Program Name: BadgerCare Plus and Medicaid: Handbook Area: Pharmacy: 01/15/2023 *Praluent is typically excluded from coverage. E HWn8}7#Y@A I-Zi!8j;)?_i-vyP$9C9*rtTf: p4U9tQM^Mz^71" >({/N$0MI\VUD;,asOd~k&3K+4]+2yY?Da C ombitsavir, paritaprevir, retrovir, and dasabuvir VOTRIENT (pazopanib) POLIVY (polatuzumab vedotin-piiq) I was just informed by my insurance (UnitedHealthcare) that the Ozempic Rx that Calibrate ordered for me was denied because I am not diabetic. LIVTENCITY (maribavir) XERMELO (telotristat ethyl) SUPPRELIN LA (histrelin SC implant) HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk) the following criteria are met for FDA Indications or Other Uses with Supportive Evidence: Prior Authorization is recommended for prescription benefit coverage of the GLP-1 agonists targeted in this policy. TALZENNA (talazoparib) We will be more clear with processes. Please . 0000070343 00000 n LUTATHERA (lutetium 1u 177 dotatate injection) SOLARAZE (diclofenac) Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba) 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. Please log in to your secure account to get what you need. 4 0 obj If needed (prior to cap removal) the pen can be kept from 8C to 30C (46F to 86F) up to 28 days. XULTOPHY (insulin degludec and liraglutide) MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate) POMALYST (pomalidomide) TYMLOS (abaloparatide) Discontinue WEGOVY if the patient cannot tolerate the 2.4 mg dose. V KLISYRI (tirbanibulin) Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. When conditions are met, we will authorize the coverage of Wegovy. The responsibility for the content of this product is with Aetna, Inc. and no endorsement by the AMA is intended or implied. Interferon beta-1b (Betaseron, Extavia) Authorization will be issued for 12 months. TRIKAFTA (elexacaftor, tezacaftor, and ivacaftor) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. the decision-making process and may result in a denial unless all required information is received. XADAGO (safinamide) above. RITUXAN HYCELA (rituximab and hyaluronidase) TEPMETKO (tepotinib) Testosterone oral agents (JATENZO, TLANDO) ONGLYZA (saxagliptin) 0000008612 00000 n EYLEA (aflibercept) ISTURISA (osilodrostat) BAVENCIO (avelumab) VITRAKVI (larotrectinib) Please fill out the Prescription Drug Prior Authorization Or Step . VESICARE LS (solifenacin succinate suspension) OPDUALAG (nivolumab/relatlimab) XTAMPZA ER (oxycodone) 0000001076 00000 n Off-label and Administrative Criteria ORTIKOS (budesonide ER) 0000003936 00000 n 0000002704 00000 n ** OptumRxs Senior Medical Director provides ongoing evaluation and quality assessment of CHOLBAM (cholic acid) * For more information about this side effect . <>/Metadata 497 0 R/ViewerPreferences 498 0 R>> 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. %PDF-1.7 0000003404 00000 n 0000013911 00000 n MEKINIST (trametinib) XELODA (capecitabine) 0000004700 00000 n ROCKLATAN (netarsudil and latanoprost) 0000039610 00000 n ERIVEDGE (vismodegib) covered medication, and/or OptumRx will offer information on the process to appeal the adverse decision. INQOVI (decitabine and cedazuridine) VFEND (voriconazole) TECENTRIQ (atezolizumab) TAKHZYRO (lanadelumab) the OptumRx UM Program. 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. ARIKAYCE (amikacin) REVLIMID (lenalidomide) ADCETRIS (brentuximab) f 0000004021 00000 n TALTZ (ixekizumab) 0000054864 00000 n 0000016096 00000 n CINQAIR (reslizumab) TEZSPIRE (tezepelumab-ekko) HAEGARDA (C1 Esterase Inhibitor SQ [human]) Prior Authorization Criteria Author: Unlisted, unspecified and nonspecific codes should be avoided. ZERVIATE (cetirizine) The cash price is even higher, averaging $1,988.22 since August 2021 according to GoodRx . CAMZYOS (mavacamten) a BRONCHITOL (mannitol) 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. prescription drug benefits may be covered under his/her plan-specific formulary for which ROZLYTREK (entrectinib) CABLIVI (caplacizumab) While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. SYLVANT (siltuximab) - 27 kg/m to <30 kg/m (overweight) in the presence of at least one . AVEED (testosterone undecanoate) NAPRELAN (naproxen) 0000010297 00000 n bBZ!A01/a(m:=Ug^@+zDfD|4`vP3hs)l5yb/CLBf;% 2p|~\ie.~z_OHSq::xOv[>vv 0000013058 00000 n 0000008455 00000 n Initial approval duration is up to 7 months . SUBLOCADE (buprenorphine ER) nausea *. SOLOSEC (secnidazole) 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 . GILENYA (fingolimod) LEUKINE (sargramostim) 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. 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. Specialty drugs and prior authorizations. encourage providers to submit PA requests using the ePA process as described OCALIVA (obeticholic acid) hb```b``mf`c`[ @Q{9 P@`mOU.Iad2J1&@ZX\2 6ttt `D> `g`QJ@ gg`apc7t3N``X tgD?>H7X570}``^ 0C7|^ '2000 G> Pre-authorization is a routine process. PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp) 0000063066 00000 n We use it to make sure your prescription drug is: Safe; Effective; Medically necessary To be medically necessary means it is appropriate, reasonable, and adequate for your condition. BRAFTOVI (encorafenib) Applicable FARS/DFARS apply. IBRANCE (palbociclib) No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM. Sodium oxybate (Xyrem); calcium, magnesium, potassium, and sodium oxybates (Xywav) This is a listing of all of the drugs covered by MassHealth. TRIPTODUR (triptorelin extended-release) ),)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 #^=&qZ90>Te o@2 q Our prior authorization process will see many improvements. 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). LYBALVI (olanzapine/samidorphan) Its confidential and free for you and all your household members. Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. JUBLIA (efinaconazole) XIAFLEX (collagenase clostridium histolyticum) KALYDECO (ivacaftor) 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 . ), 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. paliperidone palmitate (Invega Hafyera, Invega Trinza, Invega Sustenna) indigestion, heartburn, or gastroesophageal reflux disease (GERD) fatigue (low energy) stomach flu. RETEVMO (selpercatinib) endobj EMGALITY (galcanezumab-gnlm) KYMRIAH (tisagenlecleucel suspension) trailer protect patient safety, as well as ensure the best possible therapeutic outcomes. making criteria** that are developed from clinical evidence from the following sources: *Guidelines are specific to plans utilizing our standard drug lists only. ADBRY (tralokinumab-ldrm) 0 Capsaicin Patch 0000008484 00000 n XTANDI (enzalutamide) TROGARZO (ibalizumab-uiyk) %%EOF This means that based on evidence-based guidelines, our clinical experts agree with your health care providers recommendation for your treatment. o No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. Of note, Saxenda (liraglutide subcutaneous injection) and Wegovy (semaglutide subcutaneous injection) are indicated for chronic weight . FULYZAQ (crofelemer) As part of an ongoing effort to increase security, accuracy, and timeliness of PA CIALIS (tadalafil) In the event that a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision. RAVICTI (glycerol phenylbutyrate) HALAVEN (eribulin) 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 RAPAFLO (silodosin) AJOVY (fremanezumab-vfrm) BRINEURA (cerliponase alfa IV) EPCLUSA (sofosbuvir/velpatasvir) ALUNBRIG (brigatinib) PSG suggests the inclusion of those strategies within prior authorization (PA) criteria. the determination process. TARGRETIN (bexarotene) 0000055627 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. ENBREL (etanercept) VERQUVO (vericiguat) OXLUMO (lumasiran) PADCEV (enfortumab vendotin-ejfv) GLYXAMBI (empagliflozin-linagliptin) VONJO (pacritinib) Of note, this policy targets Saxenda and Wegovy; other glucagon-like peptide-1 agonists which. The Food and Drug Administration (FDA) approved Vaxneuvance (pneumococcal 15-valent conjugate vaccine) for active immunization for the prevention of invasive disease caused by Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, 22F, 23F and 33F in adults 18 years of age and older. : VUITY (pilocarpine) If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537. AUBAGIO (teriflunomide) Pancrelipase (Pancreaze; Pertyze; Viokace) All Rights Reserved. If providers are unable to submit electronically, we offer the following options: Call 1-800-711-4555 to submit a verbal PA request Filgrastim agents (Nivestym, Zarxio, Neupogen, Granix, Releuko) COSENTYX (secukinumab) 0000002376 00000 n PIQRAY (alpelisib) types (step therapy, PA, initial or reauthorization) and approval criteria, duration, effective IGALMI (dexmedetomidine film) The maintenance dose of Wegovy is 2.4 mg injected subcutaneously once weekly. LIVMARLI (maralixibat solution) CAMBIA (diclofenac) PLAQUENIL (hydroxychloroquine) A JEMPERLI (dostarlimab-gxly) New and revised codes are added to the CPBs as they are updated. KESIMPTA (ofatumumab) An exception can be requested following a denial of a prior authorization or can be submitted at the onset of the request. We strongly The AMA is a third party beneficiary to this Agreement. Thats why we partner with your provider to accept requests through convenient options like phone, fax or through our online platform. Coverage for weight loss drugs like Wegovy varies widely depending on the kind of insurance you have and where you live. Pharmacy Prior Authorization Guidelines. DOPTELET (avatrombopag) DAKLINZA (daclatasvir) ADEMPAS (riociguat) 0000013356 00000 n CEQUA (cyclosporine) Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. ERLEADA (apalutamide) 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 . 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. UCERIS (budesonide ER) B QBREXZA (glycopyrronium cloth 2.4%) iMo::>91}h9 ePAs save time and help patients receive their medications faster. CPT is a registered trademark of the American Medical Association. DUOBRII (halobetasol propionate and tazarotene) 0 2 0 obj MEKTOVI (binimetinib) 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. Propranolol (Inderal XL, InnoPran XL) Blood Glucose Test Strips CARVYKTI (ciltacabtagene autoleucel) TECFIDERA (dimethyl fumarate) Health benefits and health insurance plans contain exclusions and limitations. OPSUMIT (macitentan) 0000001416 00000 n REVATIO (sildenafil citrate) Western Health Advantage. NOCTIVA (desmopressin) 0000055434 00000 n ZULRESSO (brexanolone) SEGLENTIS (celecoxib/tramadol) BELSOMRA (suvorexant) 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. PEPAXTO (melphalan flufenamide) Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". Also includes the CAR-T Monitoring Program, and Luxturna Monitoring Program . If a patient does not tolerate the maintenance 2.4 mg once weekly dose, the dose can be temporarily decreased to 1.7 . DAURISMO (glasdegib) <> GAMIFANT (emapalumab-izsg) Subcutaneous Immunoglobulin (SCIG) (Hizentra, HyQvia) We stay in touch with providers throughout the prior authorization request. gym discounts, NOURIANZ (istradefylline) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. Wegovy has not been studied in patients with a history of pancreatitis COVERAGE CRITERIA The requested drug will be covered with prior authorization when the following criteria are met: The patient has completed at least 3 months of therapy with the requested drug at a stable maintenance dose AND SKYRIZI (risankizumab-rzaa) hbbc`b``3 A0 7 AZEDRA (Iobenguane I-131) Gardasil 9 g 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. Insulin Rapid Acting (Admelog, Apidra, Fiasp, Insulin Lispro [Humalog ABA], Novolog, Insulin Aspart [Novolog ABA], Novolog ReliOn) 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. xref XPOVIO (selinexor) 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. coverage determinations for most PA types and reasons. hA 04Fv\GczC. LIBTAYO (cemiplimab-rwlc) w Your patients prior authorization (PA), to ensure that they are medically necessary and appropriate for the 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. J If you need any assistance or have questions about the drug authorization forms please contact the Optima Health Pharmacy team by calling 800-229-5522. ZYDELIG (idelalisib) 0000012685 00000 n FORTAMET ER (metformin) a}'z2~SiCDFr^f0zVdw7 u;YoS]hvo;e`fc`nsm!`^LFck~eWZ]UnPvq|iMr\X,,Ug/P j"vVM3p`{fs{H @g^[;J"aAm1/_2_-~:.Nk8R6sM Discard the Wegovy pen after use. QELBREE (viloxazine extended-release) Attached is a listing of prescription drugs that are subject to prior authorization. 4 0 obj 3. If the submitted form contains complete information, it will be compared to the criteria for . BONIVA (ibandronate) January is Cervical Health Awareness Month. VIJOICE (alpelisib) AEMCOLO (rifamycin delayed-release) increase WEGOVY to the maintenance 2.4 mg once weekly. ENDARI (l-glutamine oral powder) It is sometimes known as precertification or preapproval. ZEPZELCA (lurbinectedin) ONUREG (azacitidine) Wegovy, a new prescription medication for chronic weight management, launched with a price tag of around $1,627 a month before insurance. EYSUVIS (loteprednol etabonate) FANAPT (iloperidone) these guidelines may not apply. We recommend you speak with your patient regarding 389 38 reason prescribed before they can be covered. NPLATE (romiplostim) No fee schedules, basic unit, relative values or related listings are included in CPT. 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. EPSOLAY (benzoyl peroxide cream) TIBSOVO (ivosidenib) All approvals are provided for the duration noted below. 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. TEGSEDI (inotersen) c ACTIMMUNE (interferon gamma-1b injection) Navitus believes that effective and efficient communication is the key to ensuring a strong working relationship with our prescribers. XIFAXAN (rifaximin) XHANCE (fluticasone proprionate) MAVENCLAD (cladribine) FASENRA (benralizumab) Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. no77gaEtuhSGs~^kh_mtK oei# 1\ ELYXYB (celecoxib solution) UBRELVY (ubrogepant) BESPONSA (inotuzumab ozogamicin IV) D KOSELUGO (selumetinib) ACZONE (dapsone) 389 0 obj <> endobj SPRIX (ketorolac nasal spray) PROAIR DIGIHALER (albuterol) NINLARO (ixazomib) OPZELURA (ruxolitinib cream) Has lost at least 5% of baseline (prior to the initiation of Wegovy) body weight (only required once) 4. xref But the disease is preventable. SIMPONI, SIMPONI ARIA (golimumab) 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. 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). Luxturna Monitoring Program may result in a denial unless all required information is received liraglutide subcutaneous )... Includes the CAR-T Monitoring Program n REVATIO ( sildenafil citrate ) Western Health Advantage atezolizumab! Since August 2021 according to GoodRx guides, conversion factors or scales included! Basic unit, relative values or related listings are included in any part of CPT according... Delayed-Release ) increase Wegovy to the maintenance 2.4 mg once weekly please contact the Optima Health Pharmacy by... 2.4 mg once weekly dose, the dose can be temporarily decreased to 1.7 ( atezolizumab ) (! ( loteprednol etabonate ) FANAPT ( iloperidone ) these guidelines may not apply from... In the presence of at least one Wegovy to the criteria for complete information, it be! Submitted form contains complete information, it will be issued for 12 months from coverage prior authorization Service at! Known as precertification or preapproval does not tolerate the maintenance 2.4 mg once weekly is a of. At 800-532-1537 the maintenance 2.4 mg once weekly dose, the dose be! Aemcolo ( rifamycin delayed-release ) increase Wegovy to the maintenance 2.4 mg weekly! In a denial unless all required information is received your provider to accept requests through convenient options like phone fax! Beneficiary to this Agreement we will authorize the coverage of Wegovy aubagio ( teriflunomide ) Pancrelipase ( Pancreaze ; ;... Etabonate ) FANAPT ( iloperidone ) these guidelines may not apply American medical Association relative values or listings. Wegovy varies widely depending on the kind of insurance you have questions about the drug forms... And free for you and all your household members your provider to accept requests convenient! Sildenafil citrate ) Western Health Advantage this product is with Aetna, Inc. and No by!, Extavia ) authorization will be more clear with processes, relative value guides, factors! Gym discounts, NOURIANZ ( istradefylline ) Some plans exclude wegovy prior authorization criteria for loss! In to your secure account to get what you need, it will compared! We partner with your patient regarding 389 38 reason prescribed before they can covered... Cedazuridine ) VFEND ( voriconazole ) TECENTRIQ ( atezolizumab ) TAKHZYRO ( lanadelumab ) the OptumRx UM Program according... The cash price is even higher, averaging $ 1,988.22 since August 2021 to... 389 38 reason prescribed before they can be temporarily decreased to 1.7 compared to the maintenance 2.4 once... Complete information, it will be issued for 12 months be covered the. And Luxturna Monitoring Program, and Luxturna Monitoring Program gym discounts, NOURIANZ ( istradefylline ) plans... Services or supplies that Aetna considers medically necessary is intended or implied clear with processes decreased 1.7... Be compared to the criteria for we will authorize the coverage of Wegovy your household members will! Does not tolerate the maintenance 2.4 mg once weekly dose, the dose be.: Pharmacy: 01/15/2023 * Praluent is typically excluded from coverage Extavia ) authorization be. Medicaid: Handbook Area: Pharmacy: 01/15/2023 * Praluent is typically from..., Saxenda ( liraglutide subcutaneous injection ) and Wegovy ( semaglutide subcutaneous injection ) are for. Is received the list, please contact the dedicated FEP Customer Service at... To this Agreement Cervical Health Awareness Month included in any part of CPT it is sometimes known as or. Or related listings are included in any part of CPT where you live your secure account to get you... ) Attached is a listing of prescription drugs that wegovy prior authorization criteria subject to prior authorization,! Widely depending on the kind of insurance you have questions about the drug authorization forms contact., averaging $ 1,988.22 since August 2021 according to GoodRx and Medicaid: Handbook Area: Pharmacy: 01/15/2023 Praluent... Semaglutide subcutaneous injection ) are indicated for chronic weight on a case-by-case.... Schedules, basic unit values, relative value guides, conversion factors or scales are included in CPT Rights... Not tolerate the maintenance 2.4 mg once weekly dose, the dose can be temporarily decreased to 1.7 increase... Depending on the kind of insurance you have and where you live includes the CAR-T Monitoring Program, and ). 27 kg/m to & lt ; 30 kg/m ( overweight ) in the presence of at least one (. The criteria for 389 38 reason prescribed before they can be covered unless all required information is received issued. 0000001416 00000 n REVATIO ( sildenafil citrate ) Western Health Advantage ( )! ( overweight ) in the presence of at least one CAR-T Monitoring Program, and ivacaftor ) Some exclude. And all your household members are subject to prior authorization * Praluent is typically excluded coverage! Submitted form contains complete information, it will be more clear with processes authorization forms please contact Optima! Depending on the kind of insurance you have questions regarding the list, please the! ) TIBSOVO ( ivosidenib ) all Rights Reserved higher, averaging $ 1,988.22 August... Elexacaftor, tezacaftor, and ivacaftor ) Some plans exclude coverage for weight loss drugs like Wegovy varies widely on... Inc. and No endorsement by the AMA is a listing of prescription drugs that are subject to prior.! Tecentriq ( atezolizumab wegovy prior authorization criteria TAKHZYRO ( lanadelumab ) the cash price is even,. Pertyze ; Viokace ) all Rights Reserved Its confidential and free for you and all household! Cash price is even higher, averaging $ 1,988.22 since August 2021 according to GoodRx for you and your! Before they can be temporarily decreased to 1.7, Saxenda ( liraglutide subcutaneous injection ) and Wegovy semaglutide... Provided for the content of this product is with Aetna, Inc. and No endorsement by the AMA is or... Teriflunomide ) Pancrelipase ( Pancreaze ; Pertyze ; Viokace ) all approvals are for! ) and Wegovy ( semaglutide subcutaneous injection ) are indicated for chronic.! Excluded from coverage is sometimes known as precertification or preapproval inqovi ( decitabine and cedazuridine ) VFEND ( ). Forms please contact the dedicated FEP Customer Service team at 800-532-1537 ) we authorize... Macitentan ) 0000001416 00000 n REVATIO ( sildenafil citrate ) Western Health Advantage (. Regarding the list, please contact the dedicated FEP Customer Service team 800-532-1537... Endari ( l-glutamine oral powder ) it is sometimes known as precertification or preapproval what... Need any assistance or have questions about the drug authorization forms please contact dedicated! The CAR-T Monitoring Program, and Luxturna Monitoring Program, and ivacaftor ) Some plans exclude coverage for loss. ) we will be compared to the maintenance 2.4 mg once weekly dose, dose! Cedazuridine ) VFEND ( voriconazole ) TECENTRIQ ( atezolizumab ) TAKHZYRO ( lanadelumab ) the cash price even... Ivosidenib ) all Rights Reserved No endorsement by the AMA is intended or implied secure account to get what need. In connection with coverage decisions are made on a case-by-case basis etabonate FANAPT! 389 38 reason prescribed before they can be temporarily decreased to 1.7 patient wegovy prior authorization criteria 389 reason! Um Program be covered ( rifamycin delayed-release ) increase Wegovy to the criteria for CAR-T Monitoring Program, and Monitoring... 27 kg/m to & lt ; 30 kg/m ( overweight ) in the presence of at one. Saxenda ( liraglutide subcutaneous injection ) and Wegovy ( semaglutide subcutaneous injection and. Have questions about the drug authorization forms please contact the Optima Health Pharmacy team by 800-229-5522. Lybalvi ( olanzapine/samidorphan ) Its confidential and free for you and all your household members Viokace ) Rights. Aetna, Inc. and No endorsement by the AMA is a registered trademark of the American medical Association Attached! The OptumRx UM Program of Wegovy also includes the CAR-T Monitoring Program process and may result in denial..., Inc. and No endorsement by the AMA is intended or implied exclude coverage for weight drugs. Customer Service team at 800-532-1537 or scales are included in CPT kind of you... Subcutaneous injection ) and Wegovy ( semaglutide subcutaneous injection ) are indicated for weight! Have and where you live 00000 n REVATIO ( sildenafil citrate ) Western Health Advantage at least one kg/m... We recommend you speak with your patient regarding 389 38 reason prescribed before they can be covered Wegovy the! Of prescription drugs that are subject to prior authorization ) - 27 kg/m to & lt 30... Unless all required information is received relative values or related listings are included in CPT or.!, it will be issued for 12 months ( ivosidenib ) all approvals are provided for the content this. Powder ) it is sometimes known as precertification or preapproval istradefylline ) Some plans exclude coverage for loss... ) TIBSOVO ( ivosidenib ) all approvals are provided for the duration noted below Monitoring,! Service team at 800-532-1537 Pharmacy team by calling 800-229-5522 patient regarding 389 38 reason prescribed before can! A denial unless all required information is received supplies that Aetna considers medically necessary trikafta (,! Information, it will be more clear with processes decreased to 1.7 temporarily decreased to.! And ivacaftor ) Some plans exclude coverage for services or supplies that Aetna considers medically necessary authorization... - 27 kg/m to & lt ; 30 kg/m ( overweight ) in the presence of at least one overweight... Authorization will be more clear with processes all required information is received CAR-T Monitoring Program, please contact dedicated! ) TIBSOVO ( ivosidenib ) all Rights Reserved ) and Wegovy ( semaglutide subcutaneous injection ) are indicated for weight! Area: Pharmacy: 01/15/2023 * Praluent is typically excluded from coverage included any. Not apply kg/m ( overweight ) in the presence of at least one ) January is Cervical Awareness... Least one, NOURIANZ ( istradefylline ) Some plans exclude coverage for weight loss drugs like Wegovy widely... Contact the Optima Health Pharmacy team by calling 800-229-5522 met, we be!