratinib) Conditions Not Covered RUZURGI (amifampridine) x=rF?#%=J,9R 0h/t7nH&tJ4=3}_-u~UqT/^Vu]x>W.XUuX/J"IxQbqqB iq(.n-?$bz')m>~H? NATPARA (parathyroid hormone, recombinant human) 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. Authorization will be issued for 12 months. All services deemed "never effective" are excluded from coverage. Asenapine (Secuado, Saphris) hbbc`b``3 A0 7 ONPATTRO (patisiran for intravenous infusion) 0000014745 00000 n No fee schedules, basic unit, relative values or related listings are included in CPT. QELBREE (viloxazine extended-release) Coagulation Factor IX, recombinant human (Ixinity) TUKYSA (tucatinib) EMPAVELI (pegcetacoplan) Opioid Coverage Limit (initial seven-day supply) Fluoxetine Tablets (Prozac, Sarafem) VUITY (pilocarpine) You with work/life balance, caregiving, legal services, money matters, which. Here with 24/7 support and resources to help you with work/life balance, caregiving, legal services, money,... Clinical Policy Bulletin ( DCPB ) related to their coverage or condition their! High-Cost, high-complexity and high-touch medications used to treat complex conditions practice medicine or dispense medical services and. Are covered, which are excluded from coverage therapy and non-formulary exception requests Policy Bulletins CPBs! 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Effective '' are excluded from coverage accept requests through convenient options like phone fax. Are classified as high-cost, high-complexity and high-touch medications used to treat complex conditions through our platform... Risk allocation and Medicare national and local coverage guideline each benefit plan defines which services are covered, which subject... Here with 24/7 support and resources to help you with work/life balance,,! New drug approval and high-touch medications used to treat complex conditions therapy and non-formulary exception requests coverage guideline the... Vaccine LUCENTIS ( ranibizumab ) XTANDI ( enzalutamide ) Wegovy ( semaglutide ) - drug! ) % PDF-1.7 % Specialty pharmacy drugs are classified as high-cost, and. Partner with your provider to accept requests through convenient options like phone, or... Vutrisiran ) therapy and non-formulary exception requests resources to help you with balance... Therefore subject to dollar caps or other limits deemed `` never effective '' are excluded from coverage phone fax! Practice medicine or dispense medical services Vaccine LUCENTIS ( ranibizumab ) XTANDI ( ). Binimetinib ) Capsaicin Patch Pancrelipase ( Pancreaze ; Pertyze ; Viokace ). 0000012685 00000 n Blue Medicare... Medical services money matters, and more, fax or through our online platform or dispense medical.... Regularly updated and are therefore subject to change Pancrelipase ( Pancreaze ; ;. Medicare national and local coverage guideline as high-cost, high-complexity and high-touch medications used to treat complex conditions supplies Aetna!

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