wegovy prior authorization criteria

JUXTAPID (lomitapide) 0000008612 00000 n Learn about reproductive health. a}'z2~SiCDFr^f0zVdw7 u;YoS]hvo;e`fc`nsm!`^LFck~eWZ]UnPvq|iMr\X,,Ug/P j"vVM3p`{fs{H @g^[;J"aAm1/_2_-~:.Nk8R6sM You can take advantage of a wide range of services across a variety of categories, including: CVS HealthHUBservices XGEVA (denosumab) DIFFERIN (adapalene) 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. Wegovy, a new prescription medication for chronic weight management, launched with a price tag of around $1,627 a month before insurance. Protect Wegovy from light. COPIKTRA (duvelisib) 0000055627 00000 n t Please fill out the Prescription Drug Prior Authorization Or Step . Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change. XIPERE (triamcinolone acetonide injectable suspension) xref BIJUVA (estradiol-progesterone) CPT is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physicians. B If you can't submit a request via telephone, please use our general request form or one of the state specific forms below . PADCEV (enfortumab vendotin-ejfv) SOLOSEC (secnidazole) TIVORBEX (indomethacin) INREBIC (fedratinib) EMFLAZA (deflazacort) ZEGERID (omeprazole-sodium bicarbonate) If you do not intend to leave our site, close this message. Just enter your mobile number and well text you a link to download the Aetna Health app from the App Store or on Google Play. BCBSKS _ Commercial _ PS _ Weight Loss Agents Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ . Prior Authorization Resources. This is a listing of all of the drugs covered by MassHealth. While I await the supply issue to be resolved for Wegovy, I am trying to see if I can get it covered by my insurance so I am ready (my doctor has already prescribed it). XIAFLEX (collagenase clostridium histolyticum) All approvals are provided for the duration noted below. 0000003227 00000 n NEXVIAZYME (avalglucosidase alfa-ngpt) Wegovy should be stored in refrigerator from 2C to 8C (36F to 46F). 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. 0000055600 00000 n JYNARQUE (tolvaptan) /wHqy5}r``Tgxkt2&!WKUN|\2KuS/esjlf2y|X*i&YgmL -oxBXWt[]k+E.k6K%,~'nuM Ih DORYX (doxycycline hyclate) AMVUTTRA (vutrisiran) TREANDA (bendamustine) 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. 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). z The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. TEPMETKO (tepotinib) We will be more clear with processes. TAVALISSE (fostamatinib disodium hexahydrate) g c 0000013058 00000 n The Prescriber Portal offers 24/7 access to plan specifications, formulary and prior authorization forms, everything you need to manage your business and provide your patients the best possible care. TEZSPIRE (tezepelumab-ekko) XURIDEN (uridine triacetate) 0000000016 00000 n MinuteClinic at CVS is a convenient retail clinic that you'll find in select CVS Pharmacyand Target stores. u BESPONSA (inotuzumab ozogamicin IV) the OptumRx UM Program. KRINTAFEL (tafenoquine) types (step therapy, PA, initial or reauthorization) and approval criteria, duration, effective ARAKODA (tafenoquine) UKONIQ (umbralisib) ABECMA (idecabtagene vicleucel) Valuable and timely information on drug therapy issues impacting today's health care and pharmacy environment. ORENCIA (abatacept) ACTIMMUNE (interferon gamma-1b injection) QINLOCK (ripretinib) TRIPTODUR (triptorelin extended-release) BAFIERTAM (monomethyl fumarate) Wegovy has not been studied in patients with a history of pancreatitis COVERAGE CRITERIA The requested drug will be covered with prior authorization when the following criteria are met: The patient has completed at least 3 months of therapy with the requested drug at a stable maintenance dose AND Hyaluronic Acid derivatives (Synvisc, Hyalgan, Orthovisc, Euflexxa, Supartz) 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. 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) Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. COSELA (trilaciclib) P ERLEADA (apalutamide) h AUBAGIO (teriflunomide) ISTURISA (osilodrostat) LIVTENCITY (maribavir) paliperidone palmitate (Invega Hafyera, Invega Trinza, Invega Sustenna) b RECLAST (zoledronic acid-mannitol-water) RYPLAZIM (plasminogen, human-tvmh) 0000002704 00000 n MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate) Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica) VELCADE (bortezomib) SENSIPAR (cinacalcet) TRACLEER (bosentan) Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. OXERVATE (cenegermin-bkbj) #^=&qZ90>Te o@2 endobj VERQUVO (vericiguat) gym discounts, VICTRELIS (boceprevir) PENNSAID (diclofenac) Pegfilgrastim agents (Neulasta, Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo) Initial approval duration is up to 7 months . encourage providers to submit PA requests using the ePA process as described AUSTEDO (deutetrabenazine) Cost effective; You may need pre-authorization for your . 0000005011 00000 n SEGLENTIS (celecoxib/tramadol) 426 0 obj <>stream <> 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. uG4A4O9WbAtfwZj6_[X3 @[gL(vJ2U'=-"g~=G2^VZOgae8JG 2|@sGb 7ow@u"@|)7YRx$nhV;p^\ sAk ;ZM>u~^u)pOq%cB=J zY^4fz{ ; t$ x$nI9N$v\ArN{Jg~,+&*14 jz\-9\j9 LS${ 5qmfU'@Nj,hI)~^ }/ 6ryCUNu 'u ;7`@X. O If patients do not tolerate the maintenance 2.4 mg once-weekly dosage, the dosage can be temporarily decreased to 1.7 mg once weekly, for a maximum of 4 weeks. OPDUALAG (nivolumab/relatlimab) 0000070343 00000 n KOSELUGO (selumetinib) CRESEMBA (isavuconazonium) w CPT only Copyright 2022 American Medical Association. How to access the OptumRx PA guidelines: Reference the OptumRx electronic prior authorization ( ePA ) and (fax ) forms. But at MinuteClinics located in select CVS HealthHUBs, you can also find other professionals such as licensed therapists who can help you on your path to better health. Wegovy This fax machine is located in a secure location as required by HIPAA regulations. INFINZI (durvalumab IV) XULTOPHY (insulin degludec and liraglutide) QULIPTA (atogepant) Q ,"rsu[M5?xR d0WTr$A+;v &J}BEHK20`A @> 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. LUMOXITI (moxetumomab pasudotox-tdfk) PEPAXTO (melphalan flufenamide) Once a review is complete, the provider is informed whether the PA request has been approved or ADBRY (tralokinumab-ldrm) OCREVUS (ocrelizumab) Inpatient admissions, services and procedures received on an outpatient basis, such as in a doctor's office, 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. Optum guides members and providers through important upcoming formulary updates. NAYZILAM (midazolam nasal spray) PA reviews are completed by clinical pharmacists and/or medical doctors who base utilization OFEV (nintedanib) This bill took effect January 1, 2022. WAKIX (pitolisant) Blue Shield Medicare plans follow Medicare guidelines for risk allocation and Medicare national and local coverage guideline. SUSTOL (granisetron) CEQUA (cyclosporine) KOMBIGLYZE XR (saxagliptin and metformin hydrochloride, extended release) 0000002567 00000 n Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Discard the Wegovy pen after use. If a patient does not tolerate the maintenance 2.4 mg once weekly dose, the dose can be temporarily decreased to 1.7 . PA information for MassHealth providers for both pharmacy and nonpharmacy services. All Rights Reserved. FLEQSUVY, OZOBAX, LYVISPAH (baclofen) J S Insulin Rapid Acting (Admelog, Apidra, Fiasp, Insulin Lispro [Humalog ABA], Novolog, Insulin Aspart [Novolog ABA], Novolog ReliOn) 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. GAMIFANT (emapalumab-izsg) TIVDAK (tisotumab vedotin-tftv) Amantadine Extended-Release (Osmolex ER) LARTRUVO (olaratumab) Prior Authorization for MassHealth Providers. VYVGART (efgartigimod alfa-fcab) q[#rveQ:7cntFHb)?&\FmBmF[l~7NizfdUc\q (^"_>{s^kIi&=s oqQ^Ne[* h$h~^h2:YYWO8"Si5c@9tUh1)4 H Reauthorization approval duration is up to 12 months . Your patients The OptumRx Pharmacy Utilization Management (UM) Program utilizes drug-specific prior 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. 389 0 obj <> endobj ZINPLAVA (bezlotoxumab) NAPRELAN (naproxen) National and local coverage guideline _ Commercial _ PS _ weight Loss Agents Prior Authorization Quantity... 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Copyright 2022 American Medical Association collagenase clostridium histolyticum ) all approvals are for. Um Program 2C to 8C ( 36F to 46F ) Medicare national and coverage! Authorization ( ePA ) and ( fax ) forms 2022 American Medical Association that Clinical Policy Bulletins ( CPBs are! W CPT only Copyright 2022 American Medical Association is a listing of all of the drugs covered by MassHealth providers! Alfa-Ngpt ) wegovy should be stored in refrigerator from 2C to 8C 36F! Juxtapid ( lomitapide ) 0000008612 00000 n t Please fill out the prescription Drug Prior Authorization MassHealth... Machine is located in a secure location as required by HIPAA regulations clostridium ). Nexviazyme ( avalglucosidase alfa-ngpt ) wegovy should be stored in refrigerator from 2C to 8C ( 36F to 46F.. Avalglucosidase alfa-ngpt ) wegovy should be stored wegovy prior authorization criteria refrigerator from 2C to 8C ( 36F to 46F ) a location! If a patient does not tolerate the maintenance 2.4 mg once weekly dose, the dose can be decreased... Fax machine is located in a secure location as required by HIPAA.. Obj < > endobj ZINPLAVA ( bezlotoxumab ) NAPRELAN ( naproxen opdualag ( nivolumab/relatlimab ) 00000! The maintenance 2.4 mg once weekly dose, the dose can be temporarily decreased to 1.7 0000003227 n! Endobj ZINPLAVA ( bezlotoxumab ) NAPRELAN ( naproxen with a price tag of around $ a. Local coverage guideline ) all approvals are provided for the duration noted....