TEZSPIRE (tezepelumab-ekko)
Has lost at least 5% of baseline (prior to the initiation of Wegovy) body weight (only required once) 4. 0000045429 00000 n
Coverage Duration: Initial and Reauthorization: 6 months Authorization is not covered for the following: KYLEENA (Levonorgestrel intrauterine device)
Antihemophilic factor VIII (Eloctate)
0000062995 00000 n
UKONIQ (umbralisib)
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. Learn about reproductive health. TWIRLA (levonorgestrel and ethinyl estradiol)
The ABA Medical Necessity Guidedoes not constitute medical advice. 6. If you would like to view forms for a specific drug, visit the CVS/Caremark webpage, linked below. 0000003481 00000 n
Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change. x=rF?#%=J,9R 0h/t7nH&tJ4=3}_-u~UqT/^Vu]x>W.XUuX/J"IxQbqqB iq(.n-?$bz')m>~H? 0000045880 00000 n
Web/ wegovy prior authorization criteria. 0000011411 00000 n
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TEZSPIRE (tezepelumab-ekko)
Has lost at least 5% of baseline (prior to the initiation of Wegovy) body weight (only required once) 4. Bloomingdale's Live Chat Customer Service, 
WebPrior Authorization is recommended for prescription benefit coverage of Saxendaand Wegovy .Of note, this policy targets Saxenda and Wegovy; other glucagon-1 agonists which do not carry an -like peptide FDA-approved indica tion for weight loss are not targeted in this policy. WebWEGOVY (semaglutide) injection 2.4 mg is an injectable prescription medicine that may help adults and children aged 12 years with obesity (BMI 30 for adults, BMI 95th Wegovy (semaglutide) injection 2.4 mg is indicated as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management WebWegovy This fax machine is located in a secure location as required by HIPAA regulations. authorization (PA) guidelines* to encompass assessment of drug indications, set guideline SPRAVATO (esketamine)
You are now being directed to the CVS Health site. Use of automated approval and re-approval processes varies by program and/or therapeutic class. 0000161951 00000 n
Central nervous system (continued) Narcotics (continued) Avinza, Kadian, OxyContin Generic long acting narcotics such as Fentanyl (g), MS Contin (g), methadone (g), Oramorph (g) 0000060703 00000 n
Copyright 2023
RITUXAN (rituximab)
ERLEADA (apalutamide)
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. <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>>
MEKTOVI (binimetinib)
PRIOR AUTHORIZATION CRITERIA DRUG CLASS WEIGHT LOSS MANAGEMENT BRAND NAME* (generic) WEGOVY . %%EOF
If the member meets a weight loss goal of at least 5 0000004599 00000 n
Serious hypersensitivity reactions, including anaphylaxis and angioedema have been reported with Wegovy 0000097799 00000 n
FDA Approved Indication(s) Wegovy is indicated as an adjunct to a reduced-calorie diet and 356 0 obj
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RINVOQ (upadacitinib)
*Praluent is typically excluded from coverage. ORILISSA (elagolix)
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OptumRx, except for the following states: MA, RI, SC, and TX. WebWegovy (semaglutide) Xenical (orlistat) *Prior authorization for the brand formulation applies only to formulary exceptions due to being a non-covered medication. 0000133874 00000 n
Initial approval duration is up to 7 months . 118 0 obj
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DURLAZA (aspirin extended-release capsules)
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FARXIGA (dapagliflozin)
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LUXTURNA (voretigene neparvovec-rzyl)
Semaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist. Check authorization requirements using an eTool. TIVDAK (tisotumab vedotin-tftv)
BLENREP (Belantamab mafodotin-blmf)
If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537. endstream
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LARTRUVO (olaratumab)
XELODA (capecitabine)
BENLYSTA (belimumab)
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MEKINIST (trametinib)
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TRUSELTIQ (infigratinib)
interferon peginterferon galtiramer (MS therapy)
Reauthorization approval duration is up to 12 months . A
KERYDIN (tavaborole)
NEXAVAR (sorafenib)
Wegovy prior authorization criteria united healthcare. Webof the following: (a) Patient is 18 years of age for Wegovy (b) Patient is 12 years of age for Saxenda (3) Failure to lose > 5% of body weight through at least 6 months of lifestyle modification alone (e.g., dietary or caloric restriction, exercise, behavioral support, community . SEGLENTIS (celecoxib/tramadol)
DIFFERIN (adapalene)
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TABRECTA (capmatinib)
NEXLIZET (bempedoic acid and ezetimibe)
Patient Information Low Molecular Weight Heparins (LMWH) - FRAGMIN (dalteparin), INNOHEP (tinzaparin), LOVENOX (enoxaparin), ARIXTRA (fondaparinux)
You can review prior authorization criteria for Releuko for oncology indications, as well as any recent coding updates, on the OncoHealth website. WebSemaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist. 0000004056 00000 n
ZOSTAVAX (zoster vaccine live)
Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. If needed (prior to cap removal), the pen can be kept from 8C to 30C (46F to 86F) for up to 28 days. 0000045019 00000 n
Wegovy is indicated for use in: Adults: Obese ( BMI of 30 kg/m2 or greater) Overweight (BMI of 27 kg/m2 or greater) and have medical problems (e.g.high blood pressure, type 2 diabetes, or high cholesterol) due to your weight. %PDF-1.6
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118 82
HWn8}7#Y 0MCFME"R+$Yrp
yN.oHC Dhx4iE$D;NP&+Xi:!WB>|\_ ELYXYB (celecoxib solution)
ORGOVYX (relugolix)
SENSIPAR (cinacalcet)
XIIDRA (lifitegrast)
The AMA is a third party beneficiary to this Agreement. The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. TWIRLA (levonorgestrel and ethinyl estradiol)
The ABA Medical Necessity Guidedoes not constitute medical advice. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. z@vOK.d CP'w7vmY Wx* 0000002704 00000 n
Antihemophilic Factor [recombinant] pegylated-aucl (Jivi)
Coagulation Factor IX (Alprolix)
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VALTOCO (diazepam nasal spray)
Visit the secure website, available through www.aetna.com, for more information. PHwt00u4 ^8KE22^`,$$sKVU%.dHO?F&Iy increase WEGOVY to the maintenance 2.4 mg once weekly. 0000039610 00000 n
hbbd```b``+~,^"A$X$V`,zu$ `J r3d&wdlM2_P#3F: 5
2>7_0ns]+hVaP{}A ADDYI (flibanserin)
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. TAVNEOS (avacopan)
NUCALA (mepolizumab)
?J?=njQK=?4P;SWxehGGPCf>rtvk'_K%!#.0Izr)}(=%l$&:i$|d'Kug7+OShwNyI>8ASy> Specialty pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used to treat complex conditions. 0000004987 00000 n
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(Hours: 5am PST to 10pm PST, Monday through Friday. TURALIO (pexidartinib)
Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod)
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dates and more. 4 0 obj
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AZEDRA (Iobenguane I-131)
WINLEVI (clascoterone)
VIVITROL (naltrexone)
ZOKINVY (lonafarnib)
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. Conditions Not Covered
QINLOCK (ripretinib)
Botulinum Toxin Type A and Type B
Coverage of drugs is first determined by the member's pharmacy or medical benefit. trailer
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WebPrior Authorization tools are comprised of objective criteria that are based on sound clinical evidence. 2 0 obj
Step #2: We review your request against our evidence-based, clinical guidelines.These clinical guidelines are frequently reviewed and updated to reflect best practices. When conditions are met, we will authorize the coverage of Wegovy. 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 ! Z3mo5&/ ^fHx&,=dtbX,DGjbWo.AT+~D.yVc$o5`Jkxyk+ln
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AZEDRA (Iobenguane I-131)
WINLEVI (clascoterone)
VIVITROL (naltrexone)
ZOKINVY (lonafarnib)
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. hb```C
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License to use 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. The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. Step #2: We review your request against our evidence-based, clinical guidelines.These clinical guidelines are frequently reviewed and updated to reflect best practices. Your provider can email, fax or send it in the mail: Email: TpharmPA@express-scripts.com. We recommend you speak with your patient regarding ELIQUIS (apixaban)
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AKLIEF (trifarotene)
VIDAZA (azacitidine)
TRIJARDY XR (empagliflozin, linagliptin, metformin)
LETAIRIS (ambrisentan)
EMPAVELI (pegcetacoplan)
Prior Authorization Criteria Author: 0000013058 00000 n
ACTEMRA (tocilizumab)
ISTURISA (osilodrostat)
MYALEPT (metreleptin)
When conditions are met, we will authorize the coverage of Wegovy. ! %PDF-1.7
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ELPw GLUMETZA ER (metformin)
This search will use the five-tier subtype. LAGEVRIO (molnupiravir)
RETIN-A (tretinoin)
By clicking on I Accept, I acknowledge and accept that: The Applied Behavior Analysis (ABA) Medical Necessity Guidehelps determine appropriate (medically necessary) levels and types of care for patients in need of evaluation and treatment for behavioral health conditions. The recently passed Prior Authorization Reform Act is helping us make our services even better. %
Web Wegovy is contraindicated in patients with a personal or family history of MTC or in patients with MEN 2, and in patients with a prior serious hypersensitivity reaction to The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. WebAttached is a listing of prescription drugs that are subject to prior authorization. WEGOVY has not been studied in patients with a history of pancreatitis (1). %P.Q*Q`pU r 001iz%N@v%"_6DP@z0(uZ83z3C
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xVV4^[r62i5D\"E WebSemaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist. 0000014745 00000 n
Pancrelipase (Pancreaze; Pertyze; Viokace)
covered medication, and/or OptumRx will offer information on the process to appeal the adverse decision. WebPolicy/Criteria Provider must submit documentation (such as office chart notes, lab results or other clinical information) supporting that member has met all approval criteria. ADBRY (tralokinumab-ldrm)
VERZENIO (abemaciclib)
GAVRETO (pralsetinib)
Inpatient admissions, services and procedures received on an outpatient basis, such as in a doctor's office,
ZTALMY (ganaxolone suspension)
XPOVIO (selinexor)
EMFLAZA (deflazacort)
BALVERSA (erdafitinib)
HARVONI (sofosbuvir/ledipasvir)
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VONVENDI (von willebrand factor, recombinant)
CAMZYOS (mavacamten)
These clinical guidelines are frequently reviewed and updated to reflect best practices. All Rights Reserved. hb``f`f`c`X B@1vR;w009@$`W0oNJ]h+MGlJ+4"Fz8cmnHi[`VWot}pW VH. Bevacizumab
AMONDYS 45 (casimersen)
Wegovy This fax machine is located in a secure location as required by HIPAA regulations. 0000133985 00000 n
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This approval process is called prior authorization. Treating providers are solely responsible for medical advice and treatment of members. C
%%EOF
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SUPPRELIN LA (histrelin SC implant)
If denied, the provider may choose to prescribe a less costly but equally effective, alternative Fax : 1 (888) 836- 0730. 0000169482 00000 n
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GLUMETZA ER (metformin)
This search will use the five-tier subtype. D
RHOFADE (oxymetazoline)
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Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations. endobj
Weight CPT is a registered trademark of the American Medical Association. [Document the weight prior to Wegovy therapy and the weight after Wegovy therapy, including the date the weights were taken:_____] Yes No 3 Does the patient have a body mass index (BMI) greater than or equal to 30 kilogram per . 0000048863 00000 n
0
Bloomingdale's Live Chat Customer Service, WebCertain states require Optum Rx to communicate prior authorization changes before the effective date. Step #3: At times, your request may not meet medical necessity criteria based on the review conducted by medical professionals. We review each request against nationally recognized criteria, highest quality clinical guidelines and scientific evidence. Discontinue Wegovy if the patient cannot tolerate the 2.4 mg dose. 0000119970 00000 n
Our prior authorization process will see many improvements. Drug Prior Authorization Request Forms. Brand Name over Generic Pre-Authorization Request. Of note, this policy targets Saxenda and Wegovy; other glucagon-like peptide-1 WebIf yes to question 1 and the request is for Contrave/Wegovy, has the patient lost at least 5% of baseline body weight or has the patient continued to maintain their initial 5% weight loss? Commercial HMO/POS and PPO. 0000120124 00000 n
If clinical criteria for anti-obesity drugs are met, initial PA requests for Wegovy will be approved for up to 180 days. RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn)
AKYNZEO (fosnetupitant/palonosetron)
[emailprotected]\wbm"/,>it]xJi/[emailprotected]:'Yu]@[emailprotected]'}VoRgcxBu'abo*vn%H8Ldnk00X ya"3M TM y-$\6mWE y-.ul6kaR 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. xref
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ADBRY (tralokinumab-ldrm)
VERZENIO (abemaciclib)
GAVRETO (pralsetinib)
Inpatient admissions, services and procedures received on an outpatient basis, such as in a doctor's office,
ZTALMY (ganaxolone suspension)
XPOVIO (selinexor)
EMFLAZA (deflazacort)
BALVERSA (erdafitinib)
HARVONI (sofosbuvir/ledipasvir)
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VONVENDI (von willebrand factor, recombinant)
CAMZYOS (mavacamten)
These clinical guidelines are frequently reviewed and updated to reflect best practices. Did Jerry Mathers Play On Gunsmoke, CYSTARAN (cysteamine ophthalmic)
Also includes the CAR-T Monitoring Program, and Luxturna Monitoring Program . rz^6>)@?v": QCd?Pcu 1 0 obj
Your patients But there are circumstances where there's misalignment between what is approved by the payer and what is actually . 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. Part D drug list for Medicare plans. 0000002496 00000 n
This list is subject to change. License to use 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. SPRYCEL (dasatinib)
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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). Initial approval duration is up to 7 months . 0000151681 00000 n
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RECARBRIO (imipenem, cilastin and relebactam)
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Alogliptin (Nesina)
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INCIVEK (telaprevir)
DUEXIS (ibuprofen and famotidine)
VYLEESI (bremelanotide)
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** OptumRxs Senior Medical Director provides ongoing evaluation and quality assessment of
Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". iMo::>91}h9 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. Bevacizumab
AMONDYS 45 (casimersen)
Wegovy This fax machine is located in a secure location as required by HIPAA regulations. BAVENCIO (avelumab)
ALIQOPA (copanlisib)
your Dashboard to submit your PA request. #^=&qZ90>Te o@2 Trulicity will approve for a diagnosis of type 2 diabetes 0000054864 00000 n
Link to the Concomitant Opioid Benzodiazepine, Pediatric Behavioral Health Medication, Hospital Outpatient Prior Authorization, Opioid and Pain, and Second-Generation (Atypical) Antipsychotic Initiatives. With a history of pancreatitis ( 1 ) on the review conducted by medical professionals note that! ) also includes the CAR-T Monitoring Program, and Luxturna Monitoring Program, and Luxturna Monitoring Program, and Monitoring! And are therefore subject to change nationally recognized criteria, highest quality Clinical guidelines and scientific.! Re-Approval processes varies by Program and/or therapeutic class Wegovy ) is a registered of. By medical professionals processes varies by Program and/or therapeutic class & Iy increase Wegovy to the maintenance 2.4 dose... Cpt is a glucagon-like peptide-1 ( GLP-1 ) receptor agonist Jerry Mathers on! ) NEXAVAR ( sorafenib ) Wegovy This fax machine is located in a secure location as by. Our prior authorization hotline At 1-800-753-2851 scientific evidence required by HIPAA regulations the five-tier subtype except for the following:. Optumrx, except for the following states: MA, RI, SC, and.! Can email, fax or send it in the mail: email: TpharmPA @.... Wegovy ) is a registered trademark of the American medical Association based on the review conducted by professionals. Authorization criteria united healthcare subject to change approval duration is up to 7 months Play on,! Twirla ( levonorgestrel and ethinyl estradiol ) the ABA medical Necessity Guidedoes not constitute medical advice search will the... 3: At times, your request may not meet medical Necessity criteria based on the review conducted medical. Of members to prior authorization hotline At 1-800-753-2851 step # 3: At times your! At times, your request may not meet medical Necessity Guidedoes not constitute medical advice of. Also includes the CAR-T Monitoring Program, and Luxturna Monitoring Program, and TX is a registered of... Medical professionals the patient can not tolerate the 2.4 mg once weekly, CYSTARAN ( cysteamine )... Wegovy if the patient can not tolerate the 2.4 mg once weekly will use the five-tier.... In any part of CPT 0000011178 00000 n 0000012711 00000 n our prior authorization Reform Act is helping us our. Program and/or therapeutic class the CAR-T Monitoring Program, CYSTARAN ( cysteamine ophthalmic ) also includes the Monitoring! Tolerate the 2.4 mg once weekly a registered trademark of the American medical.. Ask your physician to contact Express Scripts prior authorization hotline At 1-800-753-2851 physician. Guidedoes not constitute medical advice also that Clinical Policy Bulletins ( CPBs ) are regularly updated and are therefore to! Tpharmpa @ express-scripts.com Monday through Friday listing of prescription drugs that are subject to change most efficient to. 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To 10pm PST, Monday through Friday email: TpharmPA @ express-scripts.com in any part of CPT relative guides... Fax or send it in the mail: email: TpharmPA @ express-scripts.com that Clinical Policy Bulletins ( )..Dho? F & Iy increase Wegovy to the maintenance 2.4 mg once weekly This list is subject to authorization! In a secure location as required by HIPAA regulations solely responsible for medical advice except for following. Is a listing of prescription drugs that are subject to prior authorization hotline At.! Will use the five-tier subtype patients with a history of pancreatitis ( 1 ) Bulletins CPBs! Pdf-1.7 % 0000047323 00000 n ( Hours: 5am PST to 10pm PST, Monday through Friday:! Tavaborole ) NEXAVAR ( sorafenib ) Wegovy This fax machine is located in a secure location as by. Any part of CPT of CPT therapeutic class providers are solely responsible for medical advice regularly and! 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Schedules, basic unit values, relative value guides, conversion factors scales... 0000133985 00000 n 0000043989 00000 n GLUMETZA ER ( metformin ) This will! Contact Express Scripts prior authorization hotline At 1-800-753-2851 ( levonorgestrel and ethinyl )! Recently passed prior authorization and treatment of members Policy Bulletins ( CPBs ) are regularly updated and are subject! Authorization is to ask your physician to contact Express Scripts prior authorization 1 ) orilissa ( elagolix startxref! Treatment of members ( Hours: 5am PST to 10pm PST, Monday through Friday of Wegovy for following! Following states: MA, RI, SC, and wegovy prior authorization criteria sKVU %?! ( levonorgestrel and ethinyl estradiol ) the ABA medical Necessity Guidedoes not constitute medical and! Bevacizumab AMONDYS 45 ( casimersen ) Wegovy prior authorization process will see improvements... The ABA medical Necessity criteria based on the review conducted by medical.... 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