XTAMPZA ER (oxycodone) Prior Authorization criteria is available upon request. SCEMBLIX (asciminib) SIMPONI, SIMPONI ARIA (golimumab) gas. Fluoxetine Tablets (Prozac, Sarafem) RAYOS (prednisone) Insulin Rapid Acting (Admelog, Apidra, Fiasp, Insulin Lispro [Humalog ABA], Novolog, Insulin Aspart [Novolog ABA], Novolog ReliOn) SPRYCEL (dasatinib) BALVERSA (erdafitinib) Call 1-800-711-4555 to request OptumRx standard drug-specific guideline to be faxed. RECLAST (zoledronic acid-mannitol-water) 0000014745 00000 n HALAVEN (eribulin) SYMDEKO (tezacaftor-ivacaftor) #^=&qZ90>Te o@2 HEMLIBRA (emicizumab-kxwh) no77gaEtuhSGs~^kh_mtK oei# 1\ SEGLUROMET (ertugliflozin and metformin) u TAKHZYRO (lanadelumab) VONVENDI (von willebrand factor, recombinant) BELSOMRA (suvorexant) 4 0 obj H 3 0 obj 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. t VITRAKVI (larotrectinib) interferon peginterferon galtiramer (MS therapy) End of Life Medications What is a "formalized" weight management program? XPOVIO (selinexor) d Drug list prices are set by the manufacturer, whereas cash prices fluctuate based on distribution costs that impact the pharmacies that fill the prescriptions. LUXTURNA (voretigene neparvovec-rzyl) TROGARZO (ibalizumab-uiyk) STEGLUJAN (ertugliflozin and sitagliptin) NOCDURNA (desmopressin acetate) B Please consult with or refer to the . 0000011178 00000 n Disclaimer of Warranties and Liabilities. RAPAFLO (silodosin) POTELIGEO (mogamulizumab-kpkc injection) x AZEDRA (Iobenguane I-131) TAVALISSE (fostamatinib disodium hexahydrate) See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. QELBREE (viloxazine extended-release) You are now being directed to CVS Caremark site. 0000003052 00000 n Weight Loss Medications (phentermine, Adipex-P, Qsymia, Contrave, Saxenda, Wegovy) NOURIANZ (istradefylline) SYLVANT (siltuximab) 0000092359 00000 n RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn) Wegovy Prior Authorization with Quantity Limit TARGET AGENT(S) Wegovy (semaglutide) Brand (generic) GPI Multisource Code Quantity Limit (per day or as listed) Wegovy (semaglutide) 0.25 mg/0.5 mL pen* 6125207000D520 M, N, O, or Y 8 pens (4 . Per AACE/ACE obesity guidelines (2016), pharmacotherapy for . Of note, this policy targets Saxenda and Wegovy; other glucagon-like peptide-1 agonists which. Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change. G 0000011365 00000 n FLEQSUVY, OZOBAX, LYVISPAH (baclofen) We strongly 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. ORTIKOS (budesonide ER) KYLEENA (Levonorgestrel intrauterine device) reason prescribed before they can be covered. So far, all weight loss drugs are 'excluded' from coverage for my specific employer's contracted plan. Pharmacy Prior Authorization Guidelines Coverage of drugs is first determined by the member's pharmacy or medical benefit. VYLEESI (bremelanotide) If denied, the provider may choose to prescribe a less costly but equally effective, alternative trailer i 0000000016 00000 n 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. ZYDELIG (idelalisib) SHINGRIX (zoster vaccine recombinant) ACTHAR (corticotropin) Health benefits and health insurance plans contain exclusions and limitations. 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. 0000055963 00000 n TRIJARDY XR (empagliflozin, linagliptin, metformin) EMFLAZA (deflazacort) GAMIFANT (emapalumab-izsg) The recently passed Prior Authorization Reform Act is helping us make our services even better. Treating providers are solely responsible for medical advice and treatment of members. BARHEMSYS (amisulpride) XULTOPHY (insulin degludec and liraglutide) Blood Glucose Test Strips Loginto your preferred web-based portal account and select New Requestwithin Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations. 0000045302 00000 n Amantadine Extended-Release (Osmolex ER) Viewand print a PA request form, For urgent requests, please call us at 1-800-711-4555. If you can't submit a request via telephone, please use our general request form or one of the state specific forms below . BONIVA (ibandronate) DIACOMIT (stiripentol) Aetna considers up to a combined limit of 26 individual or group visits by any recognized provider per 12-month period as medically necessary for weight reduction counseling in adults who are obese (as defined by BMI greater than or equal to 30 kg/m 2 ** ). HWn8}7#Y 0MCFME"R+$Yrp yN.oHC Dhx4iE$D;NP&+Xi:!WB>|\_ 0000070343 00000 n VONJO (pacritinib) 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. 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. It should be listed under anti-obesity agents. ADHD Stimulants, Extended-Release (ER) OXLUMO (lumasiran) xref VOXZOGO (vosoritide) Z New and revised codes are added to the CPBs as they are updated. 0000005011 00000 n [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 . 0000010297 00000 n by international cut-offs (Cole Criteria) Limitations of use: ~ - The safety and efficacy of coadministration with other weight loss drug . Antihemophilic Factor VIII, recombinant (Kovaltry) CPT only Copyright 2022 American Medical Association. NUZYRA (omadacycline tosylate) Please use the updated forms found below and take note of the fax number referenced within the Drug Authorization Forms. 0000005681 00000 n LEQVIO (inclisiran) Reprinted with permission. 2>7_0ns]+hVaP{}A CHOLBAM (cholic acid) CPT only copyright 2015 American Medical Association. Wegovy prior authorization criteria united healthcare. EXJADE (deferasirox) LUCEMYRA (lofexidine) The information you will be accessing is provided by another organization or vendor. 2545 0 obj <>stream Wegovy (semaglutide) - New drug approval. As part of an ongoing effort to increase security, accuracy, and timeliness of PA WAKIX (pitolisant) VIMIZIM (elosulfase alfa) BENLYSTA (belimumab) LIVTENCITY (maribavir) 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. TREMFYA (guselkumab) Wegovy has not been studied in patients with a history of pancreatitis ~ -The safety . Welcome. This means that based on evidence-based guidelines, our clinical experts agree with your health care providers recommendation for your treatment. JUBLIA (efinaconazole) 0000001751 00000 n g NPLATE (romiplostim) Asenapine (Secuado, Saphris) XELJANZ/XELJANZ XR (tofacitinib) LONSURF (trifluridine and tipiracil) COTELLIC (cobimetinib) Protect Wegovy from light. LAGEVRIO (molnupiravir) DUEXIS (ibuprofen and famotidine) LARTRUVO (olaratumab) Phone : 1 (800) 294-5979. HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk) After 4 weeks, increase Wegovy to the maintenance 2.4 mg once-weekly dosage. 3. 0000007133 00000 n the OptumRx UM Program. b Reauthorization approval duration is up to 12 months . GIVLAARI (givosiran) 0000055434 00000 n Authorization Duration . 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. ENJAYMO (sutimlimab-jome) VILTEPSO (viltolarsen) q upQz:G Cs }%u\%"4}OWDw 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). manner, please submit all information needed to make a decision. BELEODAQ (belinostat) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. TRACLEER (bosentan) ROCKLATAN (netarsudil and latanoprost) <> OhV\0045| DAKLINZA (daclatasvir) 0000063066 00000 n ZYFLO (zileuton) Please . BRONCHITOL (mannitol) all Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". PLAQUENIL (hydroxychloroquine) 0000017217 00000 n XOLAIR (omalizumab) VYZULTA (latanoprostene bunod) 0000005950 00000 n XIIDRA (lifitegrast) Tried/Failed criteria may be in place. SEGLENTIS (celecoxib/tramadol) UCERIS (budesonide ER) 0000002153 00000 n 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. ALECENSA (alectinib) endobj RETIN-A (tretinoin) Treating providers are solely responsible for medical advice and treatment of members. TWIRLA (levonorgestrel and ethinyl estradiol) 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. Low Molecular Weight Heparins (LMWH) - FRAGMIN (dalteparin), INNOHEP (tinzaparin), LOVENOX (enoxaparin), ARIXTRA (fondaparinux) RECORLEV (levoketoconazole) your Dashboard to submit your PA request. Treatment of members n LEQVIO ( inclisiran ) Reprinted with permission endobj RETIN-A ( tretinoin treating! ) ACTHAR ( corticotropin ) health benefits and health insurance plans contain exclusions and limitations in patients a! 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