0000012735 00000 n MAVENCLAD (cladribine) 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. COPIKTRA (duvelisib) This Agreement will terminate upon notice if you violate its terms. endobj It will show you whether a drug is covered or not covered, but the tier information may not be the same as it is for your specific plan. VFEND (voriconazole) Fax : 1 (888) 836- 0730. ORGOVYX (relugolix) CHOLBAM (cholic acid) This list is subject to change. ZYNLONTA (loncastuximab tesirine-lpyl). X 2545 0 obj <>stream VERKAZIA (cyclosporine ophthalmic emulsion) Conditions Not Covered SUSVIMO (ranibizumab) dates and more. nausea *. Amantadine Extended-Release (Gocovri) 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. EMFLAZA (deflazacort) TEGSEDI (inotersen) O RETIN-A (tretinoin) RAYOS (prednisone) AKYNZEO (fosnetupitant/palonosetron) KOMBIGLYZE XR (saxagliptin and metformin hydrochloride, extended release) endobj ENBREL (etanercept) EYLEA (aflibercept) KYLEENA (Levonorgestrel intrauterine device) t Weight Loss Medications (phentermine, Adipex-P, Qsymia, Contrave, Saxenda, Wegovy) Were here to help. LUMOXITI (moxetumomab pasudotox-tdfk) Discontinue WEGOVY if the patient cannot tolerate the 2.4 mg dose. SIMPONI, SIMPONI ARIA (golimumab) xref EVKEEZA (evinacumab-dgnb) ORIAHNN (elagolix, estradiol, norethindrone) Specialty drugs and prior authorizations. NEXAVAR (sorafenib) Weve answered some of the most frequently asked questions about the prior authorization process and how we can help. RAVICTI (glycerol phenylbutyrate) ZIPSOR (diclofenac) Sodium oxybate (Xyrem); calcium, magnesium, potassium, and sodium oxybates (Xywav) NUPLAZID (pimavanserin) Therapeutic indication. 0000002756 00000 n This bill took effect January 1, 2022. NEXLIZET (bempedoic acid and ezetimibe) Since Clinical Policy Bulletins (CPBs) can be highly technical and are designed to be used by our professional staff in making clinical determinations in connection with coverage decisions, members should review these Bulletins with their providers so they may fully understand our policies. You are now being directed to CVS Caremark site. RYPLAZIM (plasminogen, human-tvmh) 0000008320 00000 n PROBUPHINE (buprenorphine implant for subdermal administration) QINLOCK (ripretinib) Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. REYVOW (lasmiditan) TECHNIVIE (ombitasvir, paritaprevir, and ritonavir) LEUKINE (sargramostim) Blood Glucose Test Strips 0000000016 00000 n GILENYA (fingolimod) 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. HETLIOZ/HETLIOZ LQ (tasimelton) SYLVANT (siltuximab) XADAGO (safinamide) In case of a conflict between your plan documents and this information, the plan documents will govern. BREXAFEMME (ibrexafungerp) In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government. Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. Pegfilgrastim agents (Neulasta, Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo) 0000054864 00000 n APOKYN (apomorphine) In the event that a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision. 389 0 obj <> endobj 0000004021 00000 n ZYKADIA (ceritinib) INBRIJA (levodopa) MYLOTARG (gemtuzumab ozogamicin) In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. the decision-making process and may result in a denial unless all required information is received. W Our prior authorization process will see many improvements. IMCIVREE (setmelanotide) endstream endobj 425 0 obj <>/Filter/FlateDecode/Index[21 368]/Length 35/Size 389/Type/XRef/W[1 1 1]>>stream Lack of information may delay - 27 kg/m to <30 kg/m (overweight) in the presence of at least one . f BRAFTOVI (encorafenib) INFINZI (durvalumab IV) MARGENZA (margetuximab-cmkb) NUCALA (mepolizumab) No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. ZOLGENSMA (onasemnogene abeparvovec-xioi) TRODELVY (sacituzumab govitecan-hziy) TEPMETKO (tepotinib) ADUHELM (aducanumab-avwa) REVATIO (sildenafil citrate) authorization (PA) guidelines* to encompass assessment of drug indications, set guideline RITUXAN (rituximab) Pretomanid ZEPOSIA (ozanimod) FABRAZYME (agalsidase beta) 0000011178 00000 n %PDF-1.7 % BCBSKS _ Commercial _ PS _ Weight Loss Agents Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ . ASPARLAS (calaspargase pegol) gym discounts, LIVTENCITY (maribavir) DORYX (doxycycline hyclate) XIPERE (triamcinolone acetonide injectable suspension) 0000001751 00000 n KERYDIN (tavaborole) above. 0000055177 00000 n BLENREP (Belantamab mafodotin-blmf) endobj COSELA (trilaciclib) 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. TARPEYO (budesonide capsule, delayed release) Y VEMLIDY (tenofovir alafenamide) REZUROCK (belumosudil) STEGLUJAN (ertugliflozin and sitagliptin) 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. endobj increase WEGOVY to the maintenance 2.4 mg once weekly. Antihemophilic Factor [recombinant] pegylated-aucl (Jivi) Wegovy launched with a list price of $1,350 per 28-day supply before insurance. SOLARAZE (diclofenac) BAFIERTAM (monomethyl fumarate) Do you want to continue? hA 04Fv\GczC. KRINTAFEL (tafenoquine) Asenapine (Secuado, Saphris) Wegovy must be kept in the original carton until time of administration. TEMODAR (temozolomide) <> NORTHERA (droxidopa) Prior Authorization Resources. VIVJOA (oteseconazole) UBRELVY (ubrogepant) In doing so, CVS/Caremark will be able to decide whether or not the requested prescription is included in the patient's insurance plan. NERLYNX (neratinib) : XCOPRI (cenobamate) Please use the updated forms found below and take note of the fax number referenced within the Drug Authorization Forms. 0000092359 00000 n 0000069611 00000 n FORTEO (teriparatide) Opioid Coverage Limit (initial seven-day supply) Copyright 2015 by the American Society of Addiction Medicine. INQOVI (decitabine and cedazuridine) Patient Information 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. ORACEA (doxycycline delayed-release capsule) This excerpt is provided for use in connection with the review of a claim for benefits and may not be reproduced or used for any other purpose. 0000055434 00000 n Pharmacy Prior Authorization Guidelines. 0000001416 00000 n BARHEMSYS (amisulpride) 0000003936 00000 n The prior authorization process helps ensure that you are receiving quality, effective, safe, and timely care that is medically necessary. ZILXI (minocycline 1.5% foam) 0000002567 00000 n COTELLIC (cobimetinib) To ensure that a PA determination is provided to you in a timely <> 0000003046 00000 n RADICAVA (edaravone) Insulin Rapid Acting (Admelog, Apidra, Fiasp, Insulin Lispro [Humalog ABA], Novolog, Insulin Aspart [Novolog ABA], Novolog ReliOn) bBZ!A01/a(m:=Ug^@+zDfD|4`vP3hs)l5yb/CLBf;% 2p|~\ie.~z_OHSq::xOv[>vv HUMIRA (adalimumab) JEMPERLI (dostarlimab-gxly) 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. DELESTROGEN (estradiol valerate injection) BEVYXXA (betrixaban) Any federal regulatory requirements and the member specific benefit plan coverage may also impact coverage criteria. Phone : 1 (800) 294-5979. Reprinted with permission. UPTRAVI (selexipag) QBREXZA (glycopyrronium cloth 2.4%) ONGLYZA (saxagliptin) AKLIEF (trifarotene) Criteria for a step therapy exception can be found in OHCA rules 317:30-5-77.4. All services deemed "never effective" are excluded from coverage. SOTYKTU (deucravacitinib) Long-Acting Muscarinic Antagonists (LAMA) (Tudorza, Seebri, Incruse Ellipta) Please contact CVS/Caremark at 855-582-2022 with questions regarding the prior authorization process. 0000011005 00000 n ENDARI (l-glutamine oral powder) LIVMARLI (maralixibat solution) INGREZZA (valbenazine) LETAIRIS (ambrisentan) SCEMBLIX (asciminib) RECLAST (zoledronic acid-mannitol-water) denied. The cash price is even higher, averaging $1,988.22 since August 2021 according to GoodRx . Go to the American Medical Association Web site. ZOLINZA (vorinostat) CIBINQO (abrocitinib) 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. TALZENNA (talazoparib) making criteria** that are developed from clinical evidence from the following sources: *Guidelines are specific to plans utilizing our standard drug lists only. startxref See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. AUVI-Q (epinephrine) 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). The request processes as quickly as possible once all required information is together. REVLIMID (lenalidomide) OPSUMIT (macitentan) methotrexate injectable agents (REDITREX, OTREXUP, RASUVO) o The number of medically necessary visits . Treating providers are solely responsible for medical advice and treatment of members. MassHealth Pharmacy Initiatives and Clinical Information. ORENITRAM (treprostinil) UPNEEQ (oxymetazoline hydrochloride) 2 0 obj Medicare Plans. No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM. Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod) JAKAFI (ruxolitinib) Discard the Wegovy pen after use. PEMAZYRE (pemigatinib) MEKINIST (trametinib) V SOVALDI (sofosbuvir) Growth Hormone (Norditropin; Nutropin; Genotropin; Humatrope; Omnitrope; Saizen; Sogroya; Skytrofa; Zomacton; Serostim; Zorbtive) 0000055963 00000 n XULTOPHY (insulin degludec and liraglutide) FENORTHO (fenoprofen) ERLEADA (apalutamide) INREBIC (fedratinib) This is a listing of all of the drugs covered by MassHealth. PIQRAY (alpelisib) CPT is a registered trademark of the American Medical Association. NUBEQA (darolutamide) Were here with 24/7 support and resources to help you with work/life balance, caregiving, legal services, money matters, and more. 0000009958 00000 n AMEVIVE (alefacept) startxref Step #2: We review your request against our evidence-based, clinical guidelines. TECARTUS (brexucabtagene autoleucel) 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!?). wellness classes and support groups, health education materials, and much more. 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). ZOMETA (zoledronic acid) Off-label and Administrative Criteria YUPELRI (revefenacin) XERMELO (telotristat ethyl) If you would like to view forms for a specific drug, visit the CVS/Caremark webpage, linked below. 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 . Optum guides members and providers through important upcoming formulary updates. Link to the Concomitant Opioid Benzodiazepine, Pediatric Behavioral Health Medication, Hospital Outpatient Prior Authorization, Opioid and Pain, and Second-Generation (Atypical) Antipsychotic Initiatives. TREANDA (bendamustine) ACTEMRA (tocilizumab) All approvals are provided for the duration noted below. Gardasil 9 ORKAMBI (lumacaftor/ivacaftor) XEPI (ozenoxacin) GLYXAMBI (empagliflozin-linagliptin) Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change. q ADCETRIS (brentuximab) Antihemophilic factor VIII (Eloctate) 0000002222 00000 n 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. In some cases, not enough clinical documentation could result in a denial. TABRECTA (capmatinib) ", The five character codes included in the Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology (CPT. Loginto your preferred web-based portal account and select New Requestwithin ANNOVERA (segesterone acetate/ethinyl estradiol) IMLYGIC (talimogene laherparepvec) QULIPTA (atogepant) trailer TAGRISSO (osimertinib) Other times, medical necessity criteria might not be met. The Dental Clinical Policy Bulletins (DCPBs) describe Aetna's current determinations of whether certain services or supplies are medically necessary, based upon a review of available clinical information. Please fill out the Prescription Drug Prior Authorization Or Step . Has lost at least 5% of baseline (prior to the initiation of Wegovy) body weight (only required once) 4. You can take advantage of a wide range of services across a variety of categories, including: CVS HealthHUBservices 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. RITUXAN HYCELA (rituximab and hyaluronidase) The maintenance dose of Wegovy is 2.4 mg injected subcutaneously once weekly. RUCONEST (recombinant C1 esterase inhibitor) AUBAGIO (teriflunomide) We offer a variety of resources to support you through your health care journey, including: Resources For Living Program 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. VONJO (pacritinib) AMZEEQ (minocycline) TAVNEOS (avacopan) VALTOCO (diazepam nasal spray) Viewand print a PA request form, For urgent requests, please call us at 1-800-711-4555. MinuteClinic at CVS is a convenient retail clinic that you'll find in select CVS Pharmacyand Target stores. If needed (prior to cap removal) the pen can be kept from 8C to 30C (46F to 86F) up to 28 days.