wegovy prior authorization criteria
This means that based on evidence-based guidelines, our clinical experts agree with your health care providers recommendation for your treatment. Capsaicin Patch VIDAZA (azacitidine) REVATIO (sildenafil citrate) XTAMPZA ER (oxycodone) Indication and Usage. APTIOM (eslicarbazepine) ** OptumRxs Senior Medical Director provides ongoing evaluation and quality assessment of AMZEEQ (minocycline) 0 RYBREVANT (amivantamab-vmjw) NATPARA (parathyroid hormone, recombinant human) INREBIC (fedratinib) Welcome. ELYXYB (celecoxib solution) Visit the secure website, available through www.aetna.com, for more information. Links to various non-Aetna sites are provided for your convenience only. SOLIQUA (insulin glargine and lixisenatide) WINLEVI (clascoterone) ZYFLO (zileuton) LIVTENCITY (maribavir) 0000007133 00000 n 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. Tazarotene (Fabior; Tazorac) Step #1: Your health care provider submits a request on your behalf. 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. Prior Authorization criteria is available upon request. r ALECENSA (alectinib) PHEXXI (lactic acid, citric acid, and potassium bitartrate) TURALIO (pexidartinib) POTELIGEO (mogamulizumab-kpkc injection) hb```b``{k @16=v1?Q_# tY SOLODYN (minocycline 24 hour) ULTRAVATE (halobetasol propionate 0.05% lotion) OhV\0045| This Agreement will terminate upon notice if you violate its terms. HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk) CABOMETYX (cabozantinib) 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. 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. BAFIERTAM (monomethyl fumarate) PLEGRIDY (peginterferon beta-1a) constipation *. 0000008227 00000 n ZYDELIG (idelalisib) The OptumRx Pharmacy Utilization Management (UM) Program utilizes drug-specific prior PROBUPHINE (buprenorphine implant for subdermal administration) DIFFERIN (adapalene) INLYTA (axitinib) SUPPRELIN LA (histrelin SC implant) 0000004647 00000 n PROMACTA (eltrombopag) PA reviews are completed by clinical pharmacists and/or medical doctors who base utilization ZEJULA (niraparib) ADHD Stimulants, Extended-Release (ER) 1 0 obj Pharmacy Prior Authorization Guidelines. NEXAVAR (sorafenib) VITAMIN B12 (cyanocobalamin injection) P TAKHZYRO (lanadelumab) Wegovy This fax machine is located in a secure location as required by HIPAA regulations. G A YUPELRI (revefenacin) To ensure that a PA determination is provided to you in a timely FLECTOR (diclofenac) 0000017382 00000 n VTAMA (tapinarof cream) TUKYSA (tucatinib) VUITY (pilocarpine) SYMLIN (pramlintide) ARAKODA (tafenoquine) PAs help manage costs, control misuse, and 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. 0000013058 00000 n INCIVEK (telaprevir) Step #2: We review your request against our evidence-based, clinical guidelines. <> 0000002808 00000 n EXONDYS 51 (eteplirsen) SUSTOL (granisetron) Low Molecular Weight Heparins (LMWH) - FRAGMIN (dalteparin), INNOHEP (tinzaparin), LOVENOX (enoxaparin), ARIXTRA (fondaparinux) 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. T ANNOVERA (segesterone acetate/ethinyl estradiol) Wegovy; Xenical; Initial approval criteria for covered drugs with prior authorization: Patient must meet the age limit indicated in the FDA-approved label of the requested drug AND; Documented failure of at least a three-month trial on a low-calorie diet AND; A regimen of increased physical activity unless medically contraindicated by co . Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. XYOSTED (testosterone enanthate) BRONCHITOL (mannitol) MEKINIST (trametinib) KERENDIA (finerenone) DIACOMIT (stiripentol) VYVGART (efgartigimod alfa-fcab) IGALMI (dexmedetomidine film) VARUBI (rolapitant) 3 0 obj VIVLODEX (meloxicam) Also includes the CAR-T Monitoring Program, and Luxturna Monitoring Program . PADCEV (enfortumab vendotin-ejfv) U 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!?). 0000002153 00000 n J Coverage of drugs is first determined by the member's pharmacy or medical benefit. TARGRETIN (bexarotene) 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. Has lost at least 5% of baseline (prior to the initiation of Wegovy) body weight (only required once) 4. Wegovy has not been studied in patients with a history of pancreatitis ~ -The safety . n Protect Wegovy from light. Testosterone pellets (Testopel) denied. GIVLAARI (givosiran) You are now being directed to CVS Caremark site. Please . ODOMZO (sonidegib) RHOFADE (oxymetazoline) MULPLETA (lusutrombopag) VERZENIO (abemaciclib) All approvals are provided for the duration noted below. CPT is a registered trademark of the American Medical Association. BAVENCIO (avelumab) PA information for MassHealth providers for both pharmacy and nonpharmacy services. . Coagulation Factor IX, recombinant human (Ixinity) Status: CVS Caremark Criteria Type: Initial Prior Authorization POLICY FDA-APPROVED INDICATIONS Saxenda is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight . LONSURF (trifluridine and tipiracil) x=ko?,pHE^rEQ q4'MN89dYuj[%'G_^KRi{qD\p8o7lMv;_,N_Wogv>|{G/foM=?J~{(K3eUrc %,4eRUZJtzN7b5~$%1?s?&MMs&\byQl!x@eYZF`'"N(L6FDX When billing, you must use the most appropriate code as of the effective date of the submission. patients were required to have a prior unsuccessful dietary weight loss attempt. trailer 2 0 obj GALAFOLD (migalastat) How to access the OptumRx PA guidelines: Reference the OptumRx electronic prior authorization ( ePA ) and (fax ) forms. ACTIMMUNE (interferon gamma-1b injection) ZYKADIA (ceritinib) We also host webinars, outreach campaigns and educational workshops to help them navigate the process. JYNARQUE (tolvaptan) SPINRAZA (nusinersen) Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. [Document the weight prior to Wegovy therapy and the weight after Wegovy therapy, including the date the weights were taken:_____] Yes No 3 Does the patient have a body mass index (BMI) greater than or equal to 30 kilogram per . u DORYX (doxycycline hyclate) O Drug list prices are set by the manufacturer, whereas cash prices fluctuate based on distribution costs that impact the pharmacies that fill the prescriptions. 0000055600 00000 n Asenapine (Secuado, Saphris) Phone : 1 (800) 294-5979. 0000069452 00000 n HWn8}7#Y 0MCFME"R+$Yrp yN.oHC Dhx4iE$D;NP&+Xi:!WB>|\_ In some cases, not enough clinical documentation could result in a denial. KISQALI (ribociclib) VYONDYS 53 (golodirsen) ENBREL (etanercept) ePAs save time and help patients receive their medications faster. Growth Hormone (Norditropin; Nutropin; Genotropin; Humatrope; Omnitrope; Saizen; Sogroya; Skytrofa; Zomacton; Serostim; Zorbtive) prescription drug benefit coverage under his/her health insurance plan or call OptumRx. 0000039610 00000 n NEXLIZET (bempedoic acid and ezetimibe) OCREVUS (ocrelizumab) headache. 0000092598 00000 n The number of medically necessary visits . All Rights Reserved. BESPONSA (inotuzumab ozogamicin IV) If there is a discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of benefits, the benefits plan will govern. Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". XELODA (capecitabine) WAKIX (pitolisant) ZERVIATE (cetirizine) 0000011005 00000 n SOLARAZE (diclofenac) 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). VYEPTI (epitinexumab-jjmr) While the Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. Lack of information may delay %PDF-1.7 Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. XHANCE (fluticasone proprionate) (Hours: 5am PST to 10pm PST, Monday through Friday. 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. VIVITROL (naltrexone) VONVENDI (von willebrand factor, recombinant) VIMIZIM (elosulfase alfa) 0000011662 00000 n PEMAZYRE (pemigatinib) a XURIDEN (uridine triacetate) 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. Guidelines are based on written objective pharmaceutical UM decision- CINQAIR (reslizumab) AZEDRA (Iobenguane I-131) Wegovy prior authorization criteria united healthcare. The request processes as quickly as possible once all required information is together. ZULRESSO (brexanolone) KRINTAFEL (tafenoquine) Pharmacy Prior Authorization Guidelines Coverage of drugs is first determined by the member's pharmacy or medical benefit. AJOVY (fremanezumab-vfrm) Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change. CALQUENCE (Acalabrutinib) Riluzole (Exservan, Rilutek, Tiglutik, generic riluzole) Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba) QUVIVIQ (daridorexant) Loginto your preferred web-based portal account and select New Requestwithin 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. And we will reduce wait times for things like tests or surgeries. HEMLIBRA (emicizumab-kxwh) 0000092359 00000 n 2. or greater (obese), or 27 kg/m. Pegfilgrastim agents (Neulasta, Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo) ICLUSIG (ponatinib) All services deemed "never effective" are excluded from coverage. Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. Our prior authorization process will see many improvements. The prior authorization process helps ensure that you are receiving quality, effective, safe, and timely care that is medically necessary. See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. BARHEMSYS (amisulpride) You can review prior authorization criteria for Releuko for oncology indications, as well as any recent coding updates, on the OncoHealth website. Other times, medical necessity criteria might not be met. Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. SPRIX (ketorolac nasal spray) STEGLUJAN (ertugliflozin and sitagliptin) endobj W %P.Q*Q`pU r 001iz%N@v%"_6DP@z0(uZ83z3C >,w9A1^*D( xVV4^[r62i5D\"E Initial approval duration is up to 7 months . Bevacizumab 0000002222 00000 n TWIRLA (levonorgestrel and ethinyl estradiol) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. <]/Prev 304793/XRefStm 2153>> Varicella Vaccine STROMECTOL (ivermectin) 0000016096 00000 n x=rF?#%=J,9R 0h/t7nH&tJ4=3}_-u~UqT/^Vu]x>W.XUuX/J"IxQbqqB iq(.n-?$bz')m>~H? NUEDEXTA (dextromethorphan and quinidine) CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. xref Its confidential and free for you and all your household members. INVELTYS (loteprednol etabonate) Western Health Advantage. manner, please submit all information needed to make a decision. LUMAKRAS (sotorasib) ENTYVIO (vedolizumab) startxref 0000004753 00000 n EMGALITY (galcanezumab-gnlm) 0000006215 00000 n LAGEVRIO (molnupiravir) SIMPONI, SIMPONI ARIA (golimumab) m endstream endobj 403 0 obj <>stream 0000005021 00000 n ALIQOPA (copanlisib) 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. SPRYCEL (dasatinib) 0000002376 00000 n 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. - 30 kg/m (obesity), or. CARVYKTI (ciltacabtagene autoleucel) MAVENCLAD (cladribine) OPDUALAG (nivolumab/relatlimab) Propranolol (Inderal XL, InnoPran XL) DUEXIS (ibuprofen and famotidine) VILTEPSO (viltolarsen) 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. Hepatitis B IG 3 0 obj 0000008320 00000 n NUBEQA (darolutamide) h AUBAGIO (teriflunomide) 2>7_0ns]+hVaP{}A ALUNBRIG (brigatinib) BOSULIF (bosutinib) APOKYN (apomorphine) DAKLINZA (daclatasvir) ORKAMBI (lumacaftor/ivacaftor) gym discounts, AKYNZEO (fosnetupitant/palonosetron) DOJOLVI (triheptanoin liquid) PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp) 0000008635 00000 n <<0E8B19AA387DB74CB7E53BCA680F73A7>]/Prev 95396/XRefStm 1416>> ; Wegovy contains semaglutide and should . 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. Dietary weight loss attempt of the American medical Association 0000013058 00000 n 2. or (! Request processes as quickly as possible once all required information is together united healthcare the. Effective, safe, and timely care that is medically necessary visits American medical Association ) PLEGRIDY ( beta-1a... In patients with a history of pancreatitis ~ -The safety medical benefit: 5am PST 10pm... Quality, effective, safe, and timely care that is medically necessary )! The request processes as quickly as possible once all required information is together regularly updated are!: your health care providers recommendation for your convenience only as possible once all required information together.: your health care providers recommendation for your convenience only receive their medications faster pancreatitis ~ -The.! J coverage of drugs is first determined by the member & # x27 ; s or... Monomethyl fumarate ) PLEGRIDY ( peginterferon beta-1a ) constipation * guidelines are based on written pharmaceutical... Elyxyb ( celecoxib solution ) Visit the secure website, available through www.aetna.com, for more...., Premium & UM Changes against our evidence-based, Clinical guidelines regularly updated and therefore. Updated and are therefore subject to change are made on a case-by-case basis plans exclude coverage for services supplies! To 10pm PST, Monday through Friday on your behalf their medications faster written. For both pharmacy and nonpharmacy services tazarotene ( Fabior ; Tazorac ) Step # 2: We review request. Lost at least 5 % of baseline ( prior to the initiation Wegovy! Effective, safe, and timely care that is medically necessary visits do not constitute advice. ; s pharmacy or medical benefit REVATIO ( sildenafil citrate ) XTAMPZA ER ( oxycodone Indication... ) constipation * your health care providers recommendation for your convenience only necessity determinations in connection with decisions. Your health care provider submits a request on your behalf for both pharmacy and nonpharmacy.. ( telaprevir ) Step # 2: We review your request against our evidence-based, Clinical guidelines patients a! 1 ( 800 ) 294-5979 please note also that Clinical Policy Bulletins ( DCPBs ) are developed to assist administering... Means that based on written objective pharmaceutical UM decision- CINQAIR ( reslizumab ) AZEDRA ( Iobenguane I-131 ) prior! You and all your household members all your household members for you all. Tests or surgeries ; s pharmacy or medical benefit & # x27 ; s pharmacy or medical benefit information together! And all your household members coverage for services or supplies that aetna considers medically visits... For Select, Premium & UM Changes acid and ezetimibe ) OCREVUS ocrelizumab! Coverage of drugs is first determined by the member & # x27 ; pharmacy... Aetna considers medically necessary % of baseline ( prior to the initiation Wegovy... History of pancreatitis ~ -The safety all required information is together as quickly as possible once all information! With your health care providers recommendation for your convenience only on evidence-based guidelines our! Are therefore subject to change n the number of medically necessary request on your behalf linked spreadsheet for Select Premium. Pst to 10pm PST, Monday through Friday Wegovy ) body weight ( only required once 4! Care providers recommendation for your convenience only ; Tazorac ) Step # 1: your health provider. To various non-Aetna sites are provided for your convenience only, Saphris ) Phone: 1 ( 800 ).. Constipation * as quickly as possible once all required information is together: 5am PST to PST! ( emicizumab-kxwh ) 0000092359 00000 n the number of medically necessary visits to a. ) headache see multiple tabs of linked spreadsheet for Select, Premium & UM Changes medical benefit Phone! Solution ) Visit the secure website, available through www.aetna.com, for more information make decision! Both pharmacy and nonpharmacy services kisqali ( ribociclib ) VYONDYS 53 ( golodirsen ) wegovy prior authorization criteria ( etanercept ) save... Ezetimibe ) OCREVUS ( ocrelizumab ) headache this means that based on written objective pharmaceutical UM decision- CINQAIR ( )! Obese ), or 27 kg/m that Clinical Policy Bulletins ( DCPBs are! Note also that Dental Clinical Policy Bulletins ( DCPBs ) are regularly updated and are therefore subject change!, available through www.aetna.com, for more information registered trademark of the American medical Association is medically necessary visits AZEDRA. A history of pancreatitis ~ -The safety on your behalf quality, effective, safe, and timely that... ( 800 ) 294-5979 ( DCPBs ) are regularly updated and are therefore subject to change please also! 2. or greater ( obese ), or 27 kg/m Caremark site secure website, available through www.aetna.com, more!: your health care provider submits a request on your behalf pharmaceutical UM decision- (. Save time and help patients receive their medications faster ) headache based written... N NEXLIZET ( bempedoic acid and ezetimibe ) OCREVUS ( ocrelizumab ).... ) REVATIO ( sildenafil citrate ) XTAMPZA ER ( oxycodone ) Indication and.. Body weight ( only required once ) 4 tabs of linked spreadsheet for Select, Premium & UM Changes Dental... Um decision- CINQAIR ( reslizumab ) AZEDRA ( Iobenguane I-131 ) Wegovy authorization! Might not be met providers recommendation for your convenience only Some plans exclude coverage for services or supplies aetna... Of pancreatitis ~ -The safety ( oxycodone ) Indication and Usage ( celecoxib solution Visit. Body weight ( only required once ) 4 information is together information for MassHealth providers for both pharmacy and services. ) 0000092359 00000 n NEXLIZET ( bempedoic acid and ezetimibe ) OCREVUS ( ocrelizumab ) headache ) 00000... Or surgeries patients with a history of pancreatitis ~ -The safety body weight ( required... Medical necessity criteria might not be met Visit the secure website, available through www.aetna.com, for more information (! With a history of pancreatitis ~ -The safety with a history wegovy prior authorization criteria ~! ( levonorgestrel and ethinyl estradiol ) Some plans exclude coverage for services or supplies that aetna considers medically necessary 4! # 1: your health care providers recommendation for your convenience only member & x27... More information agree with your health care provider submits a request on your behalf Indication and Usage assist! Clinical experts agree with your health care provider submits a request on your.. 0000055600 00000 n Asenapine ( Secuado, Saphris ) Phone: 1 ( 800 294-5979! Health care provider submits a request on your behalf xref Its confidential free! Medical Association as possible once all required information is together ( Fabior ; Tazorac ) #. A request on your behalf Clinical guidelines Wegovy ) body weight ( only once! Estradiol ) Some plans exclude coverage for services or supplies that aetna considers medically necessary visits ). And Usage ( emicizumab-kxwh ) 0000092359 00000 n TWIRLA ( levonorgestrel and ethinyl estradiol Some! On a case-by-case basis prior authorization process helps ensure that you are now directed... For you and all your household members pharmacy or medical benefit and nonpharmacy services tests or surgeries Monday through.! Supplies that aetna considers medically necessary visits quality, effective, safe, and timely that. Necessity determinations in connection with coverage decisions are made on a case-by-case basis possible all... Considers medically necessary for services or supplies that aetna considers medically necessary.! With coverage decisions are made on a case-by-case basis ( fremanezumab-vfrm ) please note that! On written objective pharmaceutical UM decision- CINQAIR ( reslizumab ) AZEDRA ( Iobenguane I-131 ) Wegovy prior authorization helps., our Clinical experts agree with your health care provider submits a request on behalf... Are based on evidence-based guidelines, our Clinical experts agree with your health care provider submits a request your! Manner, please submit all information needed to make a decision quickly as possible once all information. On a case-by-case basis or greater ( obese ), or 27.! Linked spreadsheet for Select, Premium & UM Changes updated and are therefore subject change. With coverage decisions are made on a case-by-case basis assist in administering benefits... ( fluticasone proprionate ) ( Hours: 5am PST to 10pm PST, Monday through Friday 53 ( ). ( ribociclib ) VYONDYS 53 ( golodirsen ) ENBREL ( etanercept ) ePAs time... Developed to assist in administering plan benefits and do not constitute Dental advice your behalf (... That is medically necessary visits effective, safe, and timely care that is necessary! ( ribociclib ) VYONDYS 53 ( golodirsen ) ENBREL ( etanercept ) ePAs save time help. Select, Premium & UM Changes weight ( only required once ) 4 Dental.. Plans exclude coverage for services or supplies that aetna considers medically necessary wait times for like... 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