MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate) Wegovy will be used concomitantly with behavioral modification and a reduced-calorie diet . JUBLIA (efinaconazole) The requested drug will be covered with prior authorization when the following criteria are met: The patient is 18 years of age or . KALYDECO (ivacaftor) Guidelines are based on written objective pharmaceutical UM decision- 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. 0000014745 00000 n KESIMPTA (ofatumumab) ENTYVIO (vedolizumab) WAKIX (pitolisant) ORGOVYX (relugolix) Please select a letter to see drugs listed by that letter, or enter the name of the drug you wish to search for. c Prior review (prior plan approval, prior authorization, prospective review or certification) is the process BCBSNC uses to review the provision of certain medical services and medications against health care management guidelines prior to the services being provided. XELODA (capecitabine) EMPAVELI (pegcetacoplan) The recently passed Prior Authorization Reform Act is helping us make our services even better. 0000002567 00000 n Others have four tiers, three tiers or two tiers. ICLUSIG (ponatinib) No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM. 0000002527 00000 n % 0000002222 00000 n 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. The ABA Medical Necessity Guidedoes not constitute medical advice. GLP-1 Agonists (Bydureon, Bydureon BCise, Byetta, Ozempic, Rybelsus, Trulicity, Victoza, Adlyxin) & GIP/GLP-1 Agonist (Mounjaro) 0000012735 00000 n ILUVIEN (fluocinolone acetonide) EUCRISA (crisaborole) 4 0 obj XEPI (ozenoxacin) Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn) VYLEESI (bremelanotide) AZEDRA (Iobenguane I-131) R Your benefits plan determines coverage. Copyright 2023 v Opioid Coverage Limit (initial seven-day supply) Wegovy, a new prescription medication for chronic weight management, launched with a price tag of around $1,627 a month before insurance. The maintenance dosage of Wegovy is 2.4 mg injected subcutaneously once weekly. TRIPTODUR (triptorelin extended-release) This means that based on evidence-based guidelines, our clinical experts agree with your health care providers recommendation for your treatment. ONFI (clobazam) We strongly MOZOBIL (plerixafor) SUPPRELIN LA (histrelin SC implant) EPSOLAY (benzoyl peroxide cream) W Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. VERZENIO (abemaciclib) LETAIRIS (ambrisentan) XGEVA (denosumab) RYPLAZIM (plasminogen, human-tvmh) rz^6>)@?v": QCd?Pcu Peginterferon ASPARLAS (calaspargase pegol) the OptumRx UM Program. IMCIVREE (setmelanotide) BALVERSA (erdafitinib) 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). Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. 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. 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. A $25 copay card provided by the manufacturer may help ease the cost but only if . IMLYGIC (talimogene laherparepvec) 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. 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. 0000013029 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 Precertification Code Search Tool. no77gaEtuhSGs~^kh_mtK oei# 1\ %PDF-1.7 % Q PYRUKYND (mitapivat) 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. RINVOQ (upadacitinib) Step #2: We review your request against our evidence-based, clinical guidelines. manner, please submit all information needed to make a decision. RECORLEV (levoketoconazole) SHINGRIX (zoster vaccine recombinant) Your patients nausea *. *Praluent is typically excluded from coverage. submitting pharmacy prior authorization requests for all plans managed by CAPLYTA (lumateperone) ePA is a secure and easy method for submitting,managing, tracking PAs, step NURTEC ODT (rimegepant) <>/Metadata 133 0 R/ViewerPreferences 134 0 R>> VOSEVI (sofosbuvir/velpatasvir/voxilaprevir) S 0000004176 00000 n FLECTOR (diclofenac) We evaluate each case using clinical criteria to ensure each member receives the right care at the right time in their health care journey. But there are circumstances where there's misalignment between what is approved by the payer and what is actually . In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government. ROCKLATAN (netarsudil and latanoprost) denied. X [a=CijP)_(z ^P),]y|vqt3!X X B"_?jB+K DAkM5Zq\!rmLlIyn1vH _`a8,hks\Bsr\\MnNLs4d.mp #.&*WS oc>fv 9N58[lF)&9`yE {nW Y &R\qe SYNAGIS (palivizumab) endstream endobj 390 0 obj <>/Metadata 19 0 R/Pages 18 0 R/StructTreeRoot 21 0 R/Type/Catalog/ViewerPreferences 391 0 R>> endobj 391 0 obj <> endobj 392 0 obj <>/MediaBox[0 0 612 792]/Parent 18 0 R/Resources<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI]/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 393 0 obj <> endobj 394 0 obj <> endobj 395 0 obj <> endobj 396 0 obj <> endobj 397 0 obj <> endobj 398 0 obj <> endobj 399 0 obj [352 0 0 0 0 1076 0 0 454 454 636 0 364 454 364 454 636 636 636 636 636 636 636 636 636 636 454 0 0 0 0 0 0 684 686 698 771 632 575 775 751 421 0 0 557 843 748 787 603 787 695 684 616 0 0 989 685 615 0 0 0 0 818 636 0 601 623 521 623 596 352 623 633 272 0 592 272 973 633 607 623 623 427 521 394 633 592 818 592 592 525 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1000] endobj 400 0 obj <> endobj 401 0 obj [342 0 0 0 0 0 0 0 543 543 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 402 0 0 0 0 0 0 776 762 724 830 683 650 811 837 546 0 0 637 948 847 850 733 850 782 710 682 812 764 1128 0 0 692 0 0 0 0 0 0 668 0 588 699 664 422 699 712 342 0 0 342 1058 712 687 699 0 497 593 456 712 650 980 0 651 597] endobj 402 0 obj <>stream IGALMI (dexmedetomidine film) VESICARE LS (solifenacin succinate suspension) AMONDYS 45 (casimersen) TEPMETKO (tepotinib) RANEXA, ASPRUZYO (ranolazine) LUTATHERA (lutetium 1u 177 dotatate injection) RAVICTI (glycerol phenylbutyrate) 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. t INBRIJA (levodopa) VFEND (voriconazole) 0000013580 00000 n ** OptumRxs Senior Medical Director provides ongoing evaluation and quality assessment of Lack of information may delay ACTIMMUNE (interferon gamma-1b injection) This list is subject to change. ADDYI (flibanserin) HAEGARDA (C1 Esterase Inhibitor SQ [human]) ORIAHNN (elagolix, estradiol, norethindrone) 0000055434 00000 n ULTRAVATE (halobetasol propionate 0.05% lotion) TECFIDERA (dimethyl fumarate) 0000011178 00000 n XEMBIFY (immune globulin subcutaneous, human klhw) Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. Inpatient admissions, services and procedures received on an outpatient basis, such as in a doctor's office, DUOBRII (halobetasol propionate and tazarotene) For language services, please call the number on your member ID card and request an operator. DELATESTRYL (testosterone cypionate 100mg/ml; 200mg/ml) 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. SYMDEKO (tezacaftor-ivacaftor) ELYXYB (celecoxib solution) REYVOW (lasmiditan) 0000069922 00000 n WINLEVI (clascoterone) 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 . Buprenorphine/Naloxone (Suboxone, Zubsolv, Bunavail) ZULRESSO (brexanolone) BENLYSTA (belimumab) 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 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). Pharmacy Prior Authorization Guidelines Coverage of drugs is first determined by the member's pharmacy or medical benefit. 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. Coagulation Factor IX, recombinant, glycopegylated (Rebinyn) coagulation factor XIII (Tretten) Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod) CONTRAVE (bupropion and naltrexone) 0000054864 00000 n Saxenda [package insert]. FENORTHO (fenoprofen) BREYANZI (lisocabtagene maraleucel) bBZ!A01/a(m:=Ug^@+zDfD|4`vP3hs)l5yb/CLBf;% 2p|~\ie.~z_OHSq::xOv[>vv OhV\0045| 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). ENBREL (etanercept) ESBRIET (pirfenidone) ), 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. All Rights Reserved. PROBUPHINE (buprenorphine implant for subdermal administration) LIVTENCITY (maribavir) increase WEGOVY to the maintenance 2.4 mg once weekly. You are now being directed to CVS Caremark site. ACTEMRA (tocilizumab) MAYZENT (siponimod) PRIOR AUTHORIZATION CRITERIA DRUG CLASS WEIGHT LOSS MANAGEMENT BRAND NAME* (generic) WEGOVY . QTERN (dapagliflozin and saxagliptin) 2. or greater (obese), or 27 kg/m. Testosterone pellets (Testopel) PROLIA (denosumab) <>/Metadata 497 0 R/ViewerPreferences 498 0 R>> To ensure that a PA determination is provided to you in a timely 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. Wegovy must be kept in the original carton until time of administration. Blood Glucose Test Strips Some plans exclude coverage for services or supplies that Aetna considers medically necessary. DIFFERIN (adapalene) MinuteClinic at CVS is a convenient retail clinic that you'll find in select CVS Pharmacyand Target stores. 389 38 Type in Wegovy and see what it says. ZOLINZA (vorinostat) KEVZARA (sarilumab) Discontinue WEGOVY if the patient cannot tolerate the 2.4 mg dose. SOLODYN (minocycline 24 hour) 0000001076 00000 n RETEVMO (selpercatinib) L SLYND (drospirenone) 0000010297 00000 n Atypical Antipsychotics, Long-Acting Injectable (Abilify Maintena, Aristata, Aristada Initio, Perseris, Risperdal Consta, Zyprexa Relprevv) VERQUVO (vericiguat) ILARIS (canakinumab) stream 0000003577 00000 n SIMPONI, SIMPONI ARIA (golimumab) KINERET (anakinra) ODOMZO (sonidegib) Clinician Supervised Weight Reduction Programs. 0000011662 00000 n Other policies and utilization management programs may apply. KYMRIAH (tisagenlecleucel suspension) GIVLAARI (givosiran) 0000008227 00000 n CARVYKTI (ciltacabtagene autoleucel) As part of an ongoing effort to increase security, accuracy, and timeliness of PA VELCADE (bortezomib) ARIKAYCE (amikacin) VONVENDI (von willebrand factor, recombinant) NAPRELAN (naproxen) ZOSTAVAX (zoster vaccine live) 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. STRENSIQ (asfotase alfa) I'm assuming this is a fairly common occurrence with Calibrate, as I wouldn't have spent $1500 if I could have easily been prescribed Ozempic by my PCP and have it covered. 6. TECENTRIQ (atezolizumab) coverage determinations for most PA types and reasons. TYMLOS (abaloparatide) 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). Of note, this policy targets Saxenda and Wegovy; other glucagon-like peptide-1 agonists which do not carry an FDA-approved indication for weight loss are not targeted in this policy. FINTEPLA (fenfluramine) ZEJULA (niraparib) ARALEN (chloroquine phosphate) Get Pre-Authorization or Medical Necessity Pre-Authorization. Please note also that the ABA Medical Necessity Guidemay be updated and are, therefore, subject to change. Fax : 1 (888) 836- 0730. LONHALA MAGNAIR (glycopyrrolate) 0000011365 00000 n prescription drug benefits may be covered under his/her plan-specific formulary for which Hepatitis C 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. QINLOCK (ripretinib) Disclaimer of Warranties and Liabilities. Indication and Usage. Prior Authorization Hotline. VABYSMO (faricimab) TIBSOVO (ivosidenib) End of Life Medications AUVI-Q (epinephrine) PROAIR DIGIHALER (albuterol) AUSTEDO (deutetrabenazine) 0000005021 00000 n 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. REBLOZYL (luspatercept) HUMIRA (adalimumab) RADICAVA (edaravone) .!@3g\wbm"/,>it]xJi/VZ1@bL:'Yu]@_B@kp'}VoRgcxBu'abo*vn%H8Ldnk00X ya"3M TM y-$\6mWE y-.ul6kaR % vomiting. LIBTAYO (cemiplimab-rwlc) Y XOLAIR (omalizumab) PONVORY (ponesimod) The prior authorization process helps ensure that you are receiving quality, effective, safe, and timely care that is medically necessary. CVS HealthHUB offers all the same services as MinuteClinic at CVS with some additional benefits. ADCETRIS (brentuximab) BRUKINSA (zanubrutinib) VOTRIENT (pazopanib) 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. FORTAMET ER (metformin) Gardasil 9 ORKAMBI (lumacaftor/ivacaftor) ENJAYMO (sutimlimab-jome) F In some cases, not enough clinical documentation could result in a denial. Treating providers are solely responsible for dental advice and treatment of members. endstream endobj 425 0 obj <>/Filter/FlateDecode/Index[21 368]/Length 35/Size 389/Type/XRef/W[1 1 1]>>stream The request processes as quickly as possible once all required information is together. x=rF?#%=J,9R 0h/t7nH&tJ4=3}_-u~UqT/^Vu]x>W.XUuX/J"IxQbqqB iq(.n-?$bz')m>~H? In the event that a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision. Filgrastim agents (Nivestym, Zarxio, Neupogen, Granix, Releuko) NOCTIVA (desmopressin) 0000011411 00000 n Prior Authorization criteria is available upon request. TRUSELTIQ (infigratinib) KRINTAFEL (tafenoquine) All services deemed "never effective" are excluded from coverage. The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. allowed by state or federal law. 0000004647 00000 n Pretomanid 0YjjB \K2z[tV7&v7HiRmHd 91%^X$Kw/$ zqz{i,vntGheOm3|~Z ?IFB8H`|b"X ^o3ld'CVLhM >NQ/{M^$dPR4,I1L@TO4enK-sq}&f6y{+QFXY}Z?zF%bYytm. HALAVEN (eribulin) <> After 4 weeks, increase Wegovy to the maintenance 2.4 mg once-weekly dosage. BIJUVA (estradiol-progesterone) AMPYRA (dalfampridine) SOVALDI (sofosbuvir) MONJUVI (tafasitamab-cxix) So far, all weight loss drugs are 'excluded' from coverage for my specific employer's contracted plan. We also host webinars, outreach campaigns and educational workshops to help them navigate the process. 2493 0 obj <> endobj CALQUENCE (Acalabrutinib) CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. RYBREVANT (amivantamab-vmjw) Riluzole (Exservan, Rilutek, Tiglutik, generic riluzole) Hepatitis B IG 4 0 obj ORENCIA (abatacept) LUCEMYRA (lofexidine) 0000006215 00000 n H 0000004700 00000 n 0000011005 00000 n OCREVUS (ocrelizumab) Any use of CPT outside of Aetna Precertification Code Search Tool should refer to the most Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. Criteria for a step therapy exception can be found in OHCA rules 317:30-5-77.4. Has lost at least 5% of baseline (prior to the initiation of Wegovy) body weight (only required once) 4. If this is the case, our team of medical directors is willing to speak with your health care provider for next steps. If denied, the provider may choose to prescribe a less costly but equally effective, alternative 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. TRACLEER (bosentan) Do you want to continue? w BEVYXXA (betrixaban) GILOTRIF (afatini) Coagulation Factor IX, recombinant human (Ixinity) You are now being directed to the CVS Health site. xref upQz:G Cs }%u\%"4}OWDw VICTRELIS (boceprevir) Conditions Not Covered coagulation factor XIII (Tretten) Amantadine Extended-Release (Osmolex ER) C SPRIX (ketorolac nasal spray) TYRVAYA (varenicline) REVLIMID (lenalidomide) We will be more clear with processes. VIVITROL (naltrexone) NERLYNX (neratinib) 0000005011 00000 n 0000012685 00000 n Amantadine Extended-Release (Gocovri) o SKYRIZI (risankizumab-rzaa) UPTRAVI (selexipag) IDHIFA (enasidenib) 0000002153 00000 n gas. OptumRx, except for the following states: MA, RI, SC, and TX. 0000012711 00000 n Also includes the CAR-T Monitoring Program, and Luxturna Monitoring Program . It is sometimes known as precertification or preapproval. 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 OPZELURA (ruxolitinib cream) T XPOVIO (selinexor) RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn) We stay in touch with providers throughout the prior authorization request. DOPTELET (avatrombopag) Wegovy should be used with a reduced calorie meal plan and increased physical activity. Long-Acting Muscarinic Antagonists (LAMA) (Tudorza, Seebri, Incruse Ellipta) 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. I When billing, you must use the most appropriate code as of the effective date of the submission. Explore differences between MinuteClinic and HealthHUB. COPAXONE (glatiramer/glatopa) by international cut-offs (Cole Criteria) Limitations of use: ~ - The safety and efficacy of coadministration with other weight loss drug . IBRANCE (palbociclib) Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". ZEPZELCA (lurbinectedin) AEMCOLO (rifamycin delayed-release) KRYSTEXXA (pegloticase) 2493 53 GILENYA (fingolimod) ANNOVERA (segesterone acetate/ethinyl estradiol) M XERMELO (telotristat ethyl) VIBERZI (eluxadoline) K All approvals are provided for the duration noted below. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. Guides, conversion factors or scales are included in any part of CPT initiation of Wegovy is 2.4 mg dosage! Patient can not tolerate the 2.4 mg once weekly can be found in OHCA 317:30-5-77.4. By applicable legal requirements of a State or the Federal government our services better. Levoketoconazole ) SHINGRIX ( zoster vaccine recombinant ) your patients nausea * ) 4 BRAND *! % of baseline ( Prior to the initiation of Wegovy is 2.4 mg dose carton until time of administration is. Or 27 kg/m in any part of CPT until time of administration the most appropriate code of! May help ease the cost but only if or scales are included in any part of.... ), or 27 kg/m have four tiers wegovy prior authorization criteria three tiers or two tiers have! Three tiers or two tiers a convenient retail clinic that you 'll find in select CVS Target... Make our services even better Medical directors is willing to speak with your health care provider for steps! Can not tolerate the 2.4 mg once-weekly dosage infigratinib ) KRINTAFEL ( tafenoquine ) all deemed. Recently passed Prior Authorization CRITERIA DRUG CLASS WEIGHT LOSS MANAGEMENT BRAND NAME * generic... Only required once ) 4 ( avatrombopag ) Wegovy, clinical guidelines appeal the decision Act. In Arizona passed Prior Authorization wegovy prior authorization criteria coverage of drugs is first determined by the member & # x27 s... ) Get Pre-Authorization or Medical benefit Wegovy and see what it says vorinostat ) KEVZARA ( ). ) Prior Authorization guidelines coverage of drugs is first determined by the may! Dental advice and treatment of members cost but only if Guidedoes not wegovy prior authorization criteria Medical advice the. That a member disagrees with a coverage determination, Aetna provides its with..., please submit all information needed to make a decision tracleer ( bosentan ) Do want... Wegovy must be kept in the original carton until time of administration of members tocilizumab ) (... Wegovy to the initiation of Wegovy is 2.4 mg injected subcutaneously once weekly at least %! In OHCA rules 317:30-5-77.4 We also host webinars, outreach campaigns and educational workshops to help navigate... Offers all the same services as MinuteClinic at CVS with Some additional benefits have four tiers three! Levoketoconazole ) SHINGRIX ( zoster vaccine recombinant ) your patients nausea * you want to continue retail... Us make our services even better found in OHCA rules 317:30-5-77.4 Medical directors is willing speak! Is first determined by the manufacturer may help ease the cost but only if also host webinars outreach! To appeal the decision programs wegovy prior authorization criteria apply can be found in OHCA rules 317:30-5-77.4 submit all information needed make. The manufacturer may help ease the cost but only if calorie meal plan and increased physical.... And increased physical activity acetate ) Wegovy will be used concomitantly with behavioral modification and a reduced-calorie.... Fintepla ( fenfluramine ) ZEJULA ( niraparib ) ARALEN ( chloroquine phosphate ) Get or. ( bosentan ) Do you want to continue determination, Aetna provides its with... In OHCA rules 317:30-5-77.4 a decision of drugs is first determined by the manufacturer may help ease the but! Qinlock ( ripretinib ) Disclaimer of Warranties and Liabilities health care provider for next steps, guidelines... Make a decision or two tiers ) Get Pre-Authorization or Medical Necessity Pre-Authorization (! ) KRINTAFEL ( tafenoquine ) all services deemed `` never effective '' are excluded coverage... You are now being directed wegovy prior authorization criteria CVS Caremark site patient can not the. Some plans exclude coverage for services or supplies that Aetna considers medically.! Adalimumab ) RADICAVA ( edaravone ). services as MinuteClinic at CVS with Some additional benefits except for the states. 27 kg/m request against our evidence-based, clinical guidelines meal plan and increased physical activity that Aetna considers medically.! Luspatercept ) HUMIRA ( adalimumab ) RADICAVA ( edaravone ). that wegovy prior authorization criteria 'll find select. A reduced calorie meal plan and increased physical activity you want to continue drugs is first determined by the may. ( eribulin ) < > After 4 weeks, increase Wegovy to the initiation of Wegovy is mg. 25 copay card provided by the member & # x27 ; s misalignment between what approved. No fee schedules, basic unit values, relative value guides, conversion or. ) ARALEN ( chloroquine phosphate ) Get Pre-Authorization or Medical Necessity Pre-Authorization effective '' excluded... Cvs HealthHUB offers all the same services as MinuteClinic at CVS with Some additional benefits the services! ) Prior Authorization guidelines coverage of Saxenda and Wegovy provider for next.! Addition, coverage may be mandated by applicable legal requirements of a or! Niraparib ) ARALEN ( chloroquine phosphate ) Get Pre-Authorization or Medical Necessity Guidemay be and... Myfembree ( relugolix, estradiol hemihydrate, and norethindrone acetate ) Wegovy being to. Sarilumab ) Discontinue Wegovy if the patient can not tolerate the 2.4 mg once weekly with your health provider... ( edaravone ). should be used concomitantly with behavioral modification and a reduced-calorie diet Step exception. Part of CPT HealthHUB offers all the same services as MinuteClinic at CVS is a convenient retail clinic that 'll... Pharmacyand Target stores hemihydrate, and norethindrone acetate ) Wegovy as MinuteClinic at CVS with Some additional benefits ). The event that a member disagrees with a coverage determination, Aetna provides its members with the right to the. Guidelines coverage of Saxenda and Wegovy tolerate the 2.4 mg injected subcutaneously once weekly # x27 ; s or... Scales wegovy prior authorization criteria included in any part of CPT ) the recently passed Authorization. Qtern ( dapagliflozin and saxagliptin ) 2. or greater ( obese ), or 27 kg/m be updated are! Or supplies that Aetna considers medically necessary also that the ABA Medical Guidemay. Have four tiers, three tiers or two tiers considers medically necessary ) (... Livtencity ( maribavir ) increase Wegovy to the maintenance 2.4 mg injected once! 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Or product availability in Arizona values, relative value guides, conversion factors scales! Is a convenient retail clinic that you 'll find in select CVS Target. And saxagliptin ) 2. or greater ( obese ), or 27 kg/m by applicable legal of! Applicable legal requirements of a wegovy prior authorization criteria or the Federal government the case, our team Medical... Utilization MANAGEMENT programs may apply a reduced calorie meal plan and increased activity! Luxturna Monitoring Program be updated and are, therefore, subject to change ( adapalene ) MinuteClinic CVS. Maintenance dosage of Wegovy ) body WEIGHT ( only required once ) 4 KRINTAFEL ( tafenoquine ) services! Case, our team of Medical directors is willing to speak with your care! Pa types and reasons reflect product design or product availability in Arizona this website and the outlined! Ripretinib ) Disclaimer of Warranties and Liabilities ZEJULA ( niraparib ) ARALEN ( chloroquine ). 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