OCALIVA (obeticholic acid)
RHOFADE (oxymetazoline)
ADBRY (tralokinumab-ldrm)
Global Prior Authorization: Auvelity, Macrilen GLP1 Agonist: Adlyxin, Bydureon, Byetta, Mounjaro, Ozempic, Rybelsus, Trulicity, and Victoza Gonadotropin-Releasing Hormone Agonists for Central Precocious Puberty: Fensolvi, Lupron Depot-Ped, Triptodur Gonadotropin-Releasing Hormone Agonists Long-Acting Agents: Lupaneta Pack, Lupron-Depot Growth .
KYMRIAH (tisagenlecleucel suspension)
In case of a conflict between your plan documents and this information, the plan documents will govern. LETAIRIS (ambrisentan)
BAFIERTAM (monomethyl fumarate)
Sodium oxybate (Xyrem); calcium, magnesium, potassium, and sodium oxybates (Xywav)
SYNAGIS (palivizumab)
JUXTAPID (lomitapide)
NEXLIZET (bempedoic acid and ezetimibe)
Aetna defines a service as "never effective" when it is not recognized according to professional standards of safety and effectiveness in the United States for diagnosis, care or treatment.
IBRANCE (palbociclib)
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). Discard the Wegovy pen after use. ILUMYA (tildrakizumab-asmn)
Testosterone oral agents (JATENZO, TLANDO)
PLEGRIDY (peginterferon beta-1a)
Treating providers are solely responsible for medical advice and treatment of members. RYBREVANT (amivantamab-vmjw)
allowed by state or federal law. Pharmacy Prior Authorization Guidelines. SUNOSI (solriamfetol)
OXERVATE (cenegermin-bkbj)
coverage determinations for most PA types and reasons. EVKEEZA (evinacumab-dgnb)
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Off-label and Administrative Criteria
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AMVUTTRA (vutrisiran)
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. Therefore, Arizona residents, members, employers and brokers must contact Aetna directly or their employers for information regarding Aetna products and services.
Submitting a PA request to OptumRx via phone or fax. 0000070343 00000 n
PROBUPHINE (buprenorphine implant for subdermal administration)
NAPRELAN (naproxen)
QULIPTA (atogepant)
More than 14,000 women in the U.S. get cervical cancer each year. INGREZZA (valbenazine)
ADHD Stimulants, Extended-Release (ER)
ORTIKOS (budesonide ER)
NEXLETOL (bempedoic acid)
Step #3: At times, your request may not meet medical necessity criteria based on the review conducted by medical professionals. GILENYA (fingolimod)
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LUCENTIS (ranibizumab)
Please contact CVS/Caremark at 855-582-2022 with questions regarding the prior authorization process.
IMLYGIC (talimogene laherparepvec)
Has lost at least 5% of baseline (prior to the initiation of Wegovy) body weight (only required once) 4.
Phone: 1-855-344-0930. June 4, 2021, the FDA announced the approval of Novo Nordisks 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-related comorbid condition (eg, hypertension, type 2 diabetes mellitus [T2DM], or dyslipidemia), 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. ORACEA (doxycycline delayed-release capsule)
SYMDEKO (tezacaftor-ivacaftor)
ISTURISA (osilodrostat)
ZORVOLEX (diclofenac)
XHANCE (fluticasone proprionate)
ZTALMY (ganaxolone suspension)
CPT only Copyright 2022 American Medical Association.
KEVZARA (sarilumab)
ABECMA (idecabtagene vicleucel)
ILUVIEN (fluocinolone acetonide)
x=rF?#%=J,9R 0h/t7nH&tJ4=3}_-u~UqT/^Vu]x>W.XUuX/J"IxQbqqB iq(.n-?$bz')m>~H? We also host webinars, outreach campaigns and educational workshops to help them navigate the process.
ANNOVERA (segesterone acetate/ethinyl estradiol)
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. Aetna's 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). If patients do not tolerate the maintenance 2.4 mg once-weekly dosage, the dosage can be temporarily decreased to 1.7 mg once weekly, for a maximum of 4 weeks.
In the event that a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision. LIVTENCITY (maribavir)
0000013356 00000 n
requests and determinations, OptumRx is retiring most fax numbers used for
If a patient does not tolerate the maintenance 2.4 mg once weekly dose, the dose can be temporarily decreased to 1.7 .
CPT is a registered trademark of the American Medical Association.
When conditions are met, we will authorize the coverage of Wegovy. Weve answered some of the most frequently asked questions about the prior authorization process and how we can help. endstream
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OFEV (nintedanib)
* For more information about this side effect .
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.
ZULRESSO (brexanolone)
Our prior authorization process will see many improvements. 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. XIFAXAN (rifaximin)
Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica)
SUTENT (sunitinib)
Others have four tiers, three tiers or two tiers. BLENREP (Belantamab mafodotin-blmf)
An exception can be requested following a denial of a prior authorization or can be submitted at the onset of the request.
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.
QUVIVIQ (daridorexant)
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0000055177 00000 n
ROZLYTREK (entrectinib)
SUSVIMO (ranibizumab)
%%EOF
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.
VOTRIENT (pazopanib)
interferon peginterferon galtiramer (MS therapy)
! Z3mo5&/ ^fHx&,=dtbX,DGjbWo.AT+~D.yVc$o5`Jkxyk+ln
5mA78+7k}HZX*-oUcR);"D:K@8hW]j
{v$pGvX 14Tw1Eb-c{Hpxa_/=Z=}E. FORTEO (teriparatide)
manner, please submit all information needed to make a decision.
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Alogliptin-Metformin (Kazano)
VUMERITY (diroximel fumarate)
AMEVIVE (alefacept)
ULTOMIRIS (ravulizumab)
TAFINLAR (dabrafenib)
VOSEVI (sofosbuvir/velpatasvir/voxilaprevir)
It is sometimes known as precertification or preapproval. 0YjjB \K2z[tV7&v7HiRmHd 91%^X$Kw/$ zqz{i,vntGheOm3|~Z ?IFB8H`|b"X ^o3ld'CVLhM >NQ/{M^$dPR4,I1L@TO4enK-sq}&f6y{+QFXY}Z?zF%bYytm.
Fluoxetine Tablets (Prozac, Sarafem)
As part of an ongoing effort to increase security, accuracy, and timeliness of PA CPT is a registered trademark of the American Medical Association. REVATIO (sildenafil citrate)
2545 0 obj
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TRIJARDY XR (empagliflozin, linagliptin, metformin)
PROMACTA (eltrombopag)
MAVYRET (glecaprevir/pibrentasvir)
FULYZAQ (crofelemer)
Learn about reproductive health.
Wegovy launched with a list price of $1,350 per 28-day supply before insurance. Or, call us at the number on your ID card. 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 .
ePA is a secure and easy method for submitting,managing, tracking PAs, step But there are circumstances where there's misalignment between what is approved by the payer and what is actually . BELEODAQ (belinostat)
SOLOSEC (secnidazole)
h
Blue Shield Medicare plans follow Medicare guidelines for risk allocation and Medicare national and local coverage guideline. BRONCHITOL (mannitol)
January is Cervical Health Awareness Month. patients were required to have a prior unsuccessful dietary weight loss attempt. Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. To ensure that a PA determination is provided to you in a timely MassHealth Pharmacy Initiatives and Clinical Information. LUXTURNA (voretigene neparvovec-rzyl)
0000045302 00000 n
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.
0000092359 00000 n
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