NEXAVAR (sorafenib) This list is subject to change. W TAVNEOS (avacopan) KOSELUGO (selumetinib) BARHEMSYS (amisulpride) TRACLEER (bosentan) This is a listing of all of the drugs covered by MassHealth. In case of a conflict between your plan documents and this information, the plan documents will govern. l ARIKAYCE (amikacin) ONUREG (azacitidine) OXERVATE (cenegermin-bkbj) SUBLOCADE (buprenorphine ER) TRIJARDY XR (empagliflozin, linagliptin, metformin) Coagulation Factor IX, recombinant human (Ixinity) bBZ!A01/a(m:=Ug^@+zDfD|4`vP3hs)l5yb/CLBf;% 2p|~\ie.~z_OHSq::xOv[>vv How to access the OptumRx PA guidelines: Reference the OptumRx electronic prior authorization ( ePA ) and (fax ) forms. Wegovy will be used concomitantly with behavioral modification and a reduced-calorie diet . BAFIERTAM (monomethyl fumarate) ILARIS (canakinumab) LUXTURNA (voretigene neparvovec-rzyl) HAEGARDA (C1 Esterase Inhibitor SQ [human]) EXONDYS 51 (eteplirsen) 0000005011 00000 n Prior Authorization for MassHealth Providers. RETEVMO (selpercatinib) BREYANZI (lisocabtagene maraleucel) CIALIS (tadalafil) 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. manner, please submit all information needed to make a decision. Z Alogliptin-Metformin (Kazano) TYSABRI (natalizumab) 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. these guidelines may not apply. We recommend you speak with your patient regarding NEXLETOL (bempedoic acid) Links to various non-Aetna sites are provided for your convenience only. PA reviews are completed by clinical pharmacists and/or medical doctors who base utilization Click on "Claims," "CPT/HCPCS Coding Tool," "Clinical Policy Code Search. KERENDIA (finerenone) Treating providers are solely responsible for medical advice and treatment of members. 0000008389 00000 n COSENTYX (secukinumab) PIQRAY (alpelisib) IBRANCE (palbociclib) AKLIEF (trifarotene) 0 Fax complete signed and dated forms to CVS/Caremark at 888-836-0730. 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.. Wegovy should be used with a reduced calorie meal plan and increased physical activity. AYVAKIT (avapritinib) 0000002392 00000 n 0000054934 00000 n 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. %P.Q*Q`pU r 001iz%N@v%"_6DP@z0(uZ83z3C >,w9A1^*D( xVV4^[r62i5D\"E ZYKADIA (ceritinib) NUPLAZID (pimavanserin) VOSEVI (sofosbuvir/velpatasvir/voxilaprevir) N 0000092359 00000 n Please call us at 800.753.2851 to submit a verbal prior authorization request if you are unable to use Electronic Prior Authorization. DELATESTRYL (testosterone cypionate 100mg/ml; 200mg/ml) XELJANZ/XELJANZ XR (tofacitinib) However, applicable state mandates will take precedence with respect to fully insured plans and self-funded non-ERISA (e.g., government, school boards, church) plans. CEQUA (cyclosporine) %PDF-1.7 % B indigestion, heartburn, or gastroesophageal reflux disease (GERD) fatigue (low energy) stomach flu. Antihemophilic factor VIII (Eloctate) We strongly SKYRIZI (risankizumab-rzaa) XELODA (capecitabine) M TYMLOS (abaloparatide) Specialty drugs typically require a prior authorization. SYNRIBO (omacetaxine mepesuccinate) EMPAVELI (pegcetacoplan) Pharmacy General Exception Forms SOLOSEC (secnidazole) 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. OXLUMO (lumasiran) coverage determinations for most PA types and reasons. KEVZARA (sarilumab) EMFLAZA (deflazacort) LARTRUVO (olaratumab) After 4 weeks, increase Wegovy to the maintenance 2.4 mg once-weekly dosage. GILENYA (fingolimod) Buprenorphine/Naloxone (Suboxone, Zubsolv, Bunavail) RAYOS (prednisone) 1 0 obj XPOVIO (selinexor) XIAFLEX (collagenase clostridium histolyticum) NINLARO (ixazomib) DAURISMO (glasdegib) MinuteClinic at CVS is a convenient retail clinic that you'll find in select CVS Pharmacyand Target stores. ALECENSA (alectinib) 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. SYNAGIS (palivizumab) No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. Antihemophilic Factor VIII, Recombinant (Afstyla) FULYZAQ (crofelemer) SCEMBLIX (asciminib) This search will use the five-tier subtype. ZOLINZA (vorinostat) Therapeutic indication. Off-label and Administrative Criteria trailer NPLATE (romiplostim) Q Members should discuss any matters related to their coverage or condition with their treating provider. All Rights Reserved. FABRAZYME (agalsidase beta) INVELTYS (loteprednol etabonate) Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". ULORIC (febuxostat) 3 0 obj 0000003724 00000 n Its confidential and free for you and all your household members. PLAQUENIL (hydroxychloroquine) In doing so, CVS/Caremark will be able to decide whether or not the requested prescription is included in the patient's insurance plan. stream ombitsavir, paritaprevir, retrovir, and dasabuvir ),)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 0000069922 00000 n BIJUVA (estradiol-progesterone) XOSPATA (gilteritinib) ZTALMY (ganaxolone suspension) <> endobj Other policies and utilization management programs may apply. Any use of CPT outside of Aetna Clinical Policy Bulletins (CPBs) should refer to the most current Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. NUBEQA (darolutamide) Pancrelipase (Pancreaze; Pertyze; Viokace) TASIGNA (nilotinib) Tried/Failed criteria may be in place. COTELLIC (cobimetinib) 0000003046 00000 n If you would like to view forms for a specific drug, visit the CVS/Caremark webpage, linked below. BRUKINSA (zanubrutinib) q[#rveQ:7cntFHb)?&\FmBmF[l~7NizfdUc\q (^"_>{s^kIi&=s oqQ^Ne[* h$h~^h2:YYWO8"Si5c@9tUh1)4 LEUKINE (sargramostim) If the submitted form contains complete information, it will be compared to the criteria for . protect patient safety, as well as ensure the best possible therapeutic outcomes. e VIZIMPRO (dacomitinib) ZOMETA (zoledronic acid) Visit the secure website, available through, for more information. VUITY (pilocarpine) VEMLIDY (tenofovir alafenamide) Angiotensin Receptor Blockers (e.g., Atacand, Atacand HCT, Tribenzor, Edarbi, Edarbyclor, Teveten) 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. CHOLBAM (cholic acid) Blood Glucose Test Strips CARVYKTI (ciltacabtagene autoleucel) 0000002571 00000 n endstream endobj 425 0 obj <>/Filter/FlateDecode/Index[21 368]/Length 35/Size 389/Type/XRef/W[1 1 1]>>stream increase WEGOVY to the maintenance 2.4 mg once weekly. ELYXYB (celecoxib solution) VALTOCO (diazepam nasal spray) prescription drug benefit coverage under his/her health insurance plan or call OptumRx. Prior Authorization Hotline. We offer a variety of resources to support you through your health care journey, including: Resources For Living Program Phone: 1-855-344-0930. FANAPT (iloperidone) Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica) Wegovy prior authorization criteria united healthcare. Go to the American Medical Association Web site. Status: CVS Caremark Criteria Type: Initial Prior Authorization POLICY FDA-APPROVED INDICATIONS Saxenda is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight . 0000010297 00000 n 0000054864 00000 n X666q5@E())ix cRJKKCW"(d4*_%-aLn8B4( .e`6@r Dg g`> <> Western Health Advantage. NOCDURNA (desmopressin acetate) If needed (prior to cap removal) the pen can be kept from 8C to 30C (46F to 86F) up to 28 days. Prior Authorization criteria is available upon request. CVS HealthHUB offers all the same services as MinuteClinic at CVS with some additional benefits. Each main plan type has more than one subtype. So far, all weight loss drugs are 'excluded' from coverage for my specific employer's contracted plan. endobj 0000003227 00000 n YUPELRI (revefenacin) SEYSARA (sarecycline) q <>/Metadata 497 0 R/ViewerPreferences 498 0 R>> 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). APOKYN (apomorphine) All approvals are provided for the duration noted below. 2'izZLW|zg UZFYqo M( YVuL%x=#mF"8<>Tt 9@%7z oeRa_W(T(y%*KC%KkM"J.\8,M DAKLINZA (daclatasvir) 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. RYDAPT (midostaurin) the OptumRx UM Program. Do you want to continue? t BCBSKS _ Commercial _ PS _ Weight Loss Agents Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ . But there are circumstances where there's misalignment between what is approved by the payer and what is actually . startxref 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. Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. Initial Approval Criteria Lab values are obtained within 30 days of the date of administration (unless otherwise indicated); AND Prior to initiation of therapy, patient should have adequate iron stores as demonstrated by serum ferritin 100 ng/mL (mcg/L) and transferrin saturation (TSAT) 20%*; AND As an OptumRx provider, you know that certain medications require approval, or CINRYZE (C1 esterase inhibitor [human]) ZULRESSO (brexanolone) constipation *. ZEPOSIA (ozanimod) 0000011662 00000 n JYNARQUE (tolvaptan) SUPPRELIN LA (histrelin SC implant) You can take advantage of a wide range of services across a variety of categories, including: CVS HealthHUBservices TARGRETIN (bexarotene) FYARRO (sirolimus protein-bound particles) UKONIQ (umbralisib) 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. The prior authorization process helps ensure that you are receiving quality, effective, safe, and timely care that is medically necessary. INCIVEK (telaprevir) 0000002527 00000 n LORBRENA (lorlatinib) Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. Also includes the CAR-T Monitoring Program, and Luxturna Monitoring Program . Subcutaneous Immunoglobulin (SCIG) (Hizentra, HyQvia) 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. % Or, call us at the number on your ID card. STELARA (ustekinumab) VERKAZIA (cyclosporine ophthalmic emulsion) We will be more clear with processes. 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. ULTRAVATE (halobetasol propionate 0.05% lotion) startxref TAGRISSO (osimertinib) UCERIS (budesonide ER) 0000001602 00000 n QELBREE (viloxazine extended-release) 0000012711 00000 n In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. Of note, Saxenda (liraglutide subcutaneous injection) and Wegovy (semaglutide subcutaneous injection) are indicated for chronic weight . ZERVIATE (cetirizine) FORTAMET ER (metformin) HWn8}7#Y 0MCFME"R+$Yrp yN.oHC Dhx4iE$D;NP&+Xi:!WB>|\_ 0YjjB \K2z[tV7&v7HiRmHd 91%^X$Kw/$ zqz{i,vntGheOm3|~Z ?IFB8H`|b"X ^o3ld'CVLhM >NQ/{M^$dPR4,I1L@TO4enK-sq}&f6y{+QFXY}Z?zF%bYytm. ARAKODA (tafenoquine) No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM. 0000013911 00000 n Antihemophilic Factor [recombinant] pegylated-aucl (Jivi) TAZVERIK (tazematostat) coagulation factor XIII (Tretten) NOURIANZ (istradefylline) ORENCIA (abatacept) MassHealth Pharmacy Initiatives and Clinical Information. The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. I TEMODAR (temozolomide) SYLVANT (siltuximab) PROAIR DIGIHALER (albuterol) 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 . Has anyone been able to jump through this type of hoop? BRINEURA (cerliponase alfa IV) 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. ERIVEDGE (vismodegib) 0000005021 00000 n NULOJIX (belatacept) Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn) The requested drug will be covered with prior authorization when the following criteria are met: The patient is 18 years of age or . The request processes as quickly as possible once all required information is together. ASPARLAS (calaspargase pegol) ePAs save time and help patients receive their medications faster. Peginterferon Prior Authorization Resources. NUZYRA (omadacycline tosylate) GILOTRIF (afatini) BALVERSA (erdafitinib) NUEDEXTA (dextromethorphan and quinidine) If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537. of the following: (a) Patient is 18 years of age for Wegovy (b) Patient is 12 years of age for Saxenda (3) Failure to lose > 5% of body weight through at least 6 months of lifestyle modification alone (e.g., dietary or caloric restriction, exercise, behavioral support, community . End of Life Medications 0000003404 00000 n 0000003052 00000 n ZEGERID (omeprazole-sodium bicarbonate) Coverage for weight loss drugs like Wegovy varies widely depending on the kind of insurance you have and where you live. OLUMIANT (baricitinib) 0000002808 00000 n PLEGRIDY (peginterferon beta-1a) 0000011005 00000 n RYBREVANT (amivantamab-vmjw) TREMFYA (guselkumab) ORIAHNN (elagolix, estradiol, norethindrone) ANNOVERA (segesterone acetate/ethinyl estradiol) NULIBRY (fosdenopterin) k Pharmacy Prior Authorization Guidelines Coverage of drugs is first determined by the member's pharmacy or medical benefit. ACTEMRA (tocilizumab) [a=CijP)_(z ^P),]y|vqt3!X X 0000069611 00000 n 2545 0 obj <>stream REYVOW (lasmiditan) BENLYSTA (belimumab) QBREXZA (glycopyrronium cloth 2.4%) DUOBRII (halobetasol propionate and tazarotene) While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk) 0000009958 00000 n RITUXAN (rituximab) MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate) REZUROCK (belumosudil) headache. LUCENTIS (ranibizumab) ZINPLAVA (bezlotoxumab) Wegovy; Xenical; Initial approval criteria for covered drugs with prior authorization: Patient must meet the age limit indicated in the FDA-approved label of the requested drug AND; Documented failure of at least a three-month trial on a low-calorie diet AND; A regimen of increased physical activity unless medically contraindicated by co . SILIQ (brodalumab) Medicare Plans. MAVYRET (glecaprevir/pibrentasvir) - 27 kg/m to <30 kg/m (overweight) in the presence of at least one . PAs help manage costs, control misuse, and ROZLYTREK (entrectinib) LONSURF (trifluridine and tipiracil) Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba) Botulinum Toxin Type A and Type B XOLAIR (omalizumab) PHEXXI (lactic acid, citric acid, and potassium bitartrate) AEMCOLO (rifamycin delayed-release) RECORLEV (levoketoconazole) Applicable FARS/DFARS apply. XGEVA (denosumab) Pretomanid IMCIVREE (setmelanotide) all 0000007229 00000 n XTANDI (enzalutamide) VITRAKVI (larotrectinib) Interferon beta-1b (Betaseron, Extavia) VYONDYS 53 (golodirsen) VABYSMO (faricimab) 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. ZYNLONTA (loncastuximab tesirine-lpyl). 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). Coagulation Factor IX, (recombinant), Albumin Fusion Protein (Idelvion) RECLAST (zoledronic acid-mannitol-water) As part of an ongoing effort to increase security, accuracy, and timeliness of PA hbbc`b``3 A0 7 Hyaluronic Acid derivatives (Synvisc, Hyalgan, Orthovisc, Euflexxa, Supartz) V Hepatitis B IG DORYX (doxycycline hyclate) DELESTROGEN (estradiol valerate injection) endobj Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. RECARBRIO (imipenem, cilastin and relebactam) AMPYRA (dalfampridine) 0000005705 00000 n TIVORBEX (indomethacin) Erythropoietin, Epoetin Alpha GIVLAARI (givosiran) HALAVEN (eribulin) Lack of information may delay Filgrastim agents (Nivestym, Zarxio, Neupogen, Granix, Releuko) IGALMI (dexmedetomidine film) c XCOPRI (cenobamate) This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. TECHNIVIE (ombitasvir, paritaprevir, and ritonavir) 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). MEKTOVI (binimetinib) dates and more. QULIPTA (atogepant) Attached is a listing of prescription drugs that are subject to prior authorization. INFINZI (durvalumab IV) PCSK9-Inhibitors (Repatha, Praluent) PSG suggests the inclusion of those strategies within prior authorization (PA) criteria. EXJADE (deferasirox) Optum guides members and providers through important upcoming formulary updates. endobj Wegovy should be used with a reduced calorie meal plan and increased physical activity. Please . DURLAZA (aspirin extended-release capsules) : RUCONEST (recombinant C1 esterase inhibitor) This information is neither an offer of coverage nor medical advice. QTERN (dapagliflozin and saxagliptin) hb```b``{k @16=v1?Q_# tY which contain clinical information used to evaluate the PA request as part of. PEMAZYRE (pemigatinib) COSELA (trilaciclib) 1 0 obj ARALEN (chloroquine phosphate) Pre-authorization is a routine process. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. FOTIVDA (tivozanib) OhV\0045| x gym discounts, G The American Medical Association (AMA) does not directly or indirectly practice medicine or dispense medical services. Atypical Antipsychotics, Long-Acting Injectable (Abilify Maintena, Aristata, Aristada Initio, Perseris, Risperdal Consta, Zyprexa Relprevv) INGREZZA (valbenazine) SUNOSI (solriamfetol) Submitting a PA request to OptumRx via phone or fax. TAFINLAR (dabrafenib) ESBRIET (pirfenidone) 3 0 obj 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. Initial approval duration is up to 7 months . PONVORY (ponesimod) Please log in to your secure account to get what you need. SUSVIMO (ranibizumab) 0000002756 00000 n The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. 6\ !D"'"PN~# yV)GH"4LGAK`h9c&3yzGX/EN5~jx6g"nk!{`=(`\MNUokEfOnJ "1 STRENSIQ (asfotase alfa) SUSTOL (granisetron) Welcome. ENDARI (l-glutamine oral powder) These clinical guidelines are frequently reviewed and updated to reflect best practices. therapy and non-formulary exception requests. Whats the difference? AJOVY (fremanezumab-vfrm) UBRELVY (ubrogepant) A prior authorization is a request submitted on your behalf by your health care provider for a particular procedure, test, treatment, or prescription. HEPLISAV-B (hepatitis B vaccine) Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. 0000063066 00000 n XERMELO (telotristat ethyl) EPIDIOLEX (cannabidiol) Please consult with or refer to the Evidence of Coverage or Certificate of Insurance document for a list of exclusions and limitations. no77gaEtuhSGs~^kh_mtK oei# 1\ 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 U PROBUPHINE (buprenorphine implant for subdermal administration) SUTENT (sunitinib) * For more information about this side effect . 0000092908 00000 n The maintenance dose of Wegovy is 2.4 mg injected subcutaneously once weekly. ), 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. r 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. 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. 0000013058 00000 n 0000004700 00000 n endobj Prior Authorization Criteria Author: AMZEEQ (minocycline) TIVDAK (tisotumab vedotin-tftv) 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. Applicable FARS/DFARS apply. This Agreement will terminate upon notice if you violate its terms. VUMERITY (diroximel fumarate) 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. TROGARZO (ibalizumab-uiyk) HETLIOZ/HETLIOZ LQ (tasimelton) Has lost at least 5% of baseline (prior to the initiation of Wegovy) body weight (only required once) 4. 0000008227 00000 n VITAMIN B12 (cyanocobalamin injection) 0000011365 00000 n 0000069682 00000 n For language services, please call the number on your member ID card and request an operator. 0000014745 00000 n WINLEVI (clascoterone) VIBERZI (eluxadoline) 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. Were here with 24/7 support and resources to help you with work/life balance, caregiving, legal services, money matters, and more. 0000011178 00000 n ZEJULA (niraparib) This bill took effect January 1, 2022. DOPTELET (avatrombopag) Some subtypes have five tiers of coverage. 389 0 obj <> endobj KALYDECO (ivacaftor) 0000003577 00000 n EUCRISA (crisaborole) 2>7_0ns]+hVaP{}A The OptumRx Pharmacy Utilization Management (UM) Program utilizes drug-specific prior 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 . 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 . Fax : 1 (888) 836- 0730. Type in Wegovy and see what it says. by international cut-offs (Cole Criteria) Limitations of use: ~ - The safety and efficacy of coadministration with other weight loss drug . PALYNZIQ (pegvaliase-pqpz) RINVOQ (upadacitinib) MARGENZA (margetuximab-cmkb) GAVRETO (pralsetinib) SPRIX (ketorolac nasal spray) Varicella Vaccine Please consult with or refer to the . BAVENCIO (avelumab) The recently passed Prior Authorization Reform Act is helping us make our services even better. VYZULTA (latanoprostene bunod) Protect Wegovy from light. KERYDIN (tavaborole) RHOFADE (oxymetazoline) 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.
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