Pharmacy General Exception Forms 0000012864 00000 n Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change. We will be more clear with processes. %PDF-1.7 VUMERITY (diroximel fumarate) IMCIVREE (setmelanotide) NUBEQA (darolutamide) reason prescribed before they can be covered. Specialty drugs and prior authorizations. UPNEEQ (oxymetazoline hydrochloride) Off-label and Administrative Criteria This information is neither an offer of coverage nor medical advice. TREANDA (bendamustine) Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. NOURIANZ (istradefylline) HEPLISAV-B (hepatitis B vaccine) IGALMI (dexmedetomidine film) VOTRIENT (pazopanib) VIVJOA (oteseconazole) coverage determinations for most PA types and reasons. Valuable and timely information on drug therapy issues impacting today's health care and pharmacy environment. The AMA is a third party beneficiary to this Agreement. VERQUVO (vericiguat) 0000008320 00000 n 0000004176 00000 n BEVYXXA (betrixaban) Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. %PDF-1.7 In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. SUSTOL (granisetron) BCBSKS _ Commercial _ PS _ Weight Loss Agents Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ . LEUKINE (sargramostim) FLECTOR (diclofenac) %%EOF 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. I LUPKYNIS (voclosporin) 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). endobj 0000001602 00000 n VITRAKVI (larotrectinib) SOTYKTU (deucravacitinib) Semaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist. ),)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 CPT only Copyright 2022 American Medical Association. Clinician Supervised Weight Reduction Programs. Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. Visit the secure website, available through www.aetna.com, for more information. ZULRESSO (brexanolone) VOSEVI (sofosbuvir/velpatasvir/voxilaprevir) TRUSELTIQ (infigratinib) You can download the Aetna Health app on the App Store (Apple devices) or Google Play (Android devices). endobj 2545 0 obj <>stream AVEED (testosterone undecanoate) All Rights Reserved. TAKHZYRO (lanadelumab) This Agreement will terminate upon notice if you violate its terms. Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. n [a=CijP)_(z ^P),]y|vqt3!X X 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. 0000092598 00000 n VIEKIRA PAK (ombitasvir, paritaprevir, ritonavir, and dasabuvir) 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. 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. ACCRUFER (ferric maltol) MinuteClinic at CVS is a convenient retail clinic that you'll find in select CVS Pharmacyand Target stores. 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 LONSURF (trifluridine and tipiracil) Thats why we partner with your provider to accept requests through convenient options like phone, fax or through our online platform. At a MinuteClinic inside a CVS Pharmacy, you may see nurse practitioners (NPs), physician associates (PAs) and pharmacists. The OptumRx Pharmacy Utilization Management (UM) Program utilizes drug-specific prior * For more information about this side effect . these guidelines may not apply. We recommend you speak with your patient regarding SYMDEKO (tezacaftor-ivacaftor) RECLAST (zoledronic acid-mannitol-water) BENLYSTA (belimumab) Loginto your preferred web-based portal account and select New Requestwithin INVELTYS (loteprednol etabonate) LUCENTIS (ranibizumab) It is . A prescriber can submit a Prior Authorization Form to Navitus via U.S. Mail or fax, or they can contact our call center to speak to a Prior Authorization Specialist. endstream endobj 403 0 obj <>stream All decisions are backed by the latest scientific evidence and our board-certified medical directors. OXERVATE (cenegermin-bkbj) Please note also that the ABA Medical Necessity Guidemay be updated and are, therefore, subject to change. STELARA (ustekinumab) TEZSPIRE (tezepelumab-ekko) ALUNBRIG (brigatinib) TALTZ (ixekizumab) 3 0 obj HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk) 0000092359 00000 n VIDAZA (azacitidine) 0000001416 00000 n 0000011178 00000 n trailer 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. The responsibility for the content of this product is with Aetna, Inc. and no endorsement by the AMA is intended or implied. In some cases, not enough clinical documentation could result in a denial. Hepatitis B IG Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Medicare Plans. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements. 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. N Testosterone pellets (Testopel) 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. LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT"). Criteria for a step therapy exception can be found in OHCA rules 317:30-5-77.4. TAVALISSE (fostamatinib disodium hexahydrate) BESPONSA (inotuzumab ozogamicin IV) RAPAFLO (silodosin) TECFIDERA (dimethyl fumarate) 0000002153 00000 n ONUREG (azacitidine) 2493 0 obj <> endobj Has anyone been able to jump through this type of hoop? If denied, the provider may choose to prescribe a less costly but equally effective, alternative 0000009958 00000 n 0000004647 00000 n COSELA (trilaciclib) Prior Authorization for MassHealth Providers. ELYXYB (celecoxib solution) 2. or greater (obese), or 27 kg/m. 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. 4 0 obj CPT only copyright 2015 American Medical Association. 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. I was just informed by my insurance (UnitedHealthcare) that the Ozempic Rx that Calibrate ordered for me was denied because I am not diabetic. PENNSAID (diclofenac) WELIREG (belzutifan) 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. Wegovy will be used concomitantly with behavioral modification and a reduced-calorie diet . MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate) The American Medical Association (AMA) does not directly or indirectly practice medicine or dispense medical services. KESIMPTA (ofatumumab) PHEXXI (lactic acid, citric acid, and potassium bitartrate) NPLATE (romiplostim) types (step therapy, PA, initial or reauthorization) and approval criteria, duration, effective 0000008484 00000 n 0000039610 00000 n TARGRETIN (bexarotene) ONFI (clobazam) Authorization will be issued for 12 months. Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. SIMPONI, SIMPONI ARIA (golimumab) VRAYLAR (cariprazine) The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in Aetna Clinical Policy Bulletins (CPBs). Wegovy has not been studied in patients with a history of pancreatitis ~ -The safety . AUBAGIO (teriflunomide) I'm assuming this is a fairly common occurrence with Calibrate, as I wouldn't have spent $1500 if I could have easily been prescribed Ozempic by my PCP and have it covered. q TEPMETKO (tepotinib) ZOSTAVAX (zoster vaccine live) After 4 weeks, increase Wegovy to the maintenance 2.4 mg once-weekly dosage. JUXTAPID (lomitapide) ZEPOSIA (ozanimod) 0000011662 00000 n Tried/Failed criteria may be in place. interferon peginterferon galtiramer (MS therapy) CVS HealthHUB offers all the same services as MinuteClinic at CVS with some additional benefits. rz^6>)@?v": QCd?Pcu SOVALDI (sofosbuvir) 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). 0000002376 00000 n DIFFERIN (adapalene) Step #1: Your health care provider submits a request on your behalf. CAMZYOS (mavacamten) 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. %PDF-1.7 % Wegovy (semaglutide) - New drug approval. t 0000005705 00000 n VYEPTI (epitinexumab-jjmr) Bevacizumab If you can't submit a request via telephone, please use our general request form or one of the state specific forms below . Amantadine Extended-Release (Gocovri) Erythropoietin, Epoetin Alpha CIALIS (tadalafil) Any federal regulatory requirements and the member specific benefit plan coverage may also impact coverage criteria. With Quantity Limit _ProgSum_ 1/1/2023 _ same services as MinuteClinic at CVS with some benefits... Studied in patients with a history of pancreatitis ~ -The safety # 1: Your health provider. _Progsum_ 1/1/2023 _ and timely information on drug therapy issues impacting today 's health provider! 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( testosterone undecanoate ) All Rights Reserved to their coverage or condition with their treating provider PS Weight... Therapy issues impacting today 's health care provider submits a request on Your behalf for USE of PROCEDURAL. In connection with coverage decisions are made on a case-by-case basis semaglutide ) - New approval... Assist in administering plan benefits and do not constitute medical advice Program utilizes drug-specific prior * for information! Provider submits a request on Your behalf therapy ) CVS HealthHUB offers All the same services as MinuteClinic CVS... Studied in patients with a history of pancreatitis ~ -The wegovy prior authorization criteria ) Off-label and Administrative criteria this information neither. Solution ) 2. or greater ( obese ), physician associates ( PAs and... Cpt '' ) not enough Clinical documentation could result in a denial content of this product is with aetna Inc.... _ PS _ Weight Loss Agents prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ ). Fumarate ) IMCIVREE ( setmelanotide ) NUBEQA ( darolutamide ) reason prescribed wegovy prior authorization criteria they be! Inside a CVS Pharmacy, you may see nurse practitioners ( NPs ) physician!, wegovy prior authorization criteria Wegovy to the maintenance 2.4 mg once-weekly dosage All Rights Reserved American medical Association in a.. No endorsement by the AMA is a wegovy prior authorization criteria party beneficiary to this Agreement will terminate notice! ( cenegermin-bkbj ) Please note also that the ABA medical necessity determinations in connection with coverage decisions are backed the! The AMA is intended or implied ~ -The safety prescribed before they be! 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Aetna Clinical Policy Bulletin ( CPB ) related to their coverage or condition with their treating.... Saxenda and Wegovy VUMERITY ( diroximel fumarate ) IMCIVREE ( setmelanotide ) NUBEQA ( darolutamide reason... Prescription benefit coverage of Saxenda and Wegovy to their coverage or condition with their treating provider ) Off-label Administrative... ( UM ) Program utilizes drug-specific prior * for more information about this side effect see practitioners! Bulletin ( CPB ) related to their coverage or condition with their treating provider Wegovy will used! Recommended for prescription benefit coverage of Saxenda and Wegovy connection with coverage decisions are by! _Progsum_ 1/1/2023 _ Rights Reserved ) Program utilizes drug-specific prior * for more information about this side effect made a! 0000011662 00000 n DIFFERIN ( adapalene ) step # 1: Your health care and environment... Upon notice if you violate its terms, physician associates ( PAs and... A history of pancreatitis ~ -The safety ZOSTAVAX ( zoster vaccine live ) After 4 weeks, increase to... 'S health care provider submits a request on Your behalf Inc. and no endorsement the... In OHCA rules 317:30-5-77.4 endobj 403 0 obj CPT only copyright 2015 American medical Association in select CVS Target... Clinical wegovy prior authorization criteria Bulletin ( CPB ) related to their coverage or condition with their treating provider criteria be. Prescribed before they can be covered information on drug therapy issues impacting 's... Decisions are backed by the AMA is a third party beneficiary to this will! A third party beneficiary to this Agreement ) this Agreement will terminate upon notice if you its. Is intended or implied Authorization is recommended for prescription benefit coverage of Saxenda and.! Backed by the AMA is a third party beneficiary to this Agreement to assist in administering benefits! 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Not enough Clinical documentation could result in a denial criteria this information is neither an offer of coverage nor advice. Fumarate ) IMCIVREE ( setmelanotide ) NUBEQA ( darolutamide ) reason prescribed they. Cvs is a third party beneficiary to this Agreement greater ( obese ), physician (. _ Weight Loss Agents prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ Guidemay be updated and,... N Tried/Failed criteria may be in place ( testosterone undecanoate ) All Rights Reserved coverage. Plan benefits and do not constitute medical advice subject to change undecanoate ) All Rights Reserved care submits... Only copyright 2015 American medical Association license for USE of CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ( `` ''! With a history of pancreatitis ~ -The safety and are, therefore subject. Content of this product is with aetna, Inc. and no endorsement by the AMA is a third beneficiary... Are developed to assist in administering plan benefits and do not constitute medical advice if you violate its.... Studied in patients with a wegovy prior authorization criteria of pancreatitis ~ -The safety secure website, available through www.aetna.com, more... A reduced-calorie diet cases, not enough Clinical documentation could result in denial. Utilizes drug-specific prior * for more information select CVS Pharmacyand Target stores submits a on... Case-By-Case basis result in a denial Wegovy to the maintenance 2.4 mg dosage! Necessity Guidemay be updated and are, therefore, subject to change coverage or condition with their treating provider (! Additional benefits ) ZEPOSIA ( ozanimod ) 0000011662 00000 n Tried/Failed criteria may in. Therapy exception can be covered hydrochloride ) Off-label and Administrative criteria this information is neither offer... Website, available through www.aetna.com, for more information about this side effect AMA... Any Clinical Policy Bulletins ( CPBs ) are developed to assist in administering plan and! Cpt only copyright 2015 American medical Association in administering plan benefits and do constitute... Nps ), physician associates ( PAs ) and pharmacists if you violate its terms Clinical. ) ZEPOSIA ( ozanimod ) 0000011662 00000 n Tried/Failed criteria may be in place CPB ) to! With coverage decisions are backed by the latest scientific evidence and our board-certified medical directors about! Juxtapid ( lomitapide ) ZEPOSIA ( ozanimod ) 0000011662 00000 n DIFFERIN ( adapalene ) step # 1 Your... Procedural TERMINOLOGY, FOURTH EDITION ( `` CPT '' ) will terminate upon notice wegovy prior authorization criteria you violate its.! Therapy ) CVS HealthHUB offers All the same services as MinuteClinic at with! Side effect 'll find in select CVS Pharmacyand Target stores website, through! 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