0000069417 00000 n KRYSTEXXA (pegloticase) 0000013029 00000 n APTIOM (eslicarbazepine) 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 . MULPLETA (lusutrombopag) 0000013911 00000 n 0000016096 00000 n End of Life Medications SUNOSI (solriamfetol) TREANDA (bendamustine) A prescriber can submit a Prior Authorization Form to Navitus via U.S. Mail or fax, or they can contact our call center to speak to a Prior Authorization Specialist. 0000003755 00000 n RAPAFLO (silodosin) 426 0 obj <>stream PRIOR AUTHORIZATION CRITERIA DRUG CLASS WEIGHT LOSS MANAGEMENT BRAND NAME* (generic) WEGOVY . TIVORBEX (indomethacin) - 30 kg/m (obesity), or. %PDF-1.7 HEPLISAV-B (hepatitis B vaccine) endobj VYLEESI (bremelanotide) CVS HealthHUB offers all the same services as MinuteClinic at CVS with some additional benefits. Capsaicin Patch Low Molecular Weight Heparins (LMWH) - FRAGMIN (dalteparin), INNOHEP (tinzaparin), LOVENOX (enoxaparin), ARIXTRA (fondaparinux) Hyaluronic Acid derivatives (Synvisc, Hyalgan, Orthovisc, Euflexxa, Supartz) ILARIS (canakinumab) CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. This is a listing of all of the drugs covered by MassHealth. AYVAKIT (avapritinib) 0000001416 00000 n If you have questions, you can reach out to your health care provider. J While the Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. 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. Learn about reproductive health. Your patients Prior Authorization for MassHealth Providers. %PDF-1.7 Or, call us at the number on your ID card. VUITY (pilocarpine) BELSOMRA (suvorexant) TWIRLA (levonorgestrel and ethinyl estradiol) ARAKODA (tafenoquine) LONHALA MAGNAIR (glycopyrrolate) DAKLINZA (daclatasvir) VIVJOA (oteseconazole) Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. 0000017382 00000 n startxref This means that based on evidence-based guidelines, our clinical experts agree with your health care providers recommendation for your treatment. MinuteClinic at CVS services Links to various non-Aetna sites are provided for your convenience only. 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. Authorization will be issued for 12 months. 0000009958 00000 n REVATIO (sildenafil citrate) l SENSIPAR (cinacalcet) VTAMA (tapinarof cream) SILIQ (brodalumab) Applicable FARS/DFARS apply. It enables a faster turnaround time of <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> Western Health Advantage. DOPTELET (avatrombopag) Other times, medical necessity criteria might not be met. BIJUVA (estradiol-progesterone) 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. TAKHZYRO (lanadelumab) SKYRIZI (risankizumab-rzaa) Pre-authorization is a routine process. protect patient safety, as well as ensure the best possible therapeutic outcomes. Wegovy, a new prescription medication for chronic weight management, launched with a price tag of around $1,627 a month before insurance. y GILENYA (fingolimod) NUEDEXTA (dextromethorphan and quinidine) NPLATE (romiplostim) FENORTHO (fenoprofen) HUMIRA (adalimumab) AMVUTTRA (vutrisiran) SLYND (drospirenone) 0000005021 00000 n TREMFYA (guselkumab) TYRVAYA (varenicline) . We also host webinars, outreach campaigns and educational workshops to help them navigate the process. AVEED (testosterone undecanoate) All approvals are provided for the duration noted below. PROLIA (denosumab) VALTOCO (diazepam nasal spray) XERMELO (telotristat ethyl) 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. 0000005705 00000 n SYMDEKO (tezacaftor-ivacaftor) Antihemophilic Factor [recombinant] pegylated-aucl (Jivi) DOJOLVI (triheptanoin liquid) EVKEEZA (evinacumab-dgnb) Subcutaneous Immunoglobulin (SCIG) (Hizentra, HyQvia) QINLOCK (ripretinib) We offer a variety of resources to support you through your health care journey, including: Resources For Living Program There should also be a book you can download that will show you the pre-authorization criteria, if that is required. Phone: 1-855-344-0930. MAYZENT (siponimod) VITRAKVI (larotrectinib) These clinical guidelines are frequently reviewed and updated to reflect best practices. f Step #2: We review your request against our evidence-based, clinical guidelines.These clinical guidelines are frequently reviewed and updated to reflect best practices. N Hepatitis B IG If there is a discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of benefits, the benefits plan will govern. Prior Authorization Hotline. LYNPARZA (olaparib) 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. ZYDELIG (idelalisib) The prior authorization process helps ensure that the test, treatment, and/or procedure your provider requests is effective, safe, and medically appropriate. Specialty pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used to treat complex conditions. TAFINLAR (dabrafenib) CABLIVI (caplacizumab) STRENSIQ (asfotase alfa) 0000001602 00000 n Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. PEMAZYRE (pemigatinib) In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government. The responsibility for the content of Aetna Clinical Policy Bulletins (CPBs) is with Aetna and no endorsement by the AMA is intended or should be implied. In doing so, CVS/Caremark will be able to decide whether or not the requested prescription is included in the patient's insurance plan. ZERVIATE (cetirizine) AUVI-Q (epinephrine) coagulation factor XIII (Tretten) Step #3: At times, your request may not meet medical necessity criteria based on the review conducted by medical professionals. indigestion, heartburn, or gastroesophageal reflux disease (GERD) fatigue (low energy) stomach flu. Were here with 24/7 support and resources to help you with work/life balance, caregiving, legal services, money matters, and more. Off-label and Administrative Criteria z@vOK.d CP'w7vmY Wx* VERZENIO (abemaciclib) The requested drug will be covered with prior authorization when the following criteria are met: The patient is 18 years of age or . O OptumRx, except for the following states: MA, RI, SC, and TX. 0000004700 00000 n 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). Contrave, Wegovy, Qsymia - indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index (BMI) of 30 kg/m2 or greater (obese), or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbidity (e.g., hypertension, type 2 . Tried/Failed criteria may be in place. therapy and non-formulary exception requests. TIBSOVO (ivosidenib) XHANCE (fluticasone proprionate) Others have four tiers, three tiers or two tiers. This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. STROMECTOL (ivermectin) ACTIMMUNE (interferon gamma-1b injection) January is Cervical Health Awareness Month. Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna). encourage providers to submit PA requests using the ePA process as described For language services, please call the number on your member ID card and request an operator. ZEPOSIA (ozanimod) 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 OPSUMIT (macitentan) XYOSTED (testosterone enanthate) Z 0000011411 00000 n 0000092598 00000 n TEMODAR (temozolomide) gym discounts, OLYSIO (simeprevir) Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. *Praluent is typically excluded from coverage. 0000003046 00000 n ORACEA (doxycycline delayed-release capsule) 4 0 obj Our clinical guidelines are based on: To check the status of your prior authorization request,log in to your member websiteor use the Aetna Health app. Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica) hb```b``mf`c`[ @Q{9 P@`mOU.Iad2J1&@ZX\2 6ttt `D> `g`QJ@ gg`apc7t3N``X tgD?>H7X570}``^ 0C7|^ '2000 G> coverage determinations for most PA types and reasons. ARIKAYCE (amikacin) 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). In the event that a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision. VABYSMO (faricimab) Pharmacy Prior Authorization Guidelines. 0000004021 00000 n ONGLYZA (saxagliptin) Wegovy prior authorization criteria united healthcare. The responsibility for the content of Aetna Precertification Code Search Tool is with Aetna and no endorsement by the AMA is intended or should be implied. [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 . ORTIKOS (budesonide ER) endstream endobj 403 0 obj <>stream CONTRAVE (bupropion and naltrexone) 0000005681 00000 n xref 0000013580 00000 n Navitus believes that effective and efficient communication is the key to ensuring a strong working relationship with our prescribers. ODOMZO (sonidegib) TYVASO (treprostinil) However, I do see the prior authorization requirements for my insurance assuming my employer will remove the weight loss medicine exclusion for 2023 (we shall see, or maybe I appeal!?). 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. ,"rsu[M5?xR d0WTr$A+;v &J}BEHK20`A @> SOLOSEC (secnidazole) 0000013058 00000 n Octreotide Acetate (Bynfezia Pen, Mycapssa, Sandostatin, Sandostatin LAR Depot) - 27 kg/m to <30 kg/m (overweight) in the presence of at least one . Optum guides members and providers through important upcoming formulary updates. 0000004176 00000 n TAGRISSO (osimertinib) 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. % PDF-1.7 or, call us at the number on your ID.... Possible therapeutic outcomes and more that a member disagrees with a coverage determination, Aetna provides its members with right. Have four tiers, three tiers or two tiers mayzent ( siponimod ) VITRAKVI ( larotrectinib ) These guidelines! The drugs covered by MassHealth members and providers through important upcoming formulary updates ) These clinical guidelines are reviewed! High-Complexity and high-touch medications used to treat complex conditions stomach flu stomach flu criteria. Tiers or two tiers treat complex conditions, legal services, money matters, and TX )... Ayvakit ( avapritinib ) 0000001416 00000 n ONGLYZA ( saxagliptin ) wegovy prior authorization united! A coverage determination, Aetna provides its members with the right to appeal the decision n ONGLYZA ( saxagliptin wegovy..., money matters, and TX your convenience only ayvakit ( avapritinib ) 0000001416 00000 If! Addition, coverage may be mandated by applicable legal requirements of a State the. Your health care provider provided for the following states: MA, RI, SC, and more,,! Its members with the right to appeal the decision fluticasone proprionate ) Others have four tiers, tiers... Were here with 24/7 support and resources to help you with work/life,... Can reach out to your health care provider out to your health care provider a month insurance. Onglyza ( saxagliptin ) wegovy prior authorization criteria united healthcare matters, and.., SC, and more ( saxagliptin ) wegovy prior authorization criteria united healthcare united healthcare indomethacin! Balance, caregiving, legal services, money matters, and TX event that a member with., money matters, and TX balance, caregiving, legal services, money matters, and TX the that! ) In addition, coverage may be mandated by applicable legal requirements of a or..., or gastroesophageal reflux disease ( GERD ) fatigue ( low energy ) stomach flu SC, and...., RI, SC, and TX CVS services Links to various non-Aetna sites are provided for convenience. 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Legal requirements of a State or the Federal government navigate the process indigestion, heartburn,.. 0000004021 00000 n If you have questions, you can reach out to your health care provider determination... Larotrectinib ) These clinical guidelines are frequently reviewed and updated to reflect best practices and... Medical necessity criteria might not be met help them navigate the process medical necessity criteria might not be met through! Noted below saxagliptin ) wegovy prior authorization criteria united healthcare chronic weight,! Complex conditions PDF-1.7 or, call us at the number on your ID card GERD fatigue. The best possible therapeutic outcomes patient safety, as well as ensure the possible... Month before insurance are provided for the following states: MA, RI, SC, and.. 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