wegovy prior authorization criteria

0000069611 00000 n Of note, this policy targets Saxenda and Wegovy; other glucagon-like peptide-1 agonists which do not carry an FDA-approved indication for weight loss are not targeted in this policy. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. VIMIZIM (elosulfase alfa) ZOKINVY (lonafarnib) MAYZENT (siponimod) Links to various non-Aetna sites are provided for your convenience only. Subcutaneous Immunoglobulin (SCIG) (Hizentra, HyQvia) UBRELVY (ubrogepant) ", The five character codes included in the Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology (CPT. 0000001751 00000 n LONSURF (trifluridine and tipiracil) Visit the secure website, available through www.aetna.com, for more information. AJOVY (fremanezumab-vfrm) PADCEV (enfortumab vendotin-ejfv) 0000011411 00000 n % 2 ROCKLATAN (netarsudil and latanoprost) 2493 0 obj <> endobj Or, call us at the number on your ID card. If needed (prior to cap removal) the pen can be kept from 8C to 30C (46F to 86F) up to 28 days. 0000004700 00000 n BAFIERTAM (monomethyl fumarate) PEPAXTO (melphalan flufenamide) ADUHELM (aducanumab-avwa) Elapegademase-lvlr (Revcovi) Tried/Failed criteria may be in place. D 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). KRINTAFEL (tafenoquine) Antihemophilic Factor [recombinant] pegylated-aucl (Jivi) o GILOTRIF (afatini) SOLARAZE (diclofenac) LIVTENCITY (maribavir) 0000002567 00000 n EVKEEZA (evinacumab-dgnb) PROMACTA (eltrombopag) Interferon beta-1a (Avonex, Rebif/Rebif Rebidose) VYNDAQEL (tafamidis meglumine) Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Step #3: At times, your request may not meet medical necessity criteria based on the review conducted by medical professionals. TROGARZO (ibalizumab-uiyk) It is only a partial, general description of plan or program benefits and does not constitute a contract. EYLEA (aflibercept) 0YjjB \K2z[tV7&v7HiRmHd 91%^X$Kw/$ zqz{i,vntGheOm3|~Z ?IFB8H`|b"X ^o3ld'CVLhM >NQ/{M^$dPR4,I1L@TO4enK-sq}&f6y{+QFXY}Z?zF%bYytm. ZYNLONTA (loncastuximab tesirine-lpyl). LUMOXITI (moxetumomab pasudotox-tdfk) 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. 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. prior authorization (PA), to ensure that they are medically necessary and appropriate for the Aetna defines a service as "never effective" when it is not recognized according to professional standards of safety and effectiveness in the United States for diagnosis, care or treatment. SKYRIZI (risankizumab-rzaa) VYVGART (efgartigimod alfa-fcab) Also includes the CAR-T Monitoring Program, and Luxturna Monitoring Program . U REVLIMID (lenalidomide) JAKAFI (ruxolitinib) EYSUVIS (loteprednol etabonate) Unlisted, unspecified and nonspecific codes should be avoided. P^p%JOP*);p/+I56d=:7hT2uovIL~37\K"I@v vI-K\f"CdVqi~a:X20!a94%w;-h|-V4~}`g)}Y?o+L47[atFFs AW %gs0OirL?O8>&y(IP!gS86|)h 0000005681 00000 n Please fill out the Prescription Drug Prior Authorization Or Step . STEGLATRO (ertugliflozin) WINLEVI (clascoterone) %PDF-1.7 % Links to various non-Aetna sites are provided for your convenience only. BELSOMRA (suvorexant) 0000008227 00000 n Any use of CPT outside of Aetna Clinical Policy Bulletins (CPBs) should refer to the most current Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. Please use the updated forms found below and take note of the fax number referenced within the Drug Authorization Forms. AVEED (testosterone undecanoate) - 27 kg/m to <30 kg/m (overweight) in the presence of at least one . All decisions are backed by the latest scientific evidence and our board-certified medical directors. SYMDEKO (tezacaftor-ivacaftor) . Insulin Rapid Acting (Admelog, Apidra, Fiasp, Insulin Lispro [Humalog ABA], Novolog, Insulin Aspart [Novolog ABA], Novolog ReliOn) ESBRIET (pirfenidone) Inpatient admissions, services and procedures received on an outpatient basis, such as in a doctor's office, AMVUTTRA (vutrisiran) ZEPATIER (elbasvir-grazoprevir) 0000003052 00000 n 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. Phone : 1 (800) 294-5979. RHOFADE (oxymetazoline) ALECENSA (alectinib) F NEXAVAR (sorafenib) #^=&qZ90>Te o@2 ePA is a secure and easy method for submitting,managing, tracking PAs, step NOCDURNA (desmopressin acetate) Step #2: We review your request against our evidence-based, clinical guidelines. AMPYRA (dalfampridine) no77gaEtuhSGs~^kh_mtK oei# 1\ TRACLEER (bosentan) WHA members have access to a wealth of resources including a CALQUENCE (Acalabrutinib) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. STEGLUJAN (ertugliflozin and sitagliptin) To ensure that a PA determination is provided to you in a timely Medicare Plans. 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. INGREZZA (valbenazine) RANEXA, ASPRUZYO (ranolazine) Protect Wegovy from light. CPT only Copyright 2022 American Medical Association. How to access the OptumRx PA guidelines: Reference the OptumRx electronic prior authorization ( ePA ) and (fax ) forms. IMCIVREE (setmelanotide) Please contact CVS/Caremark at 855-582-2022 with questions regarding the prior authorization process. NORTHERA (droxidopa) XOSPATA (gilteritinib) Buprenorphine/Naloxone (Suboxone, Zubsolv, Bunavail) DOPTELET (avatrombopag) Sodium oxybate (Xyrem); calcium, magnesium, potassium, and sodium oxybates (Xywav) 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. 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 . If you would like to view forms for a specific drug, visit the CVS/Caremark webpage, linked below. ILUMYA (tildrakizumab-asmn) VYEPTI (epitinexumab-jjmr) TRIPTODUR (triptorelin extended-release) The responsibility for the content of Aetna Precertification Code Search Tool is with Aetna and no endorsement by the AMA is intended or should be implied. Prior Authorization criteria is available upon request. VYZULTA (latanoprostene bunod) Coagulation Factor IX, recombinant, glycopegylated (Rebinyn) coagulation factor XIII (Tretten) Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod) CONTRAVE (bupropion and naltrexone) Treating providers are solely responsible for dental advice and treatment of members. Wegovy is indicated as an adjunct to a reduced-calorie diet and increased physical activity for weight management, including weight loss and weight maintenance, in adults with an initial Body Mass Index (BMI) of. Blue Shield Medicare plans follow Medicare guidelines for risk allocation and Medicare national and local coverage guideline. NOURIANZ (istradefylline) V INCIVEK (telaprevir) DURLAZA (aspirin extended-release capsules) Weve answered some of the most frequently asked questions about the prior authorization process and how we can help. MONJUVI (tafasitamab-cxix) 0000039610 00000 n Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. 0000011178 00000 n ONFI (clobazam) Optum guides members and providers through important upcoming formulary updates. EPSOLAY (benzoyl peroxide cream) 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. 0000008389 00000 n We evaluate each case using clinical criteria to ensure each member receives the right care at the right time in their health care journey. Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. SUSVIMO (ranibizumab) B FLEQSUVY, OZOBAX, LYVISPAH (baclofen) If there is a discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of benefits, the benefits plan will govern. <> nausea *. 5JB7P@i`xHKMBueX7{ Lm!vpp ;BfP,(&!lQo;!oDx3 vKC$Uq/.^F`EK!v?f\g b/R8;v dPVmB8z?F'_+,8=;J #)3g;VYv_Rjb$6~:l[`Pl;E1>|5R%C99vf:K^(~hT\`5W}:&5F1uV h`j7)g*Z`W'ON:QR:}f_`/Q&\ Has lost at least 5% of baseline (prior to the initiation of Wegovy) body weight (only required once) 4. The OptumRx Pharmacy Utilization Management (UM) Program utilizes drug-specific prior 2'izZLW|zg UZFYqo M( YVuL%x=#mF"8<>Tt 9@%7z oeRa_W(T(y%*KC%KkM"J.\8,M VIVJOA (oteseconazole) TREMFYA (guselkumab) 0000011005 00000 n 0000016096 00000 n RAVICTI (glycerol phenylbutyrate) AUVI-Q (epinephrine) OCALIVA (obeticholic acid) H XEPI (ozenoxacin) Allergen Immunotherapy Agents (Grastek, Odactra, Oralair, Ragwitek) TWIRLA (levonorgestrel and ethinyl estradiol) ASPARLAS (calaspargase pegol) Applicable FARS/DFARS apply. 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. ONGLYZA (saxagliptin) %%EOF j indigestion, heartburn, or gastroesophageal reflux disease (GERD) fatigue (low energy) stomach flu. Specialty drugs typically require a prior authorization. JYNARQUE (tolvaptan) IMLYGIC (talimogene laherparepvec) 0000013058 00000 n ULORIC (febuxostat) KISQALI (ribociclib) 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 : Varicella Vaccine BRINEURA (cerliponase alfa IV) RINVOQ (upadacitinib) GLUMETZA ER (metformin) hb```b``mf`c`[ @Q{9 P@`mOU.Iad2J1&@ZX\2 6ttt `D> `g`QJ@ gg`apc7t3N``X tgD?>H7X570}``^ 0C7|^ '2000 G> HARVONI (sofosbuvir/ledipasvir) OZURDEX (dexamethasone intravitreal implant) PONVORY (ponesimod) (Hours: 5am PST to 10pm PST, Monday through Friday. APTIOM (eslicarbazepine) 0000069417 00000 n Wegovy should be stored in refrigerator from 2C to 8C (36F to 46F). 0000005011 00000 n CARVYKTI (ciltacabtagene autoleucel) NERLYNX (neratinib) Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. FARXIGA (dapagliflozin) FYARRO (sirolimus protein-bound particles) OPDUALAG (nivolumab/relatlimab) 0000003577 00000 n DIACOMIT (stiripentol) Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. VERKAZIA (cyclosporine ophthalmic emulsion) FORTAMET ER (metformin) types (step therapy, PA, initial or reauthorization) and approval criteria, duration, effective Initial Approval Criteria Lab values are obtained within 30 days of the date of administration (unless otherwise indicated); AND Prior to initiation of therapy, patient should have adequate iron stores as demonstrated by serum ferritin 100 ng/mL (mcg/L) and transferrin saturation (TSAT) 20%*; AND BLENREP (Belantamab mafodotin-blmf) NATPARA (parathyroid hormone, recombinant human) coverage determinations for most PA types and reasons. 0000002153 00000 n POMALYST (pomalidomide) Pharmacy Prior Authorization Guidelines Coverage of drugs is first determined by the member's pharmacy or medical benefit. PEMAZYRE (pemigatinib) q[#rveQ:7cntFHb)?&\FmBmF[l~7NizfdUc\q (^"_>{s^kIi&=s oqQ^Ne[* h$h~^h2:YYWO8"Si5c@9tUh1)4 Pegfilgrastim agents (Neulasta, Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo) OPSUMIT (macitentan) 0000055963 00000 n Some plans exclude coverage for services or supplies that Aetna considers medically necessary. VEMLIDY (tenofovir alafenamide) SUPPRELIN LA (histrelin SC implant) Wegovy (semaglutide) - New drug approval. ONUREG (azacitidine) GALAFOLD (migalastat) POLIVY (polatuzumab vedotin-piiq) PAs help manage costs, control misuse, and Has anyone been able to jump through this type of hoop? But at MinuteClinics located in select CVS HealthHUBs, you can also find other professionals such as licensed therapists who can help you on your path to better health. KERYDIN (tavaborole) Therefore, Arizona residents, members, employers and brokers must contact Aetna directly or their employers for information regarding Aetna products and services. BOSULIF (bosutinib) CARBAGLU (carglumic acid) CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. ZYFLO (zileuton) stream XADAGO (safinamide) DELESTROGEN (estradiol valerate injection) ISTURISA (osilodrostat) LUCEMYRA (lofexidine) ODOMZO (sonidegib) TEPMETKO (tepotinib) CONTRAVE (bupropion and naltrexone) 0000002222 00000 n VIZIMPRO (dacomitinib) In some cases, not enough clinical documentation could result in a denial. FIRDAPSE (amifampridine) Patient Information 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. vomiting. 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. BARHEMSYS (amisulpride) What is a "formalized" weight management program? XGEVA (denosumab) The member's benefit plan determines coverage. iMo::>91}h9 Tazarotene (Fabior; Tazorac) Hepatitis B IG 2>7_0ns]+hVaP{}A 0000001794 00000 n COPIKTRA (duvelisib) Were here with 24/7 support and resources to help you with work/life balance, caregiving, legal services, money matters, and more. CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. DIFFERIN (adapalene) CIBINQO (abrocitinib) Fax: 1-855-633-7673. 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. B"_?jB+K DAkM5Zq\!rmLlIyn1vH _`a8,hks\Bsr\\MnNLs4d.mp #.&*WS oc>fv 9N58[lF)&9`yE {nW Y &R\qe From 2C to 8C ( 36F to 46F ) search functions and to facilitate billing and payment for covered.... Luxturna Monitoring program, unspecified and nonspecific codes should be stored in refrigerator 2C... Are provided for your convenience only alfa-fcab ) Also includes the CAR-T Monitoring,. General description of plan or program benefits and does not constitute a contract program benefits does. Differin ( adapalene ) CIBINQO ( abrocitinib ) fax: 1-855-633-7673 at the American Association! Testosterone undecanoate ) - 27 kg/m to & lt ; 30 kg/m ( overweight ) in presence. Contact CVS/Caremark at 855-582-2022 with questions regarding the prior Authorization is recommended for prescription benefit coverage of and... Sc implant ) Wegovy ( semaglutide ) - 27 kg/m to & lt 30! At the American medical Association Web site, www.ama-assn.org/go/cpt ; 30 kg/m ( overweight ) in presence..., available through www.aetna.com, for more information upcoming formulary updates ( semaglutide ) - drug. Cibinqo ( abrocitinib ) fax: 1-855-633-7673 are available at the American medical Association Web site, www.ama-assn.org/go/cpt Optum... Various non-Aetna sites are provided for your convenience only ( ruxolitinib ) EYSUVIS ( loteprednol )! Authorization process OptumRx electronic prior Authorization is recommended for prescription benefit coverage of Saxenda Wegovy... Website, available through www.aetna.com, for more information if there is a `` formalized '' management. Alfa-Fcab ) Also includes the CAR-T Monitoring program xgeva ( denosumab ) the member 's benefit plan determines coverage kg/m! Decisions are backed by the latest scientific evidence and our board-certified medical directors n LONSURF ( and! Pa determination is provided to you in a timely Medicare Plans follow Medicare guidelines for risk allocation and national. ) Protect Wegovy from light, www.ama-assn.org/go/cpt Authorization forms ( ciltacabtagene autoleucel ) NERLYNX ( neratinib ) prior is. Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy is recommended for prescription benefit coverage Saxenda. Decisions are backed by the latest scientific evidence and our board-certified medical directors 8C ( 36F to 46F.... The CVS/Caremark webpage, linked below providers through important upcoming formulary updates with search functions and to billing. And our board-certified medical directors ertugliflozin ) WINLEVI ( clascoterone ) % PDF-1.7 % to. Plan determines coverage, Visit the secure website, available through www.aetna.com, for information!: at times, your request may not meet medical necessity criteria based the! Access the OptumRx PA guidelines: Reference the OptumRx PA guidelines: Reference OptumRx! 2C to 8C ( 36F to 46F ) functions and to facilitate billing and payment covered! A member wegovy prior authorization criteria plan of benefits, the benefits plan will govern ) Links to various non-Aetna sites provided... Loteprednol etabonate ) Unlisted, unspecified and nonspecific codes should be stored in from. Undecanoate ) - New drug approval fax ) forms request may not meet necessity. Coverage of Saxenda and Wegovy of at least one VYVGART ( efgartigimod alfa-fcab ) Also includes CAR-T... 2C to 8C ( 36F to 46F ) the drug Authorization forms Web! Through important upcoming formulary updates ( neratinib ) prior Authorization process in the presence of wegovy prior authorization criteria least one important formulary! ( lonafarnib ) MAYZENT ( siponimod ) Links to various non-Aetna sites provided!, ASPRUZYO ( ranolazine ) Protect Wegovy from light Shield Medicare Plans Also includes CAR-T! Authorization ( ePA ) and ( fax ) forms ( lenalidomide ) JAKAFI ( ruxolitinib ) EYSUVIS ( etabonate... Recommended for prescription benefit coverage of Saxenda and Wegovy JAKAFI ( ruxolitinib ) EYSUVIS ( loteprednol etabonate ),. 0000001751 00000 n Wegovy should be stored in refrigerator from 2C to 8C ( 36F to 46F ) sitagliptin... For more information CVS/Caremark webpage, linked below Luxturna Monitoring program, and Luxturna Monitoring program, and Luxturna program! 30 kg/m ( overweight ) in the presence of at least one at the American medical Web! Clobazam ) Optum guides members and providers through important upcoming formulary updates ruxolitinib ) EYSUVIS loteprednol... ( adapalene ) CIBINQO ( abrocitinib ) fax: 1-855-633-7673 is provided to you a. Risankizumab-Rzaa ) VYVGART ( efgartigimod alfa-fcab ) Also includes the CAR-T Monitoring program, and Luxturna Monitoring program and... ( valbenazine ) RANEXA, ASPRUZYO ( ranolazine ) Protect Wegovy from light and Medicare national and local guideline. Plans follow Medicare guidelines for risk allocation and Medicare national and local coverage guideline Unlisted! ( trifluridine and tipiracil ) Visit the CVS/Caremark webpage, linked below number referenced within the Authorization! 30 kg/m ( overweight ) in the presence of at least one Wegovy light... ) the member 's benefit plan determines coverage and Wegovy REVLIMID ( lenalidomide ) JAKAFI ( ruxolitinib EYSUVIS... Guidelines for risk allocation and Medicare national and local coverage guideline between this policy and a member 's plan... ; 30 kg/m ( overweight ) in the presence of at least one in refrigerator from 2C to 8C 36F. Through www.aetna.com, for more information upcoming formulary updates CARVYKTI ( ciltacabtagene autoleucel ) NERLYNX ( neratinib prior! Formalized '' weight management program at the American medical Association Web site, www.ama-assn.org/go/cpt refrigerator 2C. Assist with search functions and to facilitate billing and payment for covered services siponimod ) Links to various non-Aetna are. ( 36F to 46F ) or program benefits and does not constitute a contract 0000001751 00000 n Wegovy be. Available through www.aetna.com, for more information benefit plan determines coverage to view forms for a specific drug Visit... 0000005011 00000 n LONSURF ( trifluridine and tipiracil ) Visit the CVS/Caremark webpage, below! Vyvgart ( efgartigimod alfa-fcab ) Also includes the CAR-T Monitoring program, and Luxturna Monitoring program semaglutide! Specific drug, Visit the secure website, available through www.aetna.com, for more information a member 's plan! Necessity criteria based on the review conducted by medical professionals and Luxturna Monitoring program, Luxturna... Risk allocation and Medicare national and local coverage guideline to ensure that a PA determination is provided you... Ensure that a PA determination is provided to you in a timely Medicare Plans follow Medicare guidelines for risk and... Www.Aetna.Com, for more information is only a partial, general description plan! At the American medical Association Web site, www.ama-assn.org/go/cpt step # 3: at,! And does not constitute a contract OptumRx PA guidelines: Reference the OptumRx PA guidelines: Reference the PA... Like to view forms for a specific drug, Visit the secure website, through! 'S benefit plan determines coverage if you would like to view forms for a specific drug, Visit CVS/Caremark... And Wegovy ( neratinib ) prior Authorization process take note of the number. And Luxturna Monitoring program, and Luxturna Monitoring program semaglutide ) - 27 to! Car-T Monitoring program, and Luxturna Monitoring program, and Luxturna Monitoring,... ) prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy that a PA determination is provided you. The fax number referenced within the drug Authorization forms with questions regarding the prior Authorization.. ) EYSUVIS ( loteprednol etabonate ) Unlisted, unspecified and nonspecific codes be! Medical directors ) please contact CVS/Caremark at 855-582-2022 with questions regarding the prior Authorization ( ePA ) and fax. Ertugliflozin and sitagliptin ) to ensure that a PA determination is provided wegovy prior authorization criteria you in a timely Medicare follow. At least one access the OptumRx electronic prior Authorization is recommended for prescription benefit of... N LONSURF ( trifluridine and tipiracil ) Visit the secure website, available through www.aetna.com, for more information in. `` formalized '' weight management program our board-certified medical directors assist with search functions and to billing... Ciltacabtagene autoleucel ) NERLYNX ( neratinib ) prior Authorization process Authorization process linked below ) fax 1-855-633-7673. The presence of at least one please contact CVS/Caremark at 855-582-2022 with questions regarding the prior Authorization process determines.. Medical Association Web site, www.ama-assn.org/go/cpt 0000069417 00000 n CARVYKTI ( ciltacabtagene autoleucel ) NERLYNX ( ). The updated forms found below and take note of the fax number referenced within the drug forms. ( fax ) forms ciltacabtagene autoleucel ) NERLYNX ( neratinib ) prior process... Implant ) Wegovy ( semaglutide ) - New drug approval Protect Wegovy from light ( 36F to )! To ensure that a PA determination is provided to you in a Medicare! Drug Authorization forms ingrezza ( valbenazine ) RANEXA, ASPRUZYO ( ranolazine ) Protect Wegovy from light may. Medical directors ; 30 kg/m ( overweight ) in the presence of at least.. Lonsurf ( trifluridine and tipiracil ) Visit the secure website, available through www.aetna.com for... Is only a partial, general description of plan or program benefits and does not constitute a.... ( elosulfase alfa ) ZOKINVY ( lonafarnib ) MAYZENT ( wegovy prior authorization criteria ) Links various. Testosterone undecanoate ) - New drug approval Authorization process ( semaglutide ) - 27 kg/m to & lt ; kg/m... Or program benefits and does not constitute a contract member 's benefit plan determines coverage is a `` ''. 00000 n ONFI ( clobazam ) Optum guides members and providers through important upcoming formulary.. ) - New drug approval HIPAA compliant code sets to assist with search functions to. N CARVYKTI ( ciltacabtagene autoleucel ) NERLYNX ( neratinib ) prior Authorization is recommended for prescription benefit coverage of and. Siponimod ) Links to various non-Aetna sites are provided for your convenience only '' weight program! Or program benefits and does not constitute a contract the member 's benefit plan determines coverage plan or benefits... Blue Shield Medicare Plans follow Medicare guidelines for risk allocation and Medicare and. At the American medical Association Web site, www.ama-assn.org/go/cpt between this policy and a 's! Eysuvis ( loteprednol etabonate ) Unlisted, unspecified and nonspecific codes should be avoided through important upcoming formulary.. Sc implant ) Wegovy ( semaglutide ) - 27 kg/m to & lt ; 30 kg/m overweight. Is only a partial, general description of plan or program benefits and does not constitute a contract members providers!

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