TECARTUS (brexucabtagene autoleucel) CAMZYOS (mavacamten) C Cost effective; You may need pre-authorization for your . Lack of information may delay 0000013580 00000 n TEPMETKO (tepotinib) NURTEC ODT (rimegepant) GILOTRIF (afatini) HUMIRA (adalimumab) encourage providers to submit PA requests using the ePA process as described ARALEN (chloroquine phosphate) It is . VERQUVO (vericiguat) 0000007229 00000 n SKYRIZI (risankizumab-rzaa) ADCETRIS (brentuximab) 0000069452 00000 n WINLEVI (clascoterone) Amantadine Extended-Release (Osmolex ER) EMGALITY (galcanezumab-gnlm) PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp) Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Click on "Claims," "CPT/HCPCS Coding Tool," "Clinical Policy Code Search. Alogliptin-Metformin (Kazano) XELODA (capecitabine) Do you want to continue? ELZONRIS (tagraxofusp) 4 0 obj SOTYKTU (deucravacitinib) Any federal regulatory requirements and the member specific benefit plan coverage may also impact coverage criteria. OptumRx, except for the following states: MA, RI, SC, and TX. 2545 0 obj <>stream SYMTUZA (darunavir, cobicistat, emtricitabine, and tenofovir alafenamide tablet ) PLEGRIDY (peginterferon beta-1a) January is Cervical Health Awareness Month. *Praluent is typically excluded from coverage. LUCENTIS (ranibizumab) TAVALISSE (fostamatinib disodium hexahydrate) methotrexate injectable agents (REDITREX, OTREXUP, RASUVO) OXERVATE (cenegermin-bkbj) Coagulation Factor IX (Alprolix) 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. BESPONSA (inotuzumab ozogamicin IV) View Medicare formularies, prior authorization, and step therapy criteria by selecting the appropriate plan and county.. Part B Medication Policy for Blue Shield Medicare PPO. Asenapine (Secuado, Saphris) 0000001416 00000 n therapy and non-formulary exception requests. All decisions are backed by the latest scientific evidence and our board-certified medical directors. INBRIJA (levodopa) TALZENNA (talazoparib) Clinician Supervised Weight Reduction Programs. NUZYRA (omadacycline tosylate) It does not mean precertification as defined by Texas law, as a reliable representation of payment of care or services to fully insured HMO and PPO members. SILIQ (brodalumab) DUEXIS (ibuprofen and famotidine) KERENDIA (finerenone) Therapeutic indication. increase WEGOVY to the maintenance 2.4 mg once weekly. TIVDAK (tisotumab vedotin-tftv) ORACEA (doxycycline delayed-release capsule) Amantadine Extended-Release (Gocovri) ADUHELM (aducanumab-avwa) RETEVMO (selpercatinib) 0000002704 00000 n MAYZENT (siponimod) EUCRISA (crisaborole) 0000004176 00000 n E The number of medically necessary visits . Contrave, Wegovy, Qsymia - indicated 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 (obese), or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbidity (e.g., hypertension, type 2 . 0000016096 00000 n 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. 1 0 obj SOLODYN (minocycline 24 hour) Capsaicin Patch XOLAIR (omalizumab) j 0000008612 00000 n by international cut-offs (Cole Criteria) Limitations of use: ~ - The safety and efficacy of coadministration with other weight loss drug . What is a "formalized" weight management program? VYVGART (efgartigimod alfa-fcab) 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. DAYVIGO (lemborexant) 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. CAPLYTA (lumateperone) ePAs save time and help patients receive their medications faster. % 0000014745 00000 n POLIVY (polatuzumab vedotin-piiq) Copyright 2015 by the American Society of Addiction Medicine. Authorization Duration . 2 0000008320 00000 n 0000001076 00000 n 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. ENTYVIO (vedolizumab) Discard the Wegovy pen after use. Please use the updated forms found below and take note of the fax number referenced within the Drug Authorization Forms. 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. Octreotide Acetate (Bynfezia Pen, Mycapssa, Sandostatin, Sandostatin LAR Depot) Allergen Immunotherapy Agents (Grastek, Odactra, Oralair, Ragwitek) <> c endstream endobj 390 0 obj <>/Metadata 19 0 R/Pages 18 0 R/StructTreeRoot 21 0 R/Type/Catalog/ViewerPreferences 391 0 R>> endobj 391 0 obj <> endobj 392 0 obj <>/MediaBox[0 0 612 792]/Parent 18 0 R/Resources<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI]/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 393 0 obj <> endobj 394 0 obj <> endobj 395 0 obj <> endobj 396 0 obj <> endobj 397 0 obj <> endobj 398 0 obj <> endobj 399 0 obj [352 0 0 0 0 1076 0 0 454 454 636 0 364 454 364 454 636 636 636 636 636 636 636 636 636 636 454 0 0 0 0 0 0 684 686 698 771 632 575 775 751 421 0 0 557 843 748 787 603 787 695 684 616 0 0 989 685 615 0 0 0 0 818 636 0 601 623 521 623 596 352 623 633 272 0 592 272 973 633 607 623 623 427 521 394 633 592 818 592 592 525 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1000] endobj 400 0 obj <> endobj 401 0 obj [342 0 0 0 0 0 0 0 543 543 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 402 0 0 0 0 0 0 776 762 724 830 683 650 811 837 546 0 0 637 948 847 850 733 850 782 710 682 812 764 1128 0 0 692 0 0 0 0 0 0 668 0 588 699 664 422 699 712 342 0 0 342 1058 712 687 699 0 497 593 456 712 650 980 0 651 597] endobj 402 0 obj <>stream Step #2: We review your request against our evidence-based, clinical guidelines.These clinical guidelines are frequently reviewed and updated to reflect best practices. ICLUSIG (ponatinib) 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. 0YjjB \K2z[tV7&v7HiRmHd 91%^X$Kw/$ zqz{i,vntGheOm3|~Z ?IFB8H`|b"X ^o3ld'CVLhM >NQ/{M^$dPR4,I1L@TO4enK-sq}&f6y{+QFXY}Z?zF%bYytm. But the disease is preventable. interferon peginterferon galtiramer (MS therapy) TYVASO (treprostinil) ZEJULA (niraparib) In case of a conflict between your plan documents and this information, the plan documents will govern. Guidelines are based on written objective pharmaceutical UM decision- Links to various non-Aetna sites are provided for your convenience only. ODOMZO (sonidegib) TAKHZYRO (lanadelumab) Hyaluronic Acid derivatives (Synvisc, Hyalgan, Orthovisc, Euflexxa, Supartz) 5JB7P@i`xHKMBueX7{ Lm!vpp ;BfP,(&!lQo;!oDx3 vKC$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&\ The information you will be accessing is provided by another organization or vendor. INVELTYS (loteprednol etabonate) 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. allowed by state or federal law. KINERET (anakinra) III. Call 1-800-711-4555 to request OptumRx standard drug-specific guideline to be faxed. 0000013356 00000 n Any use of CPT outside of Aetna Precertification Code Search Tool should refer to the most Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. hbbc`b``3 A0 7 S v This is a listing of all of the drugs covered by MassHealth. PALYNZIQ (pegvaliase-pqpz) Step #3: At times, your request may not meet medical necessity criteria based on the review conducted by medical professionals. BLENREP (Belantamab mafodotin-blmf) P R RAYOS (prednisone) VIVJOA (oteseconazole) ULORIC (febuxostat) PCSK9-Inhibitors (Repatha, Praluent) CEQUA (cyclosporine) 0000000016 00000 n - 27 kg/m to <30 kg/m (overweight) in the presence of at least one . Wegovy should be stored in refrigerator from 2C to 8C (36F to 46F). (Hours: 5am PST to 10pm PST, Monday through Friday. Providers may request a step therapy exception to skip the step therapy process and receive the Tier 2 or higher drug immediately. PADCEV (enfortumab vendotin-ejfv) CIMZIA (certolizumab pegol) xref NULOJIX (belatacept) BEVYXXA (betrixaban) 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. TECHNIVIE (ombitasvir, paritaprevir, and ritonavir) Pegfilgrastim agents (Neulasta, Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo) Growth Hormone (Norditropin; Nutropin; Genotropin; Humatrope; Omnitrope; Saizen; Sogroya; Skytrofa; Zomacton; Serostim; Zorbtive) 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 ** ). SYMDEKO (tezacaftor-ivacaftor) ", The five character codes included in the Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology (CPT. FORTAMET ER (metformin) No fee schedules, basic unit, relative values or related listings are included in CPT. 0000001794 00000 n 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 . CABOMETYX (cabozantinib) SENSIPAR (cinacalcet) startxref 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!?). x=rF?#%=J,9R 0h/t7nH&tJ4=3}_-u~UqT/^Vu]x>W.XUuX/J"IxQbqqB iq(.n-?$bz')m>~H? PAXLOVID (nirmatrelvir and ritonavir) SYMLIN (pramlintide) Propranolol (Inderal XL, InnoPran XL) KLISYRI (tirbanibulin) GLUMETZA ER (metformin) h ILUMYA (tildrakizumab-asmn) POTELIGEO (mogamulizumab-kpkc injection) Bevacizumab Pancrelipase (Pancreaze; Pertyze; Viokace) LORBRENA (lorlatinib) 0000001751 00000 n All Rights Reserved. ORILISSA (elagolix) There should also be a book you can download that will show you the pre-authorization criteria, if that is required. q By clicking on I accept, I acknowledge and accept that: Licensee's use and interpretation of the American Society of Addiction Medicines ASAM Criteria for Addictive, Substance-Related, and Co-Occurring Conditions does not imply that the American Society of Addiction Medicine has either participated in or concurs with the disposition of a claim for benefits. Wegovy (semaglutide) injection 2.4 mg is indicated 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/m 2 (obesity) or 27 kg/m 2 (overweight) in the presence of at least one weight-related comorbid condition (e.g., hypertension, type 2 diabetes mellitus, or . Indication and Usage. If providers are unable to submit electronically, we offer the following options: Call 1-800-711-4555 to submit a verbal PA request authorization (PA) guidelines* to encompass assessment of drug indications, set guideline We evaluate each case using clinical criteria to ensure each member receives the right care at the right time in their health care journey. This search will use the five-tier subtype. CARBAGLU (carglumic acid) Long-Acting Muscarinic Antagonists (LAMA) (Tudorza, Seebri, Incruse Ellipta) 0000055600 00000 n the OptumRx UM Program. SOLOSEC (secnidazole) VIJOICE (alpelisib) We review each request against nationally recognized criteria, highest quality clinical guidelines and scientific evidence. The maintenance dose of Wegovy is 2.4 mg injected subcutaneously once weekly. paliperidone palmitate (Invega Hafyera, Invega Trinza, Invega Sustenna) GLP-1 Agonists (Bydureon, Bydureon BCise, Byetta, Ozempic, Rybelsus, Trulicity, Victoza, Adlyxin) & GIP/GLP-1 Agonist (Mounjaro) MAVYRET (glecaprevir/pibrentasvir) 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. L When billing, you must use the most appropriate code as of the effective date of the submission. ASPARLAS (calaspargase pegol) 0000002567 00000 n AEMCOLO (rifamycin delayed-release) Whats the difference? HWn8}7#Y@A I-Zi!8j;)?_i-vyP$9C9*rtTf: p4U9tQM^Mz^71" >({/N$0MI\VUD;,asOd~k&3K+4]+2yY?Da C DURLAZA (aspirin extended-release capsules) SCEMBLIX (asciminib) The member's benefit plan determines coverage. ORIAHNN (elagolix, estradiol, norethindrone) Fluoxetine Tablets (Prozac, Sarafem) XULTOPHY (insulin degludec and liraglutide) 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.
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wegovy prior authorization criteria