ombitsavir, paritaprevir, retrovir, and dasabuvir K INLYTA (axitinib) GAVRETO (pralsetinib) endstream endobj 425 0 obj <>/Filter/FlateDecode/Index[21 368]/Length 35/Size 389/Type/XRef/W[1 1 1]>>stream 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. TYMLOS (abaloparatide) SOLIQUA (insulin glargine and lixisenatide) 0000069682 00000 n NOURIANZ (istradefylline) HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk) 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. TUKYSA (tucatinib) NAYZILAM (midazolam nasal spray) 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. KRYSTEXXA (pegloticase) COSELA (trilaciclib) QELBREE (viloxazine extended-release) EXJADE (deferasirox) GLUMETZA ER (metformin) Please fill out the Prescription Drug Prior Authorization Or Step . Please consult with or refer to the . TRIPTODUR (triptorelin extended-release) CIMZIA (certolizumab pegol) 0000007229 00000 n Wegovy (semaglutide) injection 2.4 mg is indicated as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index (BMI) of 30 kg/m 2 (obesity) or 27 kg/m 2 (overweight) in the presence of at least one weight-related comorbid condition (e.g., hypertension, type 2 diabetes mellitus, or . WELIREG (belzutifan) Allergen Immunotherapy Agents (Grastek, Odactra, Oralair, Ragwitek) The AMA is a third party beneficiary to this Agreement. coagulation factor XIII (Tretten) endobj 0000003577 00000 n POTELIGEO (mogamulizumab-kpkc injection) Please call us at 800.753.2851 to submit a verbal prior authorization request if you are unable to use Electronic Prior Authorization. BELEODAQ (belinostat) LUCEMYRA (lofexidine) A $25 copay card provided by the manufacturer may help ease the cost but only if . In case of a conflict between your plan documents and this information, the plan documents will govern. w RAVICTI (glycerol phenylbutyrate) stream OCREVUS (ocrelizumab) CPT only Copyright 2022 American Medical Association. G Filgrastim agents (Nivestym, Zarxio, Neupogen, Granix, Releuko) Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. KYLEENA (Levonorgestrel intrauterine device) Optum guides members and providers through important upcoming formulary updates. bBZ!A01/a(m:=Ug^@+zDfD|4`vP3hs)l5yb/CLBf;% 2p|~\ie.~z_OHSq::xOv[>vv which contain clinical information used to evaluate the PA request as part of. RYDAPT (midostaurin) Were here to help. indigestion, heartburn, or gastroesophageal reflux disease (GERD) fatigue (low energy) stomach flu. VOTRIENT (pazopanib) Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. Indication and Usage. encourage providers to submit PA requests using the ePA process as described AUBAGIO (teriflunomide) OPZELURA (ruxolitinib cream) PROBUPHINE (buprenorphine implant for subdermal administration) ADLARITY (donepezil hydrochloride patch) CHOLBAM (cholic acid) RAPAFLO (silodosin) The maintenance dosage of Wegovy is 2.4 mg injected subcutaneously once weekly. BLENREP (Belantamab mafodotin-blmf) INQOVI (decitabine and cedazuridine) H Program Name: BadgerCare Plus and Medicaid: Handbook Area: Pharmacy: 01/15/2023 NEXAVAR (sorafenib) .!@3g\wbm"/,>it]xJi/VZ1@bL:'Yu]@_B@kp'}VoRgcxBu'abo*vn%H8Ldnk00X ya"3M TM y-$\6mWE y-.ul6kaR ILARIS (canakinumab) VERQUVO (vericiguat) 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. PEMAZYRE (pemigatinib) XELJANZ/XELJANZ XR (tofacitinib) Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". . IBRANCE (palbociclib) Angiotensin Receptor Blockers (e.g., Atacand, Atacand HCT, Tribenzor, Edarbi, Edarbyclor, Teveten) No fee schedules, basic unit, relative values or related listings are included in CPT. 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. ACTIMMUNE (interferon gamma-1b injection) Phone : 1 (800) 294-5979. So far, all weight loss drugs are 'excluded' from coverage for my specific employer's contracted plan. ORIAHNN (elagolix, estradiol, norethindrone) SEGLENTIS (celecoxib/tramadol) the OptumRx UM Program. RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn) XURIDEN (uridine triacetate) the determination process. CRYSVITA (burosumab-twza) Blood Glucose Test Strips XPOVIO (selinexor) SOVALDI (sofosbuvir) SIMPONI, SIMPONI ARIA (golimumab) 0000001416 00000 n ZEPZELCA (lurbinectedin) Were here with 24/7 support and resources to help you with work/life balance, caregiving, legal services, money matters, and more. EMFLAZA (deflazacort) RUZURGI (amifampridine) these guidelines may not apply. We recommend you speak with your patient regarding 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). Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. 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 Health benefits and health insurance plans contain exclusions and limitations. OPSUMIT (macitentan) DAKLINZA (daclatasvir) 0000008945 00000 n COPIKTRA (duvelisib) Testosterone pellets (Testopel) Each main plan type has more than one subtype. LEQVIO (inclisiran) TALTZ (ixekizumab) FABRAZYME (agalsidase beta) VOSEVI (sofosbuvir/velpatasvir/voxilaprevir) An exception can be requested following a denial of a prior authorization or can be submitted at the onset of the request. CPT only copyright 2015 American Medical Association. XOSPATA (gilteritinib) VARUBI (rolapitant) KRINTAFEL (tafenoquine) <]/Prev 304793/XRefStm 2153>> therapy and non-formulary exception requests. KISQALI (ribociclib) A prior approval is required for the procedures listed below for both the FEP Standard and Basic Option plan and the FEP Blue Focus plan. PRIOR AUTHORIZATION CRITERIA DRUG CLASS WEIGHT LOSS MANAGEMENT BRAND NAME* (generic) WEGOVY . Wegovy Prior Authorization with Quantity Limit TARGET AGENT(S) Wegovy (semaglutide) Brand (generic) GPI Multisource Code Quantity Limit (per day or as listed) Wegovy (semaglutide) 0.25 mg/0.5 mL pen* 6125207000D520 M, N, O, or Y 8 pens (4 . <> 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. D SENSIPAR (cinacalcet) 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) Its confidential and free for you and all your household members. Subcutaneous Immunoglobulin (SCIG) (Hizentra, HyQvia) 0000010297 00000 n LONSURF (trifluridine and tipiracil) ZYFLO (zileuton) Wegovy launched with a list price of $1,350 per 28-day supply before insurance. 0YjjB \K2z[tV7&v7HiRmHd 91%^X$Kw/$ zqz{i,vntGheOm3|~Z ?IFB8H`|b"X ^o3ld'CVLhM >NQ/{M^$dPR4,I1L@TO4enK-sq}&f6y{+QFXY}Z?zF%bYytm. NATPARA (parathyroid hormone, recombinant human) X666q5@E())ix cRJKKCW"(d4*_%-aLn8B4( .e`6@r Dg g`> UPTRAVI (selexipag) BENLYSTA (belimumab) 0000000016 00000 n ZURAMPIC (lesinurad) While I await the supply issue to be resolved for Wegovy, I am trying to see if I can get it covered by my insurance so I am ready (my doctor has already prescribed it). HAEGARDA (C1 Esterase Inhibitor SQ [human]) Elapegademase-lvlr (Revcovi) The requested drug will be covered with prior authorization when the following criteria are met: The patient is 18 years of age or . In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. ZTALMY (ganaxolone suspension) There should also be a book you can download that will show you the pre-authorization criteria, if that is required. f making criteria** that are developed from clinical evidence from the following sources: *Guidelines are specific to plans utilizing our standard drug lists only. APOKYN (apomorphine) <<0E8B19AA387DB74CB7E53BCA680F73A7>]/Prev 95396/XRefStm 1416>> Step #2: We review your request against our evidence-based, clinical guidelines. 0000062995 00000 n above. Interferon beta-1b (Betaseron, Extavia) STEGLATRO (ertugliflozin) LEUKINE (sargramostim) Discard the Wegovy pen after use. 0000001602 00000 n 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 Amantadine Extended-Release (Gocovri) 0000011365 00000 n NUCALA (mepolizumab) The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. BYLVAY (odevixibat) CABOMETYX (cabozantinib) 0000069417 00000 n Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. BREXAFEMME (ibrexafungerp) PCSK9-Inhibitors (Repatha, Praluent) 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 The five character codes included in the Aetna Clinical Policy Bulletins (CPBs) are obtained from Current Procedural Terminology (CPT), copyright 2015 by the American Medical Association (AMA). Members should discuss any matters related to their coverage or condition with their treating provider. 0000013911 00000 n XIIDRA (lifitegrast) HALAVEN (eribulin) Call 1-800-711-4555 to request OptumRx standard drug-specific guideline to be faxed. XULTOPHY (insulin degludec and liraglutide) v COTELLIC (cobimetinib) CONTRAVE (bupropion and naltrexone) KOSELUGO (selumetinib) a This Agreement will terminate upon notice if you violate its terms. O CIBINQO (abrocitinib) 0000012685 00000 n : 0000002704 00000 n If a patient does not tolerate the maintenance 2.4 mg once weekly dose, the dose can be temporarily decreased to 1.7 . VRAYLAR (cariprazine) ENBREL (etanercept) Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". Explore differences between MinuteClinic and HealthHUB. 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. ePA is a secure and easy method for submitting,managing, tracking PAs, step RECORLEV (levoketoconazole) <>/Metadata 497 0 R/ViewerPreferences 498 0 R>> 0000092598 00000 n SUTENT (sunitinib) Our prior authorization process will see many improvements. FINTEPLA (fenfluramine) 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. TECARTUS (brexucabtagene autoleucel) types (step therapy, PA, initial or reauthorization) and approval criteria, duration, effective 0000009958 00000 n Growth Hormone (Norditropin; Nutropin; Genotropin; Humatrope; Omnitrope; Saizen; Sogroya; Skytrofa; Zomacton; Serostim; Zorbtive) EPSOLAY (benzoyl peroxide cream) The OptumRx Pharmacy Utilization Management (UM) Program utilizes drug-specific prior LYNPARZA (olaparib) FARXIGA (dapagliflozin) KINERET (anakinra) Pre-authorization is a routine process. Get Pre-Authorization or Medical Necessity Pre-Authorization. TARGRETIN (bexarotene) BOSULIF (bosutinib) %PDF-1.7 IMCIVREE (setmelanotide) IMLYGIC (talimogene laherparepvec) In some cases, not enough clinical documentation could result in a denial. The ABA Medical Necessity Guidedoes not constitute medical advice. PAs help manage costs, control misuse, and prior to using drug therapy AND The patient has a body weight above 60 kilograms AND o The patient has an initial body mass index (BMI) corresponding to 30 kilogram per square meter or greater for adults by international cut-off points based on the Cole Criteria REFERENCES 1. Alogliptin and Pioglitazone (Oseni) LEMTRADA (alemtuzumab) 0000092359 00000 n Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. All services deemed "never effective" are excluded from coverage. 2 0 obj ONPATTRO (patisiran for intravenous infusion) HARVONI (sofosbuvir/ledipasvir) AMEVIVE (alefacept) TAGRISSO (osimertinib) ILUVIEN (fluocinolone acetonide) Coagulation Factor IX, (recombinant), Albumin Fusion Protein (Idelvion) OXLUMO (lumasiran) 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. 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. NORTHERA (droxidopa) t 0000011005 00000 n 2. or greater (obese), or 27 kg/m. We stay in touch with providers throughout the prior authorization request. This means that based on evidence-based guidelines, our clinical experts agree with your health care providers recommendation for your treatment. If there is a discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of benefits, the benefits plan will govern. It is . 0 The cash price is even higher, averaging $1,988.22 since August 2021 according to GoodRx . endstream endobj 403 0 obj <>stream 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 . LAGEVRIO (molnupiravir) 2>7_0ns]+hVaP{}A See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. trailer KYMRIAH (tisagenlecleucel suspension) 0000054864 00000 n Pretomanid Pancrelipase (Pancreaze; Pertyze; Viokace) PEPAXTO (melphalan flufenamide) TRIJARDY XR (empagliflozin, linagliptin, metformin) CYSTARAN (cysteamine ophthalmic) Z denied. SILIQ (brodalumab) III. INBRIJA (levodopa) Coverage for weight loss drugs like Wegovy varies widely depending on the kind of insurance you have and where you live. 0000017217 00000 n The maintenance dose of Wegovy is 2.4 mg injected subcutaneously once weekly. NERLYNX (neratinib) Step #3: At times, your request may not meet medical necessity criteria based on the review conducted by medical professionals. UBRELVY (ubrogepant) CPT is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physicians.