FENORTHO (fenoprofen) BRUKINSA (zanubrutinib) ADCETRIS (brentuximab) Buprenorphine/Naloxone (Suboxone, Zubsolv, Bunavail) 0000005011 00000 n The AMA is a third party beneficiary to this Agreement. ZOLINZA (vorinostat) CRESEMBA (isavuconazonium) 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). Initial approval duration is up to 7 months . Botulinum Toxin Type A and Type B NEXAVAR (sorafenib) a b 6. H TAVNEOS (avacopan) XADAGO (safinamide) PLAQUENIL (hydroxychloroquine) ), 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, Food and Drug Administration (FDA) information, Peer-reviewed medical/pharmacy literature, including randomized clinical trials, meta-, Treatment guidelines, practice parameters, policy statements, consensus statements, Pharmaceutical, device, and/or biotech company information, Medical and pharmacy tertiary resources, including those recognized by CMS, Relevant and reputable medical and pharmacy textbooks and or websites, Reference the OptumRx electronic prior authorization. VEMLIDY (tenofovir alafenamide) MOZOBIL (plerixafor) the determination process. 0000011365 00000 n TECHNIVIE (ombitasvir, paritaprevir, and ritonavir) AYVAKIT (avapritinib) GIVLAARI (givosiran) coverage determinations for most PA types and reasons. STRENSIQ (asfotase alfa) Get Pre-Authorization or Medical Necessity Pre-Authorization. LORBRENA (lorlatinib) VITRAKVI (larotrectinib) S No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM. hb```b``{k @16=v1?Q_# tY v TRIPTODUR (triptorelin extended-release) PROBUPHINE (buprenorphine implant for subdermal administration) BESPONSA (inotuzumab ozogamicin IV) gym discounts, <> Tazarotene (Fabior; Tazorac) 0000012685 00000 n ROCKLATAN (netarsudil and latanoprost) 2493 53 CPT only copyright 2015 American Medical Association. ,"rsu[M5?xR d0WTr$A+;v &J}BEHK20`A @> SPRIX (ketorolac nasal spray) AUVI-Q (epinephrine) INQOVI (decitabine and cedazuridine) 0000054934 00000 n RANEXA, ASPRUZYO (ranolazine) Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. z 0000008227 00000 n Unlisted, unspecified and nonspecific codes should be avoided. Optum guides members and providers through important upcoming formulary updates. VYEPTI (epitinexumab-jjmr) <> paliperidone palmitate (Invega Hafyera, Invega Trinza, Invega Sustenna) LEUKINE (sargramostim) RUCONEST (recombinant C1 esterase inhibitor) ),)W!lD,NrJXB^9L 6ZMb>L+U8x[_a(Yw k6>HWlf>0l//l\pvy]}{&K`%&CKq&/[a4dKmWZvH(R\qaU %8d Hj @`H2i7( CN57+m:#94@.U]\i.I/)"G"tf -5 j ! Z3mo5&/ ^fHx&,=dtbX,DGjbWo.AT+~D.yVc$o5`Jkxyk+ln 5mA78+7k}HZX*-oUcR);"D:K@8hW]j {v$pGvX 14Tw1Eb-c{Hpxa_/=Z=}E. .!@3g\wbm"/,>it]xJi/VZ1@bL:'Yu]@_B@kp'}VoRgcxBu'abo*vn%H8Ldnk00X ya"3M TM y-$\6mWE y-.ul6kaR 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. 0000005021 00000 n %%EOF Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. 0000003404 00000 n denied. 3 0 obj Tried/Failed criteria may be in place. SEGLENTIS (celecoxib/tramadol) 0000055627 00000 n VARUBI (rolapitant) FLEQSUVY, OZOBAX, LYVISPAH (baclofen) 0000003577 00000 n Navitus believes that effective and efficient communication is the key to ensuring a strong working relationship with our prescribers. CPT is a registered trademark of the American Medical Association. ABECMA (idecabtagene vicleucel) SYMDEKO (tezacaftor-ivacaftor) In case of a conflict between your plan documents and this information, the plan documents will govern. And we will reduce wait times for things like tests or surgeries. 2 We stay in touch with providers throughout the prior authorization request. The ABA Medical Necessity Guidedoes not constitute medical advice. Wegovy (semaglutide) - New drug approval. COPAXONE (glatiramer/glatopa) endobj 0000001386 00000 n Semaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist. PLEGRIDY (peginterferon beta-1a) Conditions Not Covered GLEEVEC (imatinib) Call 1-800-711-4555 to request OptumRx standard drug-specific guideline to be faxed. ELYXYB (celecoxib solution) KADCYLA (Ado-trastuzumab emtansine) RAPAFLO (silodosin) CAMBIA (diclofenac) Authorization Duration . Please use the updated forms found below and take note of the fax number referenced within the Drug Authorization Forms. FULYZAQ (crofelemer) 0000045302 00000 n PAs help manage costs, control misuse, and VIZIMPRO (dacomitinib) ROZLYTREK (entrectinib) 0000011411 00000 n VERZENIO (abemaciclib) % RYBREVANT (amivantamab-vmjw) The cash price is even higher, averaging $1,988.22 since August 2021 according to GoodRx . SYMTUZA (darunavir, cobicistat, emtricitabine, and tenofovir alafenamide tablet ) The 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) for a particular member. Members should discuss any matters related to their coverage or condition with their treating provider. BYLVAY (odevixibat) DUOBRII (halobetasol propionate and tazarotene) U ZEJULA (niraparib) 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. 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. PADCEV (enfortumab vendotin-ejfv) Please be sure to add a 1 before your mobile number, ex: 19876543210, Guidelines from nationally recognized health care organizations such as the Centers for Medicare and Medicaid Services (CMS), Peer-reviewed, published medical journals, A review of available studies on a particular topic, Expert opinions of health care professionals. O 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. Please consult with or refer to the Evidence of Coverage or Certificate of Insurance document for a list of exclusions and limitations. DIFFERIN (adapalene) CINRYZE (C1 esterase inhibitor [human]) Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change. KINERET (anakinra) TABRECTA (capmatinib) Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". q TUKYSA (tucatinib) Wegovy This fax machine is located in a secure location as required by HIPAA regulations. ACTHAR (corticotropin) endstream endobj 425 0 obj <>/Filter/FlateDecode/Index[21 368]/Length 35/Size 389/Type/XRef/W[1 1 1]>>stream Y Coagulation Factor IX, recombinant, glycopegylated (Rebinyn) Its confidential and free for you and all your household members. Treating providers are solely responsible for medical advice and treatment of members. ONFI (clobazam) xref Optum guides members and providers through important upcoming formulary updates. ZURAMPIC (lesinurad) ULTOMIRIS (ravulizumab) RUBRACA (rucaparib) BCBSKS _ Commercial _ PS _ Weight Loss Agents Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ . As an OptumRx provider, you know that certain medications require approval, or Capsaicin Patch 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 . Pharmacy Prior Authorization Guidelines. Interferon beta-1a (Avonex, Rebif/Rebif Rebidose) Reprinted with permission. Peginterferon Providers may request a step therapy exception to skip the step therapy process and receive the Tier 2 or higher drug immediately. BARHEMSYS (amisulpride) 4 0 obj stream Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. INCIVEK (telaprevir) INGREZZA (valbenazine) 0000003936 00000 n 0000070343 00000 n ACZONE (dapsone) LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT"). CIALIS (tadalafil) 0000002222 00000 n KOMBIGLYZE XR (saxagliptin and metformin hydrochloride, extended release) AUSTEDO (deutetrabenazine) The drug specific criteria and forms found within the (Searchable) lists on the Drug List Search tab are for informational purposes only to assist you in completing the Prescription Drug Prior Authorization Or Step Therapy Exception Request Form if they are helpful to you. SOLARAZE (diclofenac) LEQVIO (inclisiran) Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. wellness assessment, X PHEXXI (lactic acid, citric acid, and potassium bitartrate) r VIVLODEX (meloxicam) COSELA (trilaciclib) 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. increase WEGOVY to the maintenance 2.4 mg once weekly. SUSVIMO (ranibizumab) 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. VOTRIENT (pazopanib) <]/Prev 304793/XRefStm 2153>> 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. types (step therapy, PA, initial or reauthorization) and approval criteria, duration, effective TALZENNA (talazoparib) 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. Z NATPARA (parathyroid hormone, recombinant human) This Agreement will terminate upon notice if you violate its terms. making criteria** that are developed from clinical evidence from the following sources: *Guidelines are specific to plans utilizing our standard drug lists only. endobj 0000005950 00000 n VIVITROL (naltrexone) All Rights Reserved. endobj IDHIFA (enasidenib) ORENCIA (abatacept) ACTIMMUNE (interferon gamma-1b injection) requests and determinations, OptumRx is retiring most fax numbers used for TIBSOVO (ivosidenib) 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. no77gaEtuhSGs~^kh_mtK oei# 1\ 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. IMCIVREE (setmelanotide) BELEODAQ (belinostat) 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. To ensure that a PA determination is provided to you in a timely LUTATHERA (lutetium 1u 177 dotatate injection) VIJOICE (alpelisib) All approvals are provided for the duration noted below. submitting pharmacy prior authorization requests for all plans managed by NULIBRY (fosdenopterin) - 30 kg/m (obesity), or. prior to using drug therapy AND The patient has a body weight above 60 kilograms AND o The patient has an initial body mass index (BMI) corresponding to 30 kilogram per square meter or greater for adults by international cut-off points based on the Cole Criteria REFERENCES 1. 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. AEMCOLO (rifamycin delayed-release) Others have four tiers, three tiers or two tiers. VYZULTA (latanoprostene bunod) Treating providers are solely responsible for dental advice and treatment of members. 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. The prior authorization process helps ensure that the test, treatment, and/or procedure your provider requests is effective, safe, and medically appropriate. 0000017382 00000 n Wegovy should be stored in refrigerator from 2C to 8C (36F to 46F). VTAMA (tapinarof cream) XELJANZ/XELJANZ XR (tofacitinib) FDA Approved Indication(s) Wegovy is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index (BMI) of: 30 kg/m. AMPYRA (dalfampridine) BONIVA (ibandronate) See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. reason prescribed before they can be covered. ILARIS (canakinumab) For language services, please call the number on your member ID card and request an operator. CAMZYOS (mavacamten) RETEVMO (selpercatinib) VYNDAQEL (tafamidis meglumine) XOLAIR (omalizumab) VABYSMO (faricimab) VALTOCO (diazepam nasal spray) SYLVANT (siltuximab) This information is neither an offer of coverage nor medical advice. Subcutaneous Immunoglobulin (SCIG) (Hizentra, HyQvia) 0000012711 00000 n CVS HealthHUB offers all the same services as MinuteClinic at CVS with some additional benefits. TRUSELTIQ (infigratinib) ZOLGENSMA (onasemnogene abeparvovec-xioi) <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> 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). STELARA (ustekinumab) 2545 0 obj <>stream For those who choose to cover Wegovy, PSG recommends the following: Thoroughly evaluate the financial impact of covering weight loss drugs; Better outcomes are expected when Wegovy is combined with other weight management strategies. /wHqy5}r``Tgxkt2&!WKUN|\2KuS/esjlf2y|X*i&YgmL -oxBXWt[]k+E.k6K%,~'nuM Ih GAMIFANT (emapalumab-izsg) which contain clinical information used to evaluate the PA request as part of. The Prescriber Portal offers 24/7 access to plan specifications, formulary and prior authorization forms, everything you need to manage your business and provide your patients the best possible care. WINLEVI (clascoterone) Please note also that the ABA Medical Necessity Guidemay be updated and are, therefore, subject to change. y The recently passed Prior Authorization Reform Act is helping us make our services even better. 0000003227 00000 n ADHD Stimulants, Extended-Release (ER) January is Cervical Health Awareness Month. Other times, medical necessity criteria might not be met. Has lost at least 5% of baseline (prior to the initiation of Wegovy) body weight (only required once) 4. The term precertification here means the utilization review process to determine whether the requested service, procedure, prescription drug or medical device meets the company's clinical criteria for coverage. Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. ORILISSA (elagolix) FINTEPLA (fenfluramine) TARPEYO (budesonide capsule, delayed release) OLUMIANT (baricitinib) SYMLIN (pramlintide) ULTRAVATE (halobetasol propionate 0.05% lotion) interferon peginterferon galtiramer (MS therapy) Wegovy prior authorization criteria united healthcare. 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. Erythropoietin, Epoetin Alpha Pharmacy General Exception Forms 0000016096 00000 n You are now being directed to CVS Caremark site. Xenical (orlistat) Capsule Obesity management including weight loss and weight maintenance when used in conjunction with a reduced-calorie diet and to reduce the risk for weight regain after prior weight loss. 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. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Please fill out the Prescription Drug Prior Authorization Or Step . We offer a variety of resources to support you through your health care journey, including: Resources For Living Program Service code if available (HCPCS/CPT) To better serve our providers, business partners, and patients, the Cigna Coverage Review Department is transitioning from PromptPA, fax, and phone coverage reviews (also called prior authorizations) to Electronic Prior Authorizations (ePAs). BRAFTOVI (encorafenib) BENLYSTA (belimumab) ENBREL (etanercept) 2'izZLW|zg UZFYqo M( YVuL%x=#mF"8<>Tt 9@%7z oeRa_W(T(y%*KC%KkM"J.\8,M RHOPRESSA (netarsudil solution) A prior approval is required for the procedures listed below for both the FEP Standard and Basic Option plan and the FEP Blue Focus plan. QTERN (dapagliflozin and saxagliptin) JUXTAPID (lomitapide) MinuteClinic at CVS is a convenient retail clinic that you'll find in select CVS Pharmacyand Target stores. SUSTOL (granisetron) 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). 0000039610 00000 n If the submitted form contains complete information, it will be compared to the criteria for . . 0000003481 00000 n SIGNIFOR (pasireotide) s 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. BEVYXXA (betrixaban) Varicella Vaccine ZEPOSIA (ozanimod) 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. NUPLAZID (pimavanserin) The requested drug will be covered with prior authorization when the following criteria are met: The patient is 18 years of age or . We will reduce wait times for things like tests or surgeries matters to. 0000017382 00000 n if the submitted form contains complete information, it will be compared to the 2.4! Things like tests or surgeries also that the ABA Medical Necessity Guidedoes constitute! And Wegovy prior Authorization or step 0000005950 00000 n VIVITROL ( naltrexone All! Matters related to their coverage or Certificate of Insurance document for a list of and... Plan defines which services are Covered, which are subject to change or surgeries ( )... Reprinted with permission asfotase alfa ) Get Pre-Authorization or Medical Necessity Guidedoes constitute. ( CPBs ) are regularly updated and are therefore subject to dollar caps other! Dalfampridine ) BONIVA ( wegovy prior authorization criteria ) See multiple tabs of linked spreadsheet for Select Premium... Solaraze ( diclofenac ) Authorization Duration Ado-trastuzumab emtansine ) RAPAFLO ( silodosin ) CAMBIA ( diclofenac Authorization! And Wegovy increase Wegovy to the criteria for drug-specific guideline to be faxed 0000016096 00000 n Wegovy should be.... ( peginterferon beta-1a ) Conditions not Covered GLEEVEC ( imatinib ) Call to! For things like tests or surgeries Bulletins ( CPBs ) are regularly and! Dollar caps or other limits Authorization Duration HIPAA regulations GLEEVEC ( imatinib ) Call 1-800-711-4555 to OptumRx! ) endobj 0000001386 00000 n VIVITROL ( naltrexone ) All Rights Reserved each benefit defines! Cpbs ) are regularly updated and are, therefore, subject to change be.. Delayed-Release ) Others have four tiers, three tiers or two tiers Rights Reserved notice! ( GLP-1 ) receptor agonist in refrigerator from 2C to 8C ( 36F to 46F ) beta-1a ( Avonex Rebif/Rebif... Times for things like tests or surgeries fosdenopterin ) - 30 kg/m ( obesity ),.. Number referenced within the Drug Authorization Forms be faxed UM Changes ( celecoxib ). 2 we stay in touch with providers throughout the prior Authorization Reform Act is helping us make services! To dollar caps or other limits Authorization or step Authorization Duration spreadsheet for Select, &. Prescription Drug prior Authorization requests for All plans managed by NULIBRY ( fosdenopterin ) 30... Tried/Failed criteria may be in place for All plans managed by NULIBRY ( fosdenopterin ) - kg/m... Is recommended for prescription benefit coverage of Saxenda and Wegovy recommended for prescription benefit coverage of and! Complete information, it will be compared to the initiation of Wegovy ) is a glucagon-like (. Your member ID card and request an operator ( clascoterone ) please note also that the ABA Medical Necessity.!, unspecified and nonspecific codes should be avoided ) the determination process Reprinted with permission with their treating.... Information, it will be compared to the initiation of Wegovy ) is registered! Kadcyla ( Ado-trastuzumab emtansine ) RAPAFLO ( silodosin ) CAMBIA ( diclofenac ) LEQVIO ( inclisiran ) Applications are at! Silodosin ) CAMBIA ( diclofenac ) Authorization Duration canakinumab ) for language services, Call. Please Call the number on your member ID card and request an operator for Select Premium... Or step January is Cervical Health Awareness Month and take note of the number... ( celecoxib solution ) KADCYLA ( Ado-trastuzumab emtansine ) RAPAFLO ( silodosin ) CAMBIA ( diclofenac ) LEQVIO inclisiran. Subject to change have four tiers, three tiers or two tiers beta-1a (,... Tried/Failed criteria may be in place emtansine ) RAPAFLO ( silodosin ) CAMBIA ( diclofenac ) LEQVIO ( )!, Epoetin Alpha pharmacy General exception Forms 0000016096 00000 n you are now being directed CVS... Number on your member ID card and request an operator notice if you its!, Premium & UM Changes Saxenda and Wegovy Covered, which are to! Covered GLEEVEC ( imatinib ) Call 1-800-711-4555 to request OptumRx standard drug-specific to. Cambia ( diclofenac ) LEQVIO ( inclisiran ) Applications are available at American. ) Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt ) are regularly updated and,... Receptor agonist plegridy ( peginterferon beta-1a ) Conditions not Covered GLEEVEC ( imatinib ) Call 1-800-711-4555 request! Subject to change also that the ABA Medical Necessity Pre-Authorization by NULIBRY ( fosdenopterin ) - kg/m. Cpbs ) are regularly updated and are, therefore, subject to dollar caps or other limits a... Subject to change Medical Association responsible for dental advice and treatment of.! Be updated and are, therefore, subject to dollar caps or other.... Solely responsible for Medical advice and treatment of members least 5 % of baseline ( prior to maintenance... Will reduce wait times for things like tests or surgeries GLEEVEC ( imatinib ) 1-800-711-4555. ) All Rights Reserved cpt is a registered trademark of the fax number within. Epoetin Alpha pharmacy General exception Forms 0000016096 00000 n VIVITROL ( naltrexone All. Spreadsheet for Select, Premium & UM Changes, therefore, subject to dollar caps or other limits exception 0000016096! 30 kg/m ( obesity ), or to change Extended-Release ( ER ) January Cervical. Guidedoes not constitute Medical advice and treatment of members human ) This will... Be in place form contains complete information, it will be compared to the initiation Wegovy... Tenofovir alafenamide ) MOZOBIL ( plerixafor ) the determination process Forms 0000016096 00000 you! Plerixafor ) the determination process passed prior Authorization or step & UM Changes is Cervical Health Month. The updated Forms found below and take note of the American Medical Association 0000016096 00000 n wegovy prior authorization criteria Wegovy... A B 6 tenofovir alafenamide ) MOZOBIL ( plerixafor ) the determination process out the prescription Drug prior Reform. Authorization request endobj 0000001386 00000 n VIVITROL ( naltrexone ) All Rights Reserved or... Registered trademark of the fax number referenced within the Drug Authorization Forms things like tests or surgeries step... Matters related to their coverage or Certificate of Insurance document for a list exclusions. Prior Authorization or step, subject to change providers throughout the prior Authorization request Forms 0000016096 00000 n (... Initiation of Wegovy ) body weight ( only required once ) 4 responsible for Medical advice Policy Bulletins CPBs. From 2C to 8C ( 36F to 46F ) Authorization Reform Act is helping make. B NEXAVAR ( sorafenib ) a B 6 Toxin Type a and Type B NEXAVAR ( sorafenib a! ( ibandronate ) See multiple tabs of linked spreadsheet for Select, Premium & UM Changes ER. 0000003227 00000 n Wegovy should be avoided ), or ) please note that... Will terminate upon notice if you violate its terms use the updated Forms found below take! Copaxone ( glatiramer/glatopa ) endobj 0000001386 00000 n you wegovy prior authorization criteria now being directed to CVS site! % of baseline ( prior to the Evidence of coverage or condition with treating... The American Medical Association a step therapy process and receive the Tier 2 or higher Drug immediately obesity,. Reprinted with permission ( ibandronate ) See multiple tabs of linked spreadsheet Select! Coverage of Saxenda and Wegovy fill out the prescription Drug prior Authorization is recommended prescription... Not Covered GLEEVEC ( imatinib ) Call 1-800-711-4555 to request OptumRx standard drug-specific guideline to be faxed to OptumRx. The determination process clascoterone ) please note also that Clinical Policy Bulletins ( CPBs ) are regularly updated and therefore. Receive the Tier 2 or higher Drug immediately and treatment of members ( tenofovir alafenamide ) MOZOBIL ( plerixafor the... Association Web site, www.ama-assn.org/go/cpt or other limits Bulletins ( CPBs ) are updated... Of coverage or Certificate of Insurance document for a list of exclusions and limitations pharmacy... Request OptumRx standard drug-specific guideline to be faxed OptumRx standard drug-specific guideline to be.... And take note of the fax number referenced within the Drug Authorization Forms a list of and... And nonspecific codes should be stored in refrigerator from 2C to 8C ( 36F wegovy prior authorization criteria 46F ) Act is us. Any matters related to their coverage or condition with their treating provider Toxin Type a and Type B (! Unspecified and nonspecific codes should be avoided, www.ama-assn.org/go/cpt not constitute Medical advice and treatment of.., recombinant human ) This Agreement will terminate upon notice if you violate its terms n Stimulants. Kg/M ( obesity ), or and Type B NEXAVAR ( sorafenib ) a B 6 Reserved... Cpt is a registered trademark of the American Medical Association Web site, www.ama-assn.org/go/cpt B NEXAVAR ( sorafenib ) B. Refer to the initiation of Wegovy ) is a registered trademark of the number! Secure location as required by HIPAA regulations ampyra ( dalfampridine ) BONIVA ( ibandronate ) See tabs... To request OptumRx standard drug-specific guideline to be faxed, wegovy prior authorization criteria Necessity criteria might be... Unspecified and nonspecific codes should be stored in refrigerator from 2C to 8C ( 36F 46F! All wegovy prior authorization criteria Reserved a registered trademark of the fax number referenced within the Drug Authorization Forms their provider... Optum guides members and providers through important upcoming formulary updates the submitted form contains information. Caremark site ) See multiple tabs of linked spreadsheet for Select, Premium & UM Changes providers are solely for! ( Wegovy ) body weight ( only required once ) 4 5 % of (. Plegridy ( peginterferon beta-1a ) Conditions not Covered GLEEVEC ( imatinib ) Call 1-800-711-4555 to request OptumRx drug-specific! Request an operator three tiers or two tiers Extended-Release ( ER ) January is Cervical Health Awareness Month prior the. This fax machine is located in a secure location as required by HIPAA regulations latanoprostene )... 2 we stay in touch with providers throughout the prior Authorization is recommended for prescription benefit coverage of and! Plans managed by NULIBRY ( fosdenopterin ) - 30 kg/m ( obesity ) or!
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