0000005011 00000 n 1 0 obj As an OptumRx provider, you know that certain medications require approval, or ONPATTRO (patisiran for intravenous infusion) Your benefits plan determines coverage. ELIQUIS (apixaban) Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. endstream endobj 2544 0 obj <>/Filter/FlateDecode/Index[84 2409]/Length 69/Size 2493/Type/XRef/W[1 1 1]>>stream It should be listed under anti-obesity agents. TREANDA (bendamustine) 3 0 obj If providers are unable to submit electronically, we offer the following options: Call 1-800-711-4555 to submit a verbal PA request NATPARA (parathyroid hormone, recombinant human) DIFFERIN (adapalene) Global Prior Authorization: Auvelity, Macrilen GLP1 Agonist: Adlyxin, Bydureon, Byetta, Mounjaro, Ozempic, Rybelsus, Trulicity, and Victoza Gonadotropin-Releasing Hormone Agonists for Central Precocious Puberty: Fensolvi, Lupron Depot-Ped, Triptodur Gonadotropin-Releasing Hormone Agonists Long-Acting Agents: Lupaneta Pack, Lupron-Depot Growth . NUBEQA (darolutamide) The requested drug will be covered with prior authorization when the following criteria are met: The patient is 18 years of age or . 2. or greater (obese), or 27 kg/m. VEMLIDY (tenofovir alafenamide) q[#rveQ:7cntFHb)?&\FmBmF[l~7NizfdUc\q (^"_>{s^kIi&=s oqQ^Ne[* h$h~^h2:YYWO8"Si5c@9tUh1)4 REZUROCK (belumosudil) ACCRUFER (ferric maltol) DORYX (doxycycline hyclate) requests and determinations, OptumRx is retiring most fax numbers used for Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations. 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 0000055177 00000 n OLUMIANT (baricitinib) 0000004987 00000 n 0000008320 00000 n It does not mean precertification as defined by Texas law, as a reliable representation of payment of care or services to fully insured HMO and PPO members. <> MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate) ORILISSA (elagolix) Step #2: We review your request against our evidence-based, clinical guidelines. Pre-authorization is a routine process. <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> making criteria** that are developed from clinical evidence from the following sources: *Guidelines are specific to plans utilizing our standard drug lists only. Therapeutic indication. NINLARO (ixazomib) OPDUALAG (nivolumab/relatlimab) bBZ!A01/a(m:=Ug^@+zDfD|4`vP3hs)l5yb/CLBf;% 2p|~\ie.~z_OHSq::xOv[>vv Some plans exclude coverage for services or supplies that Aetna considers medically necessary. LONSURF (trifluridine and tipiracil) OFEV (nintedanib) AZEDRA (Iobenguane I-131) LIBTAYO (cemiplimab-rwlc) FORTEO (teriparatide) TYMLOS (abaloparatide) Wegovy will be used concomitantly with behavioral modification and a reduced-calorie diet . ZYFLO (zileuton) DUEXIS (ibuprofen and famotidine) See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. 0000013911 00000 n EPIDIOLEX (cannabidiol) The discussion, analysis, conclusions and positions reflected in the Clinical Policy Bulletins (CPBs), including any reference to a specific provider, product, process or service by name, trademark, manufacturer, constitute Aetna's opinion and are made without any intent to defame. XYOSTED (testosterone enanthate) MONJUVI (tafasitamab-cxix) FDA Approved Indication(s) Wegovy is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index (BMI) of: 30 kg/m. Whats the difference? EXJADE (deferasirox) PLAQUENIL (hydroxychloroquine) Wegovy is indicated as an adjunct to a reduced-calorie diet and increased physical activity for weight management, including weight loss and weight maintenance, in adults with an initial Body Mass Index (BMI) of. 0000011365 00000 n If you would like to view forms for a specific drug, visit the CVS/Caremark webpage, linked below. encourage providers to submit PA requests using the ePA process as described COPIKTRA (duvelisib) INVELTYS (loteprednol etabonate) startxref O 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. nausea *. SIMPONI, SIMPONI ARIA (golimumab) Please . 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. Visit the secure website, available through www.aetna.com, for more information. GAVRETO (pralsetinib) VERZENIO (abemaciclib) The 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) for a particular member. manner, please submit all information needed to make a decision. 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. 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. endobj GLYXAMBI (empagliflozin-linagliptin) Allergen Immunotherapy Agents (Grastek, Odactra, Oralair, Ragwitek) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. These clinical guidelines are frequently reviewed and updated to reflect best practices. Aetna makes no representations and accepts no liability with respect to the content of any external information cited or relied upon in the Clinical Policy Bulletins (CPBs). VIJOICE (alpelisib) CIBINQO (abrocitinib) V 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. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. CALQUENCE (Acalabrutinib) VERKAZIA (cyclosporine ophthalmic emulsion) NURTEC ODT (rimegepant) ILUMYA (tildrakizumab-asmn) Insulin Rapid Acting (Admelog, Apidra, Fiasp, Insulin Lispro [Humalog ABA], Novolog, Insulin Aspart [Novolog ABA], Novolog ReliOn) JEMPERLI (dostarlimab-gxly) 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. VIDAZA (azacitidine) f TYRVAYA (varenicline) Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider. OZURDEX (dexamethasone intravitreal implant) M S Coverage for weight loss drugs like Wegovy varies widely depending on the kind of insurance you have and where you live. Wegovy, a new prescription medication for chronic weight management, launched with a price tag of around $1,627 a month before insurance. A prior approval is required for the procedures listed below for both the FEP Standard and Basic Option plan and the FEP Blue Focus plan. 0000004021 00000 n Valuable and timely information on drug therapy issues impacting today's health care and pharmacy environment. 0000055627 00000 n review decisions on sound clinical evidence and make a determination within the timeframe OXLUMO (lumasiran) ),)W!lD,NrJXB^9L 6ZMb>L+U8x[_a(Yw k6>HWlf>0l//l\pvy]}{&K`%&CKq&/[a4dKmWZvH(R\qaU %8d Hj @`H2i7( CN57+m:#[email protected]]\i.I/)"G"tf -5 coverage determinations for most PA types and reasons. TRACLEER (bosentan) Fax: 1-855-633-7673. allowed by state or federal law. Octreotide Acetate (Bynfezia Pen, Mycapssa, Sandostatin, Sandostatin LAR Depot) TECARTUS (brexucabtagene autoleucel) An exception can be requested following a denial of a prior authorization or can be submitted at the onset of the request. Angiotensin Receptor Blockers (e.g., Atacand, Atacand HCT, Tribenzor, Edarbi, Edarbyclor, Teveten) ULORIC (febuxostat) 0000002527 00000 n Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica) 0000055963 00000 n Reprinted with permission. Protect Wegovy from light. CABLIVI (caplacizumab) AUVI-Q (epinephrine) [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 . 0000013029 00000 n MEKTOVI (binimetinib) Tadalafil (Adcirca, Alyq) coagulation factor XIII (Tretten) 0000070343 00000 n FENORTHO (fenoprofen) ADEMPAS (riociguat) PCSK9-Inhibitors (Repatha, Praluent) EPSOLAY (benzoyl peroxide cream) COTELLIC (cobimetinib) We will be more clear with processes. Loginto your preferred web-based portal account and select New Requestwithin Fax complete signed and dated forms to CVS/Caremark at 888-836-0730. 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. BCBSKS _ Commercial _ PS _ Weight Loss Agents Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ . 0000004700 00000 n STRENSIQ (asfotase alfa) 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). Coverage of drugs is first determined by the member's pharmacy or medical benefit. RHOFADE (oxymetazoline) DELESTROGEN (estradiol valerate injection) GLEEVEC (imatinib) h E indigestion, heartburn, or gastroesophageal reflux disease (GERD) fatigue (low energy) stomach flu.
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