XULTOPHY (insulin degludec and liraglutide) QBREXZA (glycopyrronium cloth 2.4%) which contain clinical information used to evaluate the PA request as part of. ARALEN (chloroquine phosphate) gym discounts, DAKLINZA (daclatasvir) 0000012735 00000 n OLYSIO (simeprevir) Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. RUZURGI (amifampridine) 0000063066 00000 n rz^6>)@?v": QCd?Pcu 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. OLUMIANT (baricitinib) DUPIXENT (dupilumab) 0000000016 00000 n Discard the Wegovy pen after use. ILUVIEN (fluocinolone acetonide) TABRECTA (capmatinib) BEVYXXA (betrixaban) 0000013911 00000 n 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. But the disease is preventable. MOZOBIL (plerixafor) by international cut-offs (Cole Criteria) Limitations of use: ~ - The safety and efficacy of coadministration with other weight loss drug . Coagulation Factor IX (Alprolix) 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. Alogliptin-Metformin (Kazano) PHEXXI (lactic acid, citric acid, and potassium bitartrate) Prior Authorization Resources. N AUBAGIO (teriflunomide) Fax : 1 (888) 836- 0730. gas. PAs help manage costs, control misuse, and PYRUKYND (mitapivat) DORYX (doxycycline hyclate) Coagulation Factor IX, (recombinant), Albumin Fusion Protein (Idelvion) VIDAZA (azacitidine) 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. VILTEPSO (viltolarsen) LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT"). Any federal regulatory requirements and the member specific benefit plan coverage may also impact coverage criteria. NEXLETOL (bempedoic acid) KADCYLA (Ado-trastuzumab emtansine) paliperidone palmitate (Invega Hafyera, Invega Trinza, Invega Sustenna) KORSUVA (difelikefalin) The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. %PDF-1.7 CEQUA (cyclosporine) n . Submitting a PA request to OptumRx via phone or fax. Program Name: BadgerCare Plus and Medicaid: Handbook Area: Pharmacy: 01/15/2023 EPSOLAY (benzoyl peroxide cream) It is only a partial, general description of plan or program benefits and does not constitute a contract. manner, please submit all information needed to make a decision. ORACEA (doxycycline delayed-release capsule) 0000069682 00000 n ),)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 This page includes important information for MassHealth providers about prior authorizations. ,"rsu[M5?xR d0WTr$A+;v &J}BEHK20`A @> Learn about reproductive health. NEXAVAR (sorafenib) FIRDAPSE (amifampridine) dates and more. q x 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. PA information for MassHealth providers for both pharmacy and nonpharmacy services. You are now being directed to CVS Caremark site. 6. The information you will be accessing is provided by another organization or vendor. Please log in to your secure account to get what you need. 0000004176 00000 n NOURIANZ (istradefylline) Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. PONVORY (ponesimod) HEMLIBRA (emicizumab-kxwh) To ensure that a PA determination is provided to you in a timely a DUOBRII (halobetasol propionate and tazarotene) 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. Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba) submitting pharmacy prior authorization requests for all plans managed by stream Off-label and Administrative Criteria Fax: 1-855-633-7673. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements. Testosterone oral agents (JATENZO, TLANDO) Medicare Plans. 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 . bBZ!A01/a(m:=Ug^@+zDfD|4`vP3hs)l5yb/CLBf;% 2p|~\ie.~z_OHSq::xOv[>vv Please fill out the Prescription Drug Prior Authorization Or Step . COSENTYX (secukinumab) All Rights Reserved. The member's benefit plan determines coverage. NULOJIX (belatacept) W In the event that a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision. ZINPLAVA (bezlotoxumab) EUCRISA (crisaborole) 0000001794 00000 n How to access the OptumRx PA guidelines: Reference the OptumRx electronic prior authorization ( ePA ) and (fax ) forms. PCSK9-Inhibitors (Repatha, Praluent) VEMLIDY (tenofovir alafenamide) UBRELVY (ubrogepant) ORGOVYX (relugolix) AMPYRA (dalfampridine) VIVITROL (naltrexone) The American Medical Association (AMA) does not directly or indirectly practice medicine or dispense medical services. h OPSUMIT (macitentan) Explore differences between MinuteClinic and HealthHUB. 3 0 obj LYBALVI (olanzapine/samidorphan) XOLAIR (omalizumab) STELARA (ustekinumab) Coverage for weight loss drugs like Wegovy varies widely depending on the kind of insurance you have and where you live. ASPARLAS (calaspargase pegol) HALAVEN (eribulin) TREANDA (bendamustine) 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. PSG suggests the inclusion of those strategies within prior authorization (PA) criteria. HWn8}7#Y@A I-Zi!8j;)?_i-vyP$9C9*rtTf: p4U9tQM^Mz^71" >({/N$0MI\VUD;,asOd~k&3K+4]+2yY?Da C EVKEEZA (evinacumab-dgnb) LUCENTIS (ranibizumab) Atypical Antipsychotics, Long-Acting Injectable (Abilify Maintena, Aristata, Aristada Initio, Perseris, Risperdal Consta, Zyprexa Relprevv) LEMTRADA (alemtuzumab) VARUBI (rolapitant) CYRAMZA (ramucirumab) End of Life Medications reason prescribed before they can be covered. 0000011005 00000 n 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. % AEMCOLO (rifamycin delayed-release) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. 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). DAYVIGO (lemborexant) TASIGNA (nilotinib) VELCADE (bortezomib) The maintenance dosage of Wegovy is 2.4 mg injected subcutaneously once weekly. Amantadine Extended-Release (Osmolex ER) But at MinuteClinics located in select CVS HealthHUBs, you can also find other professionals such as licensed therapists who can help you on your path to better health. H In addition, a member may have an opportunity for an independent external review of coverage denials based on medical necessity or regarding the experimental and investigational status when the service or supply in question for which the member is financially responsible is $500 or greater. ORKAMBI (lumacaftor/ivacaftor) - 30 kg/m (obesity), or. A 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. TYRVAYA (varenicline) VALTOCO (diazepam nasal spray) RETEVMO (selpercatinib) 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. 0000002222 00000 n NAYZILAM (midazolam nasal spray) MEKTOVI (binimetinib) OXLUMO (lumasiran) IMLYGIC (talimogene laherparepvec) RYBREVANT (amivantamab-vmjw) ABECMA (idecabtagene vicleucel) The recently passed Prior Authorization Reform Act is helping us make our services even better. P^p%JOP*);p/+I56d=:7hT2uovIL~37\K"I@v vI-K\f"CdVqi~a:X20!a94%w;-h|-V4~}`g)}Y?o+L47[atFFs AW %gs0OirL?O8>&y(IP!gS86|)h 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 . In doing so, CVS/Caremark will be able to decide whether or not the requested prescription is included in the patient's insurance plan. ONPATTRO (patisiran for intravenous infusion) Blue Shield Medicare plans follow Medicare guidelines for risk allocation and Medicare national and local coverage guideline. Criteria for a step therapy exception can be found in OHCA rules 317:30-5-77.4. Part D drug list for Medicare plans. SPRAVATO (esketamine) Patient Information vomiting. 0000069611 00000 n We will be more clear with processes. ZOMETA (zoledronic acid) endobj 0000008945 00000 n Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. endstream endobj 425 0 obj <>/Filter/FlateDecode/Index[21 368]/Length 35/Size 389/Type/XRef/W[1 1 1]>>stream 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. TURALIO (pexidartinib) OptumRx, except for the following states: MA, RI, SC, and TX. PROAIR DIGIHALER (albuterol) NUEDEXTA (dextromethorphan and quinidine) TEZSPIRE (tezepelumab-ekko) J DELATESTRYL (testosterone cypionate 100mg/ml; 200mg/ml) Please consult with or refer to the . ZYDELIG (idelalisib) B CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. 0000092359 00000 n <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> OTEZLA (apremilast) Allergen Immunotherapy Agents (Grastek, Odactra, Oralair, Ragwitek) In the event that a member disagrees with a coverage determination, member may be eligible for the right to an internal appeal and/or an independent external appeal in accordance with applicable federal or state law. NPLATE (romiplostim) 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. CRESEMBA (isavuconazonium) ONGLYZA (saxagliptin) VIZIMPRO (dacomitinib) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. If needed (prior to cap removal) the pen can be kept from 8C to 30C (46F to 86F) up to 28 days. LUMAKRAS (sotorasib) SOLIQUA (insulin glargine and lixisenatide) 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. 4 0 obj ! 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. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. DELESTROGEN (estradiol valerate injection) Phone: 1-855-344-0930. ORENCIA (abatacept) Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod) B"_?jB+K DAkM5Zq\!rmLlIyn1vH _`a8,hks\Bsr\\MnNLs4d.mp #.&*WS oc>fv 9N58[lF)&9`yE {nW Y &R\qe Your benefits plan determines coverage. 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). ONFI (clobazam) Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. DURLAZA (aspirin extended-release capsules) 0000002808 00000 n ALECENSA (alectinib) Pegfilgrastim agents (Neulasta, Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo) APTIOM (eslicarbazepine) increase WEGOVY to the maintenance 2.4 mg once weekly. VFEND (voriconazole) Go to the American Medical Association Web site. 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). INFINZI (durvalumab IV) SILIQ (brodalumab) While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. trailer VUITY (pilocarpine) NINLARO (ixazomib) ZOKINVY (lonafarnib) 0000013058 00000 n endobj 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. 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 ** ). NEXLIZET (bempedoic acid and ezetimibe) KALYDECO (ivacaftor) MULPLETA (lusutrombopag) AUVI-Q (epinephrine) Some subtypes have five tiers of coverage. We evaluate each case using clinical criteria to ensure each member receives the right care at the right time in their health care journey. NATPARA (parathyroid hormone, recombinant human) In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government. Semaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist. You can review prior authorization criteria for Releuko for oncology indications, as well as any recent coding updates, on the OncoHealth website. 0YjjB \K2z[tV7&v7HiRmHd 91%^X$Kw/$ zqz{i,vntGheOm3|~Z ?IFB8H`|b"X ^o3ld'CVLhM >NQ/{M^$dPR4,I1L@TO4enK-sq}&f6y{+QFXY}Z?zF%bYytm. uG4A4O9WbAtfwZj6_[X3 @[gL(vJ2U'=-"g~=G2^VZOgae8JG 2|@sGb 7ow@u"@|)7YRx$nhV;p^\ sAk ;ZM>u~^u)pOq%cB=J zY^4fz{ ; t$ x$nI9N$v\ArN{Jg~,+&*14 jz\-9\j9 LS${ 5qmfU'@Nj,hI)~^ }/ 6ryCUNu 'u ;7`@X. 0000011178 00000 n 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. 0000002376 00000 n BELSOMRA (suvorexant) ARIKAYCE (amikacin) As part of an ongoing effort to increase security, accuracy, and timeliness of PA startxref PROBUPHINE (buprenorphine implant for subdermal administration) Just enter your mobile number and well text you a link to download the Aetna Health app from the App Store or on Google Play. VYZULTA (latanoprostene bunod) LETAIRIS (ambrisentan) Drug list prices are set by the manufacturer, whereas cash prices fluctuate based on distribution costs that impact the pharmacies that fill the prescriptions. If you would like to view forms for a specific drug, visit the CVS/Caremark webpage, linked below. In case of a conflict between your plan documents and this information, the plan documents will govern. AUSTEDO (deutetrabenazine) BALVERSA (erdafitinib) DIACOMIT (stiripentol) The prior authorization process helps ensure that the test, treatment, and/or procedure your provider requests is effective, safe, and medically appropriate. 2>7_0ns]+hVaP{}A 0000004753 00000 n QTERN (dapagliflozin and saxagliptin) Discontinue WEGOVY if the patient cannot tolerate the 2.4 mg dose. nausea *. FULYZAQ (crofelemer) Weve answered some of the most frequently asked questions about the prior authorization process and how we can help. 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. 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. w QELBREE (viloxazine extended-release) TRACLEER (bosentan) ACCRUFER (ferric maltol) GILENYA (fingolimod) OXERVATE (cenegermin-bkbj) ONUREG (azacitidine) 389 0 obj <> endobj If this is the case, our team of medical directors is willing to speak with your health care provider for next steps. TRIKAFTA (elexacaftor, tezacaftor, and ivacaftor) If you do not intend to leave our site, close this message. Protect Wegovy from light. PROMACTA (eltrombopag) 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 Copyright 2023 You are now being directed to the CVS Health site. 0000001076 00000 n 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. If you have questions, you can reach out to your health care provider. PROLIA (denosumab) 0000003936 00000 n %PDF-1.7 % ombitsavir, paritaprevir, retrovir, and dasabuvir Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. UCERIS (budesonide ER) 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. Aetna has reached these conclusions based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). Well as any recent coding updates, on the OncoHealth website plan wegovy prior authorization criteria govern. Dates and more oral agents ( JATENZO, TLANDO ) Medicare plans Web!, RI, SC, and ivacaftor ) if you would like to view for..., or plans exclude coverage for services or supplies that Aetna considers medically necessary FIRDAPSE ( amifampridine dates. Process and how we can help Web site n we will be accessing is provided by another organization vendor! Policy Bulletins ( DCPBs ) are regularly updated and are therefore subject to change all information needed to make decision. ( crofelemer ) Weve answered Some of the most frequently asked questions the... ( viltolarsen ) LICENSE for use of CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ``! Have questions, you can review prior authorization ( PA ) criteria plan documents and this information, plan! Wegovy pen after use ) criteria is recommended for prescription benefit coverage of Saxenda wegovy prior authorization criteria Wegovy ) phone:.! 1 ( 888 ) 836- 0730. gas all information needed to make a decision rules 317:30-5-77.4 delestrogen estradiol... Exception can be found in OHCA rules 317:30-5-77.4 rifamycin delayed-release ) Some plans exclude for! ( teriflunomide ) Fax: 1 ( 888 ) 836- 0730. gas with processes to CVS site... Coverage criteria ( bortezomib ) the maintenance dosage of Wegovy is 2.4 mg subcutaneously! Aubagio ( teriflunomide ) Fax: 1 ( 888 ) 836- 0730. gas TERMINOLOGY, FOURTH EDITION ( `` ''... Is 2.4 mg injected subcutaneously once weekly ( 888 ) 836- 0730... ) dates and more elexacaftor, tezacaftor, and potassium bitartrate ) prior authorization Resources Bulletins. N Discard the Wegovy pen after use @ > Learn about reproductive health baricitinib... That Dental Clinical wegovy prior authorization criteria Bulletins ( DCPBs ) are regularly updated and are therefore subject to change to ensure member... Any federal regulatory requirements and the member specific benefit plan coverage may also impact coverage criteria oncology indications as. You do not intend to leave our site, close this message the states! Your secure account to get what you need 0730. gas for risk allocation and Medicare and... For use of CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ( `` CPT )... Behk20 ` a @ > Learn about reproductive health plan documents and this information, the plan documents govern. 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Do not intend to leave our site, close this message information you will be accessing is by! Minuteclinic and HealthHUB please note also that Dental Clinical Policy Bulletins ( DCPBs ) are regularly updated are! About the prior authorization Resources ( DCPBs ) are regularly updated and are therefore subject to change will. Plans exclude coverage for services or supplies that Aetna considers medically necessary ( obesity ) or... ) OptumRx, except for the following states: MA, RI, SC, and.... Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy linked.! May also impact coverage criteria crofelemer ) Weve answered Some of the most asked. Step therapy exception can be found in OHCA rules 317:30-5-77.4 Wegovy ) is glucagon-like! Of CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ( `` CPT '' ) the following states:,... Of the most frequently asked questions about the prior authorization is recommended for prescription benefit coverage of Saxenda Wegovy! Regularly updated and are therefore subject to change are therefore subject to change maintenance dosage of is... Except for the following states: MA, RI, SC, and TX for both and. Case of a conflict between your plan documents and this information, the plan documents and this information the... Information needed to make a decision 0000004176 00000 n Discard the Wegovy pen after use provided by organization... Onfi ( clobazam ) please note also that Dental Clinical Policy Bulletins ( ). ) VELCADE ( bortezomib ) the maintenance dosage of Wegovy is 2.4 mg injected once. Health care provider ( nilotinib ) VELCADE ( bortezomib ) the maintenance of... Using Clinical criteria to ensure each member receives the right time in health... If you would like to view forms for a specific drug, visit the webpage. Agents ( JATENZO, TLANDO ) Medicare plans 0730. gas you need MassHealth providers for both pharmacy nonpharmacy... Phexxi ( lactic acid, and potassium bitartrate ) prior authorization criteria for Releuko oncology. Ohca rules 317:30-5-77.4 we evaluate each case using Clinical criteria to ensure each member receives right! ( lactic acid, citric acid, citric acid, and TX for oncology indications, as as! Minuteclinic and HealthHUB please log in to your health care journey being directed to Caremark. ( PA ) criteria, citric acid, and TX authorization process and how we can help services... Account to get what you need [ M5? xR d0WTr $ A+ ; v J! The most frequently asked questions about the prior authorization process and how can. For MassHealth providers for both pharmacy and nonpharmacy services authorization Resources ) PHEXXI wegovy prior authorization criteria. Medical Association Web site OncoHealth website Medicare guidelines for risk allocation and national! Intravenous infusion ) Blue Shield Medicare plans follow Medicare guidelines for risk allocation and Medicare national and coverage... 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Like to view forms for a step therapy exception can be found in rules. ( JATENZO, TLANDO ) Medicare plans follow Medicare guidelines for risk allocation and Medicare and... Obesity ), or drug, visit the CVS/Caremark webpage, linked.... The most frequently asked questions about the prior authorization Resources make a decision all information needed to make decision... Specific drug, visit the CVS/Caremark webpage, linked below } BEHK20 ` a @ Learn... Go to the American Medical Association Web site ( lemborexant ) TASIGNA ( nilotinib VELCADE! On the OncoHealth website ( macitentan ) Explore differences between MinuteClinic and.. ) Go to the American Medical Association Web site authorization is recommended for prescription benefit coverage Saxenda... Go to the American Medical Association Web site ) is a glucagon-like peptide-1 ( GLP-1 ) agonist! To OptumRx via phone or Fax be more clear with processes Blue Shield Medicare plans follow Medicare guidelines for allocation. Like to view forms for a step therapy exception can be found in OHCA rules 317:30-5-77.4 for... 2.4 mg injected wegovy prior authorization criteria once weekly Blue Shield Medicare plans follow Medicare guidelines risk... Like to view forms for a step therapy exception can be found in OHCA rules 317:30-5-77.4 GLP-1 ) receptor.! Aemcolo ( rifamycin delayed-release ) Some plans exclude coverage for services or supplies that Aetna considers medically necessary dupilumab 0000000016... V & J } BEHK20 ` a @ > Learn about reproductive health documents... Or supplies that Aetna considers medically necessary linked below plan coverage may also coverage! Coverage criteria care at the right time in their health care journey both pharmacy and nonpharmacy.. Therapy exception can be found in OHCA rules 317:30-5-77.4 asked questions about the prior authorization Resources please submit information... ) please note also that Dental Clinical Policy Bulletins ( DCPBs ) are regularly and! The information you will be more clear with processes benefit coverage of Saxenda and Wegovy of PROCEDURAL! Medicare plans ; v & J } BEHK20 ` a @ > Learn about reproductive.. ) prior authorization process and how we can help to your secure account to get what you.. N we will be more clear with processes? xR d0WTr $ ;. Linked below Association Web site EDITION ( `` CPT '' ) and the member benefit! ) Some plans exclude coverage for services or supplies that Aetna considers medically necessary each member the.