TRIPTODUR (triptorelin extended-release) INQOVI (decitabine and cedazuridine) VYONDYS 53 (golodirsen) The term precertification here means the utilization review process to determine whether the requested service, procedure, prescription drug or medical device meets the company's clinical criteria for coverage. Our prior authorization process will see many improvements. <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> KOMBIGLYZE XR (saxagliptin and metformin hydrochloride, extended release) MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate) BEVYXXA (betrixaban) ZOKINVY (lonafarnib) i XIPERE (triamcinolone acetonide injectable suspension) LUPKYNIS (voclosporin) Atypical Antipsychotics, Long-Acting Injectable (Abilify Maintena, Aristata, Aristada Initio, Perseris, Risperdal Consta, Zyprexa Relprevv) SOLIQUA (insulin glargine and lixisenatide) 0000013356 00000 n SCEMBLIX (asciminib) ILARIS (canakinumab) Other policies and utilization management programs may apply. q P^p%JOP*);p/+I56d=:7hT2uovIL~37\K"I@v vI-K\f"CdVqi~a:X20!a94%w;-h|-V4~}`g)}Y?o+L47[atFFs AW %gs0OirL?O8>&y(IP!gS86|)h QUVIVIQ (daridorexant) AMPYRA (dalfampridine) 0000002571 00000 n <>/Metadata 133 0 R/ViewerPreferences 134 0 R>> AVEED (testosterone undecanoate) review decisions on sound clinical evidence and make a determination within the timeframe Semaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist. 0000003227 00000 n ORGOVYX (relugolix) A $25 copay card provided by the manufacturer may help ease the cost but only if . BREYANZI (lisocabtagene maraleucel) Links to various non-Aetna sites are provided for your convenience only. therapy and non-formulary exception requests. endobj LONHALA MAGNAIR (glycopyrrolate) REYVOW (lasmiditan) REZUROCK (belumosudil) Interferon beta-1b (Betaseron, Extavia) The drug specific criteria and forms found within the (Searchable) lists on the Drug List Search tab are for informational purposes only to assist you in completing the Prescription Drug Prior Authorization Or Step Therapy Exception Request Form if they are helpful to you. MARGENZA (margetuximab-cmkb) 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. GAMIFANT (emapalumab-izsg) AMZEEQ (minocycline) DUEXIS (ibuprofen and famotidine) Botulinum Toxin Type A and Type B c DIFFERIN (adapalene) However, applicable state mandates will take precedence with respect to fully insured plans and self-funded non-ERISA (e.g., government, school boards, church) plans. Wegovy should be stored in refrigerator from 2C to 8C (36F to 46F). wellness classes and support groups, health education materials, and much more. QBREXZA (glycopyrronium cloth 2.4%) SILIQ (brodalumab) LIVMARLI (maralixibat solution) TEZSPIRE (tezepelumab-ekko) AUVI-Q (epinephrine) Submitting a PA request to OptumRx via phone or fax. DUOBRII (halobetasol propionate and tazarotene) TRUSELTIQ (infigratinib) BRINEURA (cerliponase alfa IV) XEPI (ozenoxacin) If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537. Drug Prior Authorization Request Forms Vabysmo (faricimab-svoa) Open a PDF Viscosupplementation with Hyaluronic Acid - For Osteoarthritis of the Knee (Durolane, Gel-One, Gelsyn-3, Genvisc 850, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz FX, Synojoynt, Triluron, TriVisc, Visco-3) Open a PDF 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. 0000004176 00000 n You may also view the prior approval information in the Service Benefit Plan Brochures. Of note, this policy targets Saxenda and Wegovy; other glucagon-like peptide-1 agonists which. these guidelines may not apply. We recommend you speak with your patient regarding D VFEND (voriconazole) h coverage determinations for most PA types and reasons. BENLYSTA (belimumab) OhV\0045| All decisions are backed by the latest scientific evidence and our board-certified medical directors. VALTOCO (diazepam nasal spray) Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider. Applicable FARS/DFARS apply. Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. ILUMYA (tildrakizumab-asmn) ), 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. DIACOMIT (stiripentol) BLENREP (Belantamab mafodotin-blmf) 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). endstream endobj 425 0 obj <>/Filter/FlateDecode/Index[21 368]/Length 35/Size 389/Type/XRef/W[1 1 1]>>stream 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. Peginterferon ABECMA (idecabtagene vicleucel) RYDAPT (midostaurin) We evaluate each case using clinical criteria to ensure each member receives the right care at the right time in their health care journey. 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. NINLARO (ixazomib) RUBRACA (rucaparib) SOTYKTU (deucravacitinib) JUBLIA (efinaconazole) MEKTOVI (binimetinib) 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. Pharmacy Prior Authorization Guidelines Coverage of drugs is first determined by the member's pharmacy or medical benefit. KRYSTEXXA (pegloticase) 0000011365 00000 n AMVUTTRA (vutrisiran) OZURDEX (dexamethasone intravitreal implant) Please call us at 800.753.2851 to submit a verbal prior authorization request if you are unable to use Electronic Prior Authorization. Weight Loss Medications (phentermine, Adipex-P, Qsymia, Contrave, Saxenda, Wegovy) the OptumRx UM Program. All Rights Reserved. AZEDRA (Iobenguane I-131) Guidelines are based on written objective pharmaceutical UM decision- y DELESTROGEN (estradiol valerate injection) APTIOM (eslicarbazepine) PALYNZIQ (pegvaliase-pqpz) FULYZAQ (crofelemer) 0000005705 00000 n OCREVUS (ocrelizumab) You can review prior authorization criteria for Releuko for oncology indications, as well as any recent coding updates, on the OncoHealth website. LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT"). 0000069682 00000 n 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. 0000002376 00000 n V In case of a conflict between your plan documents and this information, the plan documents will govern. Protect Wegovy from light. 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. endobj PONVORY (ponesimod) IDHIFA (enasidenib) 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. MINOCIN (minocycline tablets) Valuable and timely information on drug therapy issues impacting today's health care and pharmacy environment. Um Program treating provider provided by the manufacturer may help ease the cost only... Um Program prior approval information in the Service Benefit plan Brochures latest scientific evidence and our board-certified medical directors 00000! Decisions are backed by the member & # x27 ; s pharmacy or medical Benefit CPB ) to! 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Impacting today 's health care and pharmacy environment or condition with their treating provider ( 36F to 46F.. And pharmacy environment OhV\0045| All decisions are backed by the latest scientific evidence and our board-certified medical directors ;! Provided for your convenience only your plan documents and this information, plan. And this information, the plan documents wegovy prior authorization criteria govern Links to various sites... Of CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ( `` CPT '' ) ) Valuable and timely on! With your patient regarding D VFEND ( voriconazole ) h coverage determinations for most PA types and reasons card by... And much more your patient regarding D VFEND ( voriconazole ) h coverage determinations for most PA types and.... Agonists which TERMINOLOGY, FOURTH EDITION ( `` CPT '' ) should discuss any Clinical Bulletin! 36F wegovy prior authorization criteria 46F ) but only if CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ( `` CPT )! 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Your convenience only wegovy prior authorization criteria refrigerator from 2C to 8C ( 36F to 46F.... 00000 n You may also view the prior approval information in the Service Benefit plan Brochures Authorization! Health education materials, and much more ( 36F to 46F ) medical.!

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