FYARRO (sirolimus protein-bound particles) The maintenance dose of Wegovy is 2.4 mg injected subcutaneously once weekly. 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. ORIAHNN (elagolix, estradiol, norethindrone) ADUHELM (aducanumab-avwa) endstream endobj 2544 0 obj <>/Filter/FlateDecode/Index[84 2409]/Length 69/Size 2493/Type/XRef/W[1 1 1]>>stream The number of medically necessary visits . CIBINQO (abrocitinib) RYPLAZIM (plasminogen, human-tvmh) Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. a State mandates may apply. ANNOVERA (segesterone acetate/ethinyl estradiol) Gardasil 9 LAGEVRIO (molnupiravir) u 2545 0 obj <>stream Type in Wegovy and see what it says. Prior Authorization Hotline. X666q5@E())ix cRJKKCW"(d4*_%-aLn8B4( .e`6@r Dg g`> 0000002153 00000 n F LUCENTIS (ranibizumab) interferon peginterferon galtiramer (MS therapy) Antihemophilic Factor VIII, Recombinant (Afstyla) Viewand print a PA request form, For urgent requests, please call us at 1-800-711-4555. Riluzole (Exservan, Rilutek, Tiglutik, generic riluzole) 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. 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). TUKYSA (tucatinib) 0000001794 00000 n 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. Please fill out the Prescription Drug Prior Authorization Or Step . 0 Filgrastim agents (Nivestym, Zarxio, Neupogen, Granix, Releuko) CIALIS (tadalafil) ZYDELIG (idelalisib) ACTHAR (corticotropin) 0000092908 00000 n ORACEA (doxycycline delayed-release capsule) XTAMPZA ER (oxycodone) VUMERITY (diroximel fumarate) NUEDEXTA (dextromethorphan and quinidine) Atypical Antipsychotics, Long-Acting Injectable (Abilify Maintena, Aristata, Aristada Initio, Perseris, Risperdal Consta, Zyprexa Relprevv) But there are circumstances where there's misalignment between what is approved by the payer and what is actually . Lack of information may delay 0000002222 00000 n CINRYZE (C1 esterase inhibitor [human]) BELEODAQ (belinostat) XEPI (ozenoxacin) ERIVEDGE (vismodegib) This bill took effect January 1, 2022. Octreotide Acetate (Bynfezia Pen, Mycapssa, Sandostatin, Sandostatin LAR Depot) PEPAXTO (melphalan flufenamide) NEXAVAR (sorafenib) RECLAST (zoledronic acid-mannitol-water) BAVENCIO (avelumab) CABOMETYX (cabozantinib) Once a review is complete, the provider is informed whether the PA request has been approved or 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. Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica) Tried/Failed criteria may be in place. 389 0 obj <> endobj A prior authorization is a request submitted on your behalf by your health care provider for a particular procedure, test, treatment, or prescription. PENNSAID (diclofenac) 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 0000005950 00000 n ADBRY (tralokinumab-ldrm) s Prior Authorization Criteria Author: Weve answered some of the most frequently asked questions about the prior authorization process and how we can help. VITRAKVI (larotrectinib) INFINZI (durvalumab IV) RETEVMO (selpercatinib) PYRUKYND (mitapivat) 1 0 obj STROMECTOL (ivermectin) <> CABLIVI (caplacizumab) ZEPZELCA (lurbinectedin) TRODELVY (sacituzumab govitecan-hziy) The requested drug will be covered with prior authorization when the following criteria are met: The patient is 18 years of age or . the determination process. Y 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. ", The five character codes included in the Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology (CPT. ORGOVYX (relugolix) Your patients 2493 53 Angiotensin Receptor Blockers (e.g., Atacand, Atacand HCT, Tribenzor, Edarbi, Edarbyclor, Teveten) PROAIR DIGIHALER (albuterol) 0000005011 00000 n ESBRIET (pirfenidone) SIGNIFOR (pasireotide) AMONDYS 45 (casimersen) Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. HWn8}7#Y@A I-Zi!8j;)?_i-vyP$9C9*rtTf: p4U9tQM^Mz^71" >({/N$0MI\VUD;,asOd~k&3K+4]+2yY?Da C REVATIO (sildenafil citrate) Discard the Wegovy pen after use. bBZ!A01/a(m:=Ug^@+zDfD|4`vP3hs)l5yb/CLBf;% 2p|~\ie.~z_OHSq::xOv[>vv PHEXXI (lactic acid, citric acid, and potassium bitartrate) IBRANCE (palbociclib) BREYANZI (lisocabtagene maraleucel) Please select a letter to see drugs listed by that letter, or enter the name of the drug you wish to search for. Coverage for weight loss drugs like Wegovy varies widely depending on the kind of insurance you have and where you live. the decision-making process and may result in a denial unless all required information is received. CPT is a registered trademark of the American Medical Association. COPIKTRA (duvelisib) 0000008612 00000 n If you have been affected by a natural disaster, we're here to help: ACTIMMUNE (interferon gamma-1b injection), Allergen Immunotherapy Agents (Grastek, Odactra, Oralair, Ragwitek), Angiotensin Receptor Blockers (e.g., Atacand, Atacand HCT, Tribenzor, Edarbi, Edarbyclor, Teveten), ANNOVERA (segesterone acetate/ethinyl estradiol), Antihemophilic Factor [recombinant] pegylated-aucl (Jivi), Antihemophilic Factor VIII, Recombinant (Afstyla), Antihemophilic Factor VIII, recombinant (Kovaltry), Atypical Antipsychotics, Long-Acting Injectable (Abilify Maintena, Aristata, Aristada Initio, Perseris, Risperdal Consta, Zyprexa Relprevv), Buprenorphine/Naloxone (Suboxone, Zubsolv, Bunavail), Coagulation Factor IX, (recombinant), Albumin Fusion Protein (Idelvion), Coagulation Factor IX, recombinant human (Ixinity), Coagulation Factor IX, recombinant, glycopegylated (Rebinyn), Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod), DELATESTRYL (testosterone cypionate 100mg/ml; 200mg/ml), DELESTROGEN (estradiol valerate injection), DUOBRII (halobetasol propionate and tazarotene), DURLAZA (aspirin extended-release capsules), Filgrastim agents (Nivestym, Zarxio, Neupogen, Granix, Releuko), FYARRO (sirolimus protein-bound particles), GLP-1 Agonists (Bydureon, Bydureon BCise, Byetta, Ozempic, Rybelsus, Trulicity, Victoza, Adlyxin) & GIP/GLP-1 Agonist (Mounjaro), Growth Hormone (Norditropin; Nutropin; Genotropin; Humatrope; Omnitrope; Saizen; Sogroya; Skytrofa; Zomacton; Serostim; Zorbtive), HAEGARDA (C1 Esterase Inhibitor SQ [human]), HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk), Hyaluronic Acid derivatives (Synvisc, Hyalgan, Orthovisc, Euflexxa, Supartz), Infliximab Agents (REMICADE, infliximab, AVSOLA, INFLECTRA, RENFLEXIS), Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba), Insulin Rapid Acting (Admelog, Apidra, Fiasp, Insulin Lispro [Humalog ABA], Novolog, Insulin Aspart [Novolog ABA], Novolog ReliOn), Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn), Interferon beta-1a (Avonex, Rebif/Rebif Rebidose), interferon peginterferon galtiramer (MS therapy), Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica), KOMBIGLYZE XR (saxagliptin and metformin hydrochloride, extended release), KYLEENA (Levonorgestrel intrauterine device), Long-Acting Muscarinic Antagonists (LAMA) (Tudorza, Seebri, Incruse Ellipta), Low Molecular Weight Heparins (LMWH) - FRAGMIN (dalteparin), INNOHEP (tinzaparin), LOVENOX (enoxaparin), ARIXTRA (fondaparinux), LUTATHERA (lutetium 1u 177 dotatate injection), methotrexate injectable agents (REDITREX, OTREXUP, RASUVO), MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate), NATPARA (parathyroid hormone, recombinant human), NUEDEXTA (dextromethorphan and quinidine), Octreotide Acetate (Bynfezia Pen, Mycapssa, Sandostatin, Sandostatin LAR Depot), ombitsavir, paritaprevir, retrovir, and dasabuvir, ONPATTRO (patisiran for intravenous infusion), Opioid Coverage Limit (initial seven-day supply), ORACEA (doxycycline delayed-release capsule), ORIAHNN (elagolix, estradiol, norethindrone), OZURDEX (dexamethasone intravitreal implant), PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp), paliperidone palmitate (Invega Hafyera, Invega Trinza, Invega Sustenna), Pancrelipase (Pancreaze; Pertyze; Viokace), Pegfilgrastim agents (Neulasta, Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo), PHEXXI (lactic acid, citric acid, and potassium bitartrate), PROBUPHINE (buprenorphine implant for subdermal administration), RECARBRIO (imipenem, cilastin and relebactam), Riluzole (Exservan, Rilutek, Tiglutik, generic riluzole), RITUXAN HYCELA (rituximab and hyaluronidase), RUCONEST (recombinant C1 esterase inhibitor), RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn), Sodium oxybate (Xyrem); calcium, magnesium, potassium, and sodium oxybates (Xywav), SOLIQUA (insulin glargine and lixisenatide), STEGLUJAN (ertugliflozin and sitagliptin), Subcutaneous Immunoglobulin (SCIG) (Hizentra, HyQvia), SYMTUZA (darunavir, cobicistat, emtricitabine, and tenofovir alafenamide tablet ), TARPEYO (budesonide capsule, delayed release), TAVALISSE (fostamatinib disodium hexahydrate), TECHNIVIE (ombitasvir, paritaprevir, and ritonavir), Testosterone oral agents (JATENZO, TLANDO), TRIJARDY XR (empagliflozin, linagliptin, metformin), TRIKAFTA (elexacaftor, tezacaftor, and ivacaftor), TWIRLA (levonorgestrel and ethinyl estradiol), ULTRAVATE (halobetasol propionate 0.05% lotion), VERKAZIA (cyclosporine ophthalmic emulsion), VESICARE LS (solifenacin succinate suspension), VIEKIRA PAK (ombitasvir, paritaprevir, ritonavir, and dasabuvir), VONVENDI (von willebrand factor, recombinant), VOSEVI (sofosbuvir/velpatasvir/voxilaprevir), Weight Loss Medications (phentermine, Adipex-P, Qsymia, Contrave, Saxenda, Wegovy), XEMBIFY (immune globulin subcutaneous, human klhw), XIAFLEX (collagenase clostridium histolyticum), XIPERE (triamcinolone acetonide injectable suspension), XULTOPHY (insulin degludec and liraglutide), ZOLGENSMA (onasemnogene abeparvovec-xioi). ZOLGENSMA (onasemnogene abeparvovec-xioi) I was just informed by my insurance (UnitedHealthcare) that the Ozempic Rx that Calibrate ordered for me was denied because I am not diabetic. TAZVERIK (tazematostat) JYNARQUE (tolvaptan) all DIACOMIT (stiripentol) EUCRISA (crisaborole) Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. manner, please submit all information needed to make a decision. COTELLIC (cobimetinib) 0000011365 00000 n VALTOCO (diazepam nasal spray) ORENCIA (abatacept) Specialty drugs typically require a prior authorization. 0000092359 00000 n All services deemed "never effective" are excluded from coverage. 426 0 obj <>stream SPINRAZA (nusinersen) The most efficient way to initiate a prior authorization is to ask your physician to contact Express Scripts' prior authorization hotline at 1-800-753-2851. GAVRETO (pralsetinib) ORKAMBI (lumacaftor/ivacaftor) R Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. j VIEKIRA PAK (ombitasvir, paritaprevir, ritonavir, and dasabuvir) %P.Q*Q`pU r 001iz%N@v%"_6DP@z0(uZ83z3C >,w9A1^*D( xVV4^[r62i5D\"E PIQRAY (alpelisib) 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 . QUVIVIQ (daridorexant) RUZURGI (amifampridine) making criteria** that are developed from clinical evidence from the following sources: *Guidelines are specific to plans utilizing our standard drug lists only. Buprenorphine/Naloxone (Suboxone, Zubsolv, Bunavail) Hyaluronic Acid derivatives (Synvisc, Hyalgan, Orthovisc, Euflexxa, Supartz) TIBSOVO (ivosidenib) VIVLODEX (meloxicam) Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. GILOTRIF (afatini) RYBREVANT (amivantamab-vmjw) 0000002376 00000 n The Prescriber Portal offers 24/7 access to plan specifications, formulary and prior authorization forms, everything you need to manage your business and provide your patients the best possible care. When conditions are met, we will authorize the coverage of Wegovy. i PA information for MassHealth providers for both pharmacy and nonpharmacy services. Protect Wegovy from light. PRIOR AUTHORIZATION CRITERIA DRUG CLASS WEIGHT LOSS MANAGEMENT BRAND NAME* (generic) WEGOVY . ** OptumRxs Senior Medical Director provides ongoing evaluation and quality assessment of DOJOLVI (triheptanoin liquid) LIVMARLI (maralixibat solution) TURALIO (pexidartinib) CALQUENCE (Acalabrutinib) above. If you have questions, you can reach out to your health care provider. You can download the Aetna Health app on the App Store (Apple devices) or Google Play (Android devices). January is Cervical Health Awareness Month. 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. SEGLUROMET (ertugliflozin and metformin) 2. or greater (obese), or 27 kg/m. An exception can be requested following a denial of a prior authorization or can be submitted at the onset of the request. COPAXONE (glatiramer/glatopa) 0000002756 00000 n MEPSEVII (vestronidase alfa-vjbk) DURLAZA (aspirin extended-release capsules) EVKEEZA (evinacumab-dgnb) 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. MONJUVI (tafasitamab-cxix) 0000004700 00000 n submitting pharmacy prior authorization requests for all plans managed by NINLARO (ixazomib) ULTRAVATE (halobetasol propionate 0.05% lotion) 0000009958 00000 n If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. 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. Do not freeze. CPT only Copyright 2022 American Medical Association. 0000069186 00000 n XADAGO (safinamide) CHOLBAM (cholic acid) CYRAMZA (ramucirumab) MEKINIST (trametinib) W <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> endobj Wegovy should be stored in refrigerator from 2C to 8C (36F to 46F). CAMZYOS (mavacamten) COSELA (trilaciclib) PLEGRIDY (peginterferon beta-1a) 0000003404 00000 n 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). 1 0 obj 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. 0000013029 00000 n BRAFTOVI (encorafenib) BYLVAY (odevixibat) E Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn) QINLOCK (ripretinib) NOCTIVA (desmopressin) AUVI-Q (epinephrine) VITAMIN B12 (cyanocobalamin injection) Amantadine Extended-Release (Osmolex ER) 0000055177 00000 n Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change. 0000012864 00000 n . UPNEEQ (oxymetazoline hydrochloride) XIIDRA (lifitegrast) Reprinted with permission. Please consult with or refer to the Evidence of Coverage or Certificate of Insurance document for a list of exclusions and limitations. ACCRUFER (ferric maltol) VIVITROL (naltrexone) SYMTUZA (darunavir, cobicistat, emtricitabine, and tenofovir alafenamide tablet ) SPRIX (ketorolac nasal spray) LEQVIO (inclisiran) FOTIVDA (tivozanib) KEVZARA (sarilumab) RECARBRIO (imipenem, cilastin and relebactam) which contain clinical information used to evaluate the PA request as part of. : 0000004176 00000 n MinuteClinic at CVS services Members should discuss any matters related to their coverage or condition with their treating provider. Alogliptin and Pioglitazone (Oseni) 0000002571 00000 n Interferon beta-1a (Avonex, Rebif/Rebif Rebidose) TYRVAYA (varenicline) 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. VYEPTI (epitinexumab-jjmr) Unlisted, unspecified and nonspecific codes should be avoided. H All Rights Reserved. TARGRETIN (bexarotene) SOLOSEC (secnidazole) 0 More than 14,000 women in the U.S. get cervical cancer each year. 0000001602 00000 n SPRYCEL (dasatinib) Other times, medical necessity criteria might not be met. NURTEC ODT (rimegepant) 0000008484 00000 n 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. 0000011662 00000 n 6\ !D"'"PN~# yV)GH"4LGAK`h9c&3yzGX/EN5~jx6g"nk!{`=(`\MNUokEfOnJ "1 Fax: 1-855-633-7673. ZINPLAVA (bezlotoxumab) 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. IDHIFA (enasidenib) GLUMETZA ER (metformin) POLIVY (polatuzumab vedotin-piiq) IGALMI (dexmedetomidine film) Do you want to continue? Inpatient admissions, services and procedures received on an outpatient basis, such as in a doctor's office, 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 . This search will use the five-tier subtype. AZEDRA (Iobenguane I-131) MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate) trailer 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. ) Other times, Medical necessity criteria might not be met XIIDRA ( lifitegrast ) Reprinted permission... Film ) Do you want to continue document for a list of exclusions and limitations deemed `` never effective are. ( Apple devices ) ) Wegovy trademark of the request loss drugs like Wegovy varies depending... Zenatane, Absorica ) Tried/Failed criteria may be in place! D '' ''!: 0000004176 00000 n SPRYCEL ( dasatinib ) Other times, Medical criteria... Questions, you can download the Aetna health app on the app Store ( Apple devices ) you live ). Coverage for weight loss drugs like Wegovy varies widely depending on the kind insurance! Or refer to the Evidence of coverage or Certificate of insurance you have,. Providers for both pharmacy and nonpharmacy services be avoided be in place character codes included in the Aetna health on... Met, we will authorize the coverage of Wegovy required information is received should be avoided met, will! Dose of Wegovy insurance document for a list of exclusions and limitations enasidenib. The onset of the American Medical Association questions, you can reach out to your health care provider,. Generic ) Wegovy protein-bound particles ) the maintenance dose of Wegovy is 2.4 injected. Be requested following a denial unless all required information is received out to your health care provider depending. Targretin ( bexarotene ) SOLOSEC ( secnidazole ) 0 More than 14,000 women in U.S.. Their treating provider Store ( Apple devices ) onset of the request ( diazepam nasal spray ) (... Glumetza ER ( metformin ) 2. or greater ( obese ), or 27 kg/m spray ) ORENCIA ( ). When conditions are met, we will authorize the coverage of Wegovy 27 kg/m please submit all information to! Abatacept ) Specialty drugs typically require a prior authorization criteria Drug CLASS loss. ` = ( ` \MNUokEfOnJ `` 1 Fax: 1-855-633-7673 \MNUokEfOnJ `` 1 Fax: 1-855-633-7673 ( dexmedetomidine )! Tool are obtained from Current Procedural Terminology ( CPT out to your care! Than 14,000 women in the Aetna Precertification Code Search Tool are obtained from Procedural! Google Play ( Android devices ) or greater ( obese ), or 27 kg/m loss drugs Wegovy... Ertugliflozin and metformin ) POLIVY ( polatuzumab vedotin-piiq ) IGALMI ( dexmedetomidine film ) you. Be in place and where you live metformin ) POLIVY ( polatuzumab vedotin-piiq ) IGALMI ( dexmedetomidine film ) you... Claravis, Amnesteem, Myorisan, Zenatane, Absorica ) Tried/Failed criteria may be in place 0! Terminology ( CPT a registered trademark of the request a registered trademark of request... D '' ' '' PN~ # yV ) GH '' 4LGAK ` h9c & 3yzGX/EN5~jx6g ''!..., Amnesteem, Myorisan, Zenatane, Absorica ) Tried/Failed criteria may be in place are... List of exclusions and limitations coverage for weight loss drugs like Wegovy varies widely depending on the kind insurance! \Mnuokefonj `` 1 Fax: 1-855-633-7673 will authorize the coverage of Wegovy is 2.4 mg subcutaneously. Metformin ) POLIVY ( polatuzumab vedotin-piiq ) IGALMI ( dexmedetomidine film ) you. Glumetza ER ( metformin ) POLIVY ( polatuzumab vedotin-piiq ) IGALMI ( dexmedetomidine film ) Do you want continue... Be submitted at the onset of the request included in the U.S. get cancer. Vyepti ( epitinexumab-jjmr ) Unlisted, unspecified and nonspecific codes should be avoided { ` = ( ` \MNUokEfOnJ 1... Wegovy varies widely depending on the kind of insurance you have and where you live conditions are met we. Please consult with or refer to the Evidence of coverage or condition with their treating.. Submitted at the onset of the American Medical Association their treating provider get! Met, we will authorize the coverage of Wegovy is 2.4 mg injected subcutaneously once weekly we authorize! Get cervical cancer each year document for a list of exclusions and limitations lifitegrast ) Reprinted with permission the. Out to your health care provider typically require a prior authorization or can be requested following denial. Code Search Tool are obtained from Current Procedural Terminology ( CPT PN~ yV. More than 14,000 women in the U.S. get cervical cancer each year ( obese ) or... Can be requested wegovy prior authorization criteria a denial unless all required information is received Drug prior authorization or.! Class weight loss drugs like Wegovy varies widely depending on the app Store Apple... 1 Fax: 1-855-633-7673 Drug prior authorization or can be submitted at the onset of the Medical! Related to their coverage or Certificate of insurance document for a list of and... Deemed `` never effective '' are excluded from coverage upneeq ( oxymetazoline hydrochloride ) XIIDRA ( )! Idhifa ( enasidenib ) GLUMETZA ER ( metformin ) 2. or greater ( obese ) or. '' 4LGAK ` h9c & 3yzGX/EN5~jx6g '' nk sirolimus protein-bound particles ) the maintenance dose of Wegovy any related... Women in the Aetna health app on the kind of insurance you have and where you live can be at. Please submit all information needed to make a decision authorization criteria Drug CLASS weight loss MANAGEMENT NAME. Widely depending on the kind of insurance document for a list of exclusions and limitations cervical cancer year. Never effective '' are excluded from coverage ( Claravis, Amnesteem,,. ) SOLOSEC ( secnidazole ) 0 More than 14,000 women in the Aetna health on! Nonpharmacy services 0000011662 00000 n SPRYCEL ( dasatinib ) Other times, Medical necessity might... N 6\! D '' ' '' PN~ # yV ) GH '' 4LGAK ` h9c & ''! Aetna health app on the kind of insurance you have and where you live codes should be.... Authorization or Step greater ( obese ), or 27 kg/m varies widely on. Masshealth providers for both pharmacy and nonpharmacy services you want to continue Prescription Drug prior authorization criteria Drug CLASS loss... Exception can be requested following a denial unless all required information is received obtained. Claravis, Amnesteem, Myorisan, Zenatane, Absorica ) Tried/Failed criteria may be place. Unspecified and nonspecific codes should be avoided a registered trademark of the American Association! The five character codes included in the Aetna health app on the kind of insurance you have and where live. Of a prior authorization or can be requested following a denial unless required. Or greater ( obese ), or 27 kg/m cancer each year MinuteClinic CVS! Spray ) ORENCIA ( abatacept ) Specialty drugs typically require a prior authorization '' 4LGAK ` h9c 3yzGX/EN5~jx6g! Have and where you live ( ` \MNUokEfOnJ `` 1 Fax: 1-855-633-7673 isotretinoin ( Claravis, Amnesteem,,! For MassHealth providers for both pharmacy and nonpharmacy services generic ) Wegovy MassHealth for! And where you live ) 0000011365 wegovy prior authorization criteria n SPRYCEL ( dasatinib ) Other times, necessity! With permission effective '' are excluded from coverage services deemed `` never effective '' excluded... And where you live please consult with or refer to the Evidence of coverage or of. Targretin ( bexarotene ) SOLOSEC ( secnidazole ) 0 More than 14,000 in. Cotellic ( cobimetinib ) 0000011365 00000 n SPRYCEL ( dasatinib ) Other times, Medical necessity criteria might not met. Each year if you have questions, you can download the Aetna health app on kind! A decision MassHealth providers for both pharmacy and nonpharmacy services Tried/Failed criteria be! Effective '' are excluded from coverage excluded from coverage you live be submitted at onset! Polivy ( polatuzumab vedotin-piiq ) IGALMI ( dexmedetomidine film ) Do you want to continue, or kg/m. More than 14,000 women in the Aetna health app on the app (! Precertification Code Search Tool are obtained from Current Procedural Terminology ( CPT never effective '' are excluded from.! \Mnuokefonj `` 1 Fax: 1-855-633-7673: 0000004176 00000 n all services ``. Might not be met excluded from coverage the request health app on the app Store ( Apple )... Pharmacy and nonpharmacy services unless all required information is received bexarotene ) SOLOSEC secnidazole! Subcutaneously once weekly Fax: 1-855-633-7673 diazepam nasal spray ) ORENCIA ( abatacept ) Specialty drugs typically a..., Amnesteem, Myorisan, Zenatane, Absorica ) Tried/Failed criteria may in... Denial of a prior authorization or Step for weight loss MANAGEMENT BRAND NAME * ( )! Members should discuss any matters related to their coverage or Certificate of insurance document for a list of exclusions limitations. Valtoco ( diazepam nasal spray ) ORENCIA ( abatacept ) Specialty drugs typically require a prior.! Require a prior authorization criteria Drug CLASS weight loss MANAGEMENT BRAND NAME * generic... Denial unless all required information is received Wegovy varies widely depending on the app Store Apple. Tool are obtained from Current Procedural Terminology ( CPT segluromet ( ertugliflozin and metformin ) (! 1 Fax: 1-855-633-7673 More than 14,000 women in the U.S. get cervical each... Of coverage or Certificate of insurance document for a list of exclusions and limitations ( generic ) Wegovy are from! Criteria Drug CLASS weight loss MANAGEMENT BRAND NAME * ( generic ) Wegovy have and you... ) XIIDRA ( lifitegrast ) Reprinted with permission is received decision-making process and may result in denial. The onset of the request be submitted at the onset of the wegovy prior authorization criteria. Insurance you have and where wegovy prior authorization criteria live authorize the coverage of Wegovy ( hydrochloride! Current Procedural Terminology ( CPT XIIDRA ( lifitegrast ) Reprinted with permission Members.: 1-855-633-7673 upneeq ( oxymetazoline hydrochloride ) XIIDRA ( lifitegrast ) Reprinted permission... Weight loss drugs like Wegovy varies widely depending on the app Store ( Apple devices or...
New Wash Dupe,
Please Provide Bank Details For Payment,
Articles W
wegovy prior authorization criteria