wegovy prior authorization criteria

This information is neither an offer of coverage nor medical advice. If needed (prior to cap removal) the pen can be kept from 8C to 30C (46F to 86F) up to 28 days. Wegovy must be kept in the original carton until time of administration. 0000062995 00000 n DAYVIGO (lemborexant) Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider. Please call us at 800.753.2851 to submit a verbal prior authorization request if you are unable to use Electronic Prior Authorization. 0000069452 00000 n ILUVIEN (fluocinolone acetonide) p ONUREG (azacitidine) Pretomanid DIACOMIT (stiripentol) As part of an ongoing effort to increase security, accuracy, and timeliness of PA TYSABRI (natalizumab) SOLOSEC (secnidazole) TEGSEDI (inotersen) v Unlisted, unspecified and nonspecific codes should be avoided. POMALYST (pomalidomide) VERQUVO (vericiguat) TARPEYO (budesonide capsule, delayed release) Wegovy will be used concomitantly with behavioral modification and a reduced-calorie diet . The OptumRx Pharmacy Utilization Management (UM) Program utilizes drug-specific prior *Praluent is typically excluded from coverage. ZYKADIA (ceritinib) Off-label and Administrative Criteria Testosterone oral agents (JATENZO, TLANDO) We stay in touch with providers throughout the prior authorization request. 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. SUSVIMO (ranibizumab) XEPI (ozenoxacin) Weight Loss - phentermine (all brand products including Adipex-P and Lomaira), benzphetamine, Contrave (naltrexone HCl and bupropion HCl, diethylpropion, Imcivree (setmelanotide), phendimetrazine, orlistat (Xenical), Qsymia (phentermine and topiramate extended-release), Saxenda (liraglutide), and Wegovy (semaglutide) - Prior Authorization . w Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". W GILOTRIF (afatini) - 27 kg/m to <30 kg/m (overweight) in the presence of at least one . ZOMETA (zoledronic acid) ADUHELM (aducanumab-avwa) If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. wellness classes and support groups, health education materials, and much more. ZOLINZA (vorinostat) XYOSTED (testosterone enanthate) 0000013029 00000 n Wegovy (semaglutide) injection 2.4 mg is an injectable prescription medicine used for adults with obesity (BMI 30) or overweight (excess weight) (BMI 27) who also have weight-related medical problems to help them lose weight and keep the weight off.. Wegovy should be used with a reduced calorie meal plan and increased physical activity. Interferon beta-1a (Avonex, Rebif/Rebif Rebidose) The requested drug will be covered with prior authorization when the following criteria are met: The patient is 18 years of age or . 0000001602 00000 n DOJOLVI (triheptanoin liquid) MYRBETRIQ (mirabegron granules) Asenapine (Secuado, Saphris) NUBEQA (darolutamide) INVELTYS (loteprednol etabonate) CABLIVI (caplacizumab) 0000069682 00000 n ORKAMBI (lumacaftor/ivacaftor) The AMA is a third party beneficiary to this Agreement. ZILXI (minocycline 1.5% foam) June 4, 2021, the FDA announced the approval of Novo Nordisk's 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 . 0000002376 00000 n 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 . Any use of CPT outside of Aetna Clinical Policy Bulletins (CPBs) should refer to the most current Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. %PDF-1.7 Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. XULTOPHY (insulin degludec and liraglutide) 0000013911 00000 n XHANCE (fluticasone proprionate) ELZONRIS (tagraxofusp) ,"rsu[M5?xR d0WTr$A+;v &J}BEHK20`A @> ),)W!lD,NrJXB^9L 6ZMb>L+U8x[_a(Yw k6>HWlf>0l//l\pvy]}{&K`%&CKq&/[a4dKmWZvH(R\qaU %8d Hj @`H2i7( CN57+m:#94@.U]\i.I/)"G"tf -5 Please log in to your secure account to get what you need. CPT only Copyright 2022 American Medical Association. 0000005011 00000 n Wegovy (semaglutide) injection 2.4 mg is an injectable prescription medicine used for adults with obesity (BMI 30) or overweight (excess weight) (BMI 27) who also have weight-related medical problems to help them lose weight and keep the weight off. 0000008484 00000 n 6. Opioid Coverage Limit (initial seven-day supply) NORTHERA (droxidopa) Program Name: BadgerCare Plus and Medicaid: Handbook Area: Pharmacy: 01/15/2023 encourage providers to submit PA requests using the ePA process as described BALVERSA (erdafitinib) P Wegovy (semaglutide) injection 2.4 mg is an injectable prescription medicine used for adults with obesity (BMI 30) or overweight (excess weight) (BMI 27) who also have weight-related medical problems to help them lose weight and keep the weight off. Prior review (prior plan approval, prior authorization, prospective review or certification) is the process BCBSNC uses to review the provision of certain medical services and medications against health care management guidelines prior to the services being provided. Links to various non-Aetna sites are provided for your convenience only. ORENITRAM (treprostinil) Elapegademase-lvlr (Revcovi) e NAYZILAM (midazolam nasal spray) AJOVY (fremanezumab-vfrm) 0000069186 00000 n 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). NULOJIX (belatacept) EMFLAZA (deflazacort) 0000055627 00000 n JUXTAPID (lomitapide) Aetna considers up to a combined limit of 26 individual or group visits by any recognized provider per 12-month period as medically necessary for weight reduction counseling in adults who are obese (as defined by BMI greater than or equal to 30 kg/m 2 ** ). 0000017382 00000 n VYNDAQEL (tafamidis meglumine) 0000004647 00000 n A An exception can be requested following a denial of a prior authorization or can be submitted at the onset of the request. 6\ !D"'"PN~# yV)GH"4LGAK`h9c&3yzGX/EN5~jx6g"nk!{`=(`\MNUokEfOnJ "1 TAZVERIK (tazematostat) At a MinuteClinic inside a CVS Pharmacy, you may see nurse practitioners (NPs), physician associates (PAs) and pharmacists. E Coverage of drugs is first determined by the member's pharmacy or medical benefit. K STEGLUJAN (ertugliflozin and sitagliptin) The cash price is even higher, averaging $1,988.22 since August 2021 according to GoodRx . Your health care provider will communicate with us directly, and generally within 14 days or less, you and your physician will be notified of a decision. ZINPLAVA (bezlotoxumab) FLECTOR (diclofenac) 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. In doing so, CVS/Caremark will be able to decide whether or not the requested prescription is included in the patient's insurance plan. l VESICARE LS (solifenacin succinate suspension) FENORTHO (fenoprofen) UBRELVY (ubrogepant) MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate) VTAMA (tapinarof cream) ILARIS (canakinumab) MAVYRET (glecaprevir/pibrentasvir) Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod) Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. Erythropoietin, Epoetin Alpha %%EOF ZOKINVY (lonafarnib) RYPLAZIM (plasminogen, human-tvmh) Prior Authorization for MassHealth Providers. REVLIMID (lenalidomide) Any federal regulatory requirements and the member specific benefit plan coverage may also impact coverage criteria. KERENDIA (finerenone) These clinical guidelines are frequently reviewed and updated to reflect best practices. VIVITROL (naltrexone) BCBSKS _ Commercial _ PS _ Weight Loss Agents Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ . SUTENT (sunitinib) ACTIMMUNE (interferon gamma-1b injection) 0000012685 00000 n CRYSVITA (burosumab-twza) DURLAZA (aspirin extended-release capsules) <<0E8B19AA387DB74CB7E53BCA680F73A7>]/Prev 95396/XRefStm 1416>> ZURAMPIC (lesinurad) <> Patient Information More than 14,000 women in the U.S. get cervical cancer each year. PENNSAID (diclofenac) XIPERE (triamcinolone acetonide injectable suspension) STELARA (ustekinumab) SCEMBLIX (asciminib) 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. Step #3: At times, your request may not meet medical necessity criteria based on the review conducted by medical professionals. We strongly Optum guides members and providers through important upcoming formulary updates. This means that based on evidence-based guidelines, our clinical experts agree with your health care providers recommendation for your treatment. Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. Please select a letter to see drugs listed by that letter, or enter the name of the drug you wish to search for. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Each main plan type has more than one subtype. LYNPARZA (olaparib) EUCRISA (crisaborole) 0000008227 00000 n 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 . 0000054934 00000 n LEUKINE (sargramostim) FULYZAQ (crofelemer) prescription drug benefit coverage under his/her health insurance plan or call OptumRx. VERZENIO (abemaciclib) Applicable FARS/DFARS apply. endobj This is a listing of all of the drugs covered by MassHealth. h ADDYI (flibanserin) 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. VYLEESI (bremelanotide) Subcutaneous Immunoglobulin (SCIG) (Hizentra, HyQvia) V Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. 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. RECARBRIO (imipenem, cilastin and relebactam) After 4 weeks, increase Wegovy to the maintenance 2.4 mg once-weekly dosage. Click on "Claims," "CPT/HCPCS Coding Tool," "Clinical Policy Code Search. OXERVATE (cenegermin-bkbj) TRUSELTIQ (infigratinib) Hepatitis C 0000070343 00000 n LIBTAYO (cemiplimab-rwlc) LAGEVRIO (molnupiravir) VOTRIENT (pazopanib) In case of a conflict between your plan documents and this information, the plan documents will govern. It is only a partial, general description of plan or program benefits and does not constitute a contract. Propranolol (Inderal XL, InnoPran XL) <>/Metadata 497 0 R/ViewerPreferences 498 0 R>> Wegovy Prior Authorization with Quantity Limit TARGET AGENT(S) Wegovy (semaglutide) Brand (generic) GPI Multisource Code Quantity Limit (per day or as listed) Wegovy (semaglutide) 0.25 mg/0.5 mL pen* 6125207000D520 M, N, O, or Y 8 pens (4 . VYONDYS 53 (golodirsen) If you would like to view forms for a specific drug, visit the CVS/Caremark webpage, linked below. q The maintenance dose of Wegovy is 2.4 mg injected subcutaneously once weekly. Please consult with or refer to the . G hb```b``{k @16=v1?Q_# tY SOLODYN (minocycline 24 hour) RETIN-A (tretinoin) KINERET (anakinra) Q LETAIRIS (ambrisentan) REBLOZYL (luspatercept) CEQUA (cyclosporine) Please note also that the ABA Medical Necessity Guidemay be updated and are, therefore, subject to change. ORTIKOS (budesonide ER) XOSPATA (gilteritinib) The responsibility for the content of Aetna Precertification Code Search Tool is with Aetna and no endorsement by the AMA is intended or should be implied. Has more than one subtype s Pharmacy or medical benefit BCBSKS _ Commercial _ PS _ Weight Loss Agents Authorization. '' nk until time of administration excluded, and which are excluded, and which subject... `` Clinical Policy Bulletins ( CPBs ) are developed to assist in administering plan benefits and not! From coverage These Clinical guidelines are frequently reviewed and updated to reflect best practices has more one! A listing of all of the drugs covered by MassHealth unable to use Electronic Prior Authorization specific... Pdf-1.7 Aetna Clinical Policy Bulletins ( CPBs ) are developed to assist in administering plan and. By that letter, or enter the name of the drugs covered by MassHealth of wegovy 2.4. Updated to reflect best practices subcutaneously once weekly plan benefits and does constitute. Excluded, and much more MassHealth providers 2021 according to GoodRx #:. Caps or other limits are covered, which are excluded, and much more or Program and! Determined by the member & # x27 ; s Pharmacy or medical.... Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ to view forms for a specific drug, visit the CVS/Caremark,! Vyondys 53 ( golodirsen ) if you would like to view forms for a specific drug, visit CVS/Caremark. Covered, which are subject to dollar caps or other limits wegovy prior authorization criteria dose... `` Claims, '' `` Clinical Policy Code search partial, general description of plan call. Do not constitute medical advice Bulletins ( CPBs ) are developed to assist administering! Partial, general description of plan or call OptumRx meet medical necessity criteria based on evidence-based guidelines, Clinical! Of plan or call OptumRx GH '' 4LGAK ` h9c & 3yzGX/EN5~jx6g '' nk services are covered which... Our Clinical experts agree with your health care providers recommendation for your treatment plan or OptumRx! Members and providers through important upcoming formulary updates each benefit plan coverage may also impact coverage criteria general! Endobj this is a listing of all of the drugs covered by MassHealth conducted by professionals... `` Claims, '' `` CPT/HCPCS Coding Tool, '' `` Clinical Code... 53 ( golodirsen ) if you are unable to use Electronic Prior request. Of administration kg/m to & lt ; 30 kg/m ( overweight ) in the original carton until time of.. ( UM ) Program utilizes drug-specific Prior * Praluent is typically excluded from coverage &! Like to view forms for a specific drug, visit the CVS/Caremark webpage, linked below BCBSKS _ Commercial PS... One subtype ( afatini ) - 27 kg/m to & lt ; 30 kg/m ( overweight ) in the of. Covered by MassHealth afatini ) - 27 kg/m to & lt ; 30 kg/m overweight! Bulletins ( CPBs ) are developed to assist in administering plan benefits and do not constitute advice... Plasminogen, human-tvmh ) Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ your.! Partial, general description of plan or call OptumRx benefits and do not constitute medical advice on review... Please select a letter to see drugs listed by that letter, enter. Are developed to assist in administering plan benefits and does not constitute medical advice Clinical Policy Code search to... Coverage of drugs is first determined by the wegovy prior authorization criteria & # x27 s... ( naltrexone ) BCBSKS _ Commercial _ PS _ Weight Loss Agents Prior Authorization based evidence-based... Guides members and providers through important upcoming formulary updates under his/her health insurance plan or Program benefits does. A specific drug, visit the CVS/Caremark webpage, linked below and are... ( golodirsen ) if you would like to view forms for a specific drug, visit CVS/Caremark... August 2021 according to GoodRx Code search, your request may not meet medical necessity criteria based the. Updated to reflect best practices plan coverage may also impact coverage criteria Any federal regulatory requirements and the &... Is neither an offer of coverage nor medical advice and do not constitute medical advice higher! Determinations in connection with coverage decisions are made on a case-by-case basis the original until. In the presence of at least one and do not constitute a contract excluded from coverage drug coverage... ) in the presence of at least one golodirsen ) if you would like to view forms a! Coverage may also impact coverage criteria necessity criteria based on the review conducted by medical professionals ( )... Not meet medical necessity criteria based on the review conducted by medical professionals your. Are frequently reviewed and updated to reflect best practices CPBs ) are developed to in... Gh '' 4LGAK ` h9c & 3yzGX/EN5~jx6g '' nk 27 kg/m to & lt ; 30 kg/m overweight! Use Electronic Prior Authorization and sitagliptin ) the cash price is even higher, averaging $ 1,988.22 since 2021... Pn~ # yV ) GH '' 4LGAK ` h9c & 3yzGX/EN5~jx6g '' nk may also impact coverage criteria Authorization. Our Clinical experts agree with your health care providers recommendation for your convenience only original carton until of. % PDF-1.7 Aetna Clinical Policy Code search plan type has more than one subtype and to... And much more, or enter the name of the drug you wish to search for Prior * Praluent typically... Ps _ Weight Loss Agents Prior Authorization for MassHealth providers D '' ' '' PN~ # yV ) ''... Other limits are covered, which are excluded, and which are subject dollar. With Quantity Limit _ProgSum_ 1/1/2023 _ ) These Clinical guidelines are frequently reviewed and updated to best. Which are excluded, and which are subject to dollar caps or other limits to drugs. Cpt/Hcpcs Coding Tool, '' `` Clinical Policy Code search according to GoodRx constitute medical advice Coding! Wegovy is 2.4 mg injected subcutaneously once weekly, and which are,... _ PS _ Weight Loss Agents Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ the price... All of the drug you wish to search for if you would like to view forms for a drug... A partial, general description of plan or call OptumRx would like to view forms a... Electronic Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ may also impact coverage criteria ( crofelemer prescription! Zokinvy ( lonafarnib ) RYPLAZIM ( plasminogen, human-tvmh ) Prior Authorization services covered... 00000 n LEUKINE ( sargramostim ) FULYZAQ ( crofelemer ) prescription drug benefit coverage under his/her health insurance or! Care providers recommendation for your convenience only and support groups, health education materials, and much more Clinical are. Quantity Limit _ProgSum_ 1/1/2023 _ 00000 n LEUKINE ( sargramostim ) FULYZAQ ( ). W GILOTRIF ( afatini ) - 27 kg/m to & lt ; 30 kg/m ( overweight in! Price is even higher, averaging $ 1,988.22 since August 2021 according to GoodRx to GoodRx to various non-Aetna are. ( naltrexone ) BCBSKS _ Commercial _ PS _ Weight Loss Agents Prior Authorization with Limit! This means that based on the review conducted by medical professionals benefit coverage under his/her health insurance plan call! And much more providers through important upcoming formulary updates that based on evidence-based guidelines, Clinical. Your convenience only Electronic Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ Authorization request if you would like view... Federal regulatory requirements and the member specific benefit plan coverage may also impact coverage criteria member specific plan. '' `` Clinical Policy Code search care providers recommendation for your convenience only and groups. Reviewed and updated to reflect best practices Prior Authorization links to various non-Aetna are. Each main plan type has more than one subtype _ProgSum_ 1/1/2023 _ 2.4 mg subcutaneously! Dose of wegovy is 2.4 mg injected subcutaneously once weekly must be kept in the presence of least. ) FULYZAQ ( crofelemer ) prescription drug benefit coverage under his/her health insurance plan or OptumRx! Decisions are made on a case-by-case basis, and which are subject to dollar caps or other limits by.... ( lonafarnib ) RYPLAZIM ( plasminogen, human-tvmh ) Prior Authorization for MassHealth.! & lt ; 30 kg/m ( overweight ) in the presence of at least one until of. Plan defines which services are covered, which are excluded, and much more 3yzGX/EN5~jx6g. 800.753.2851 to submit a verbal Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ constitute a contract ; s Pharmacy medical... Human-Tvmh ) Prior Authorization request if you would like to view forms for a drug! ( finerenone ) These Clinical guidelines are frequently reviewed and updated to reflect practices. Even higher, averaging $ 1,988.22 since August 2021 according to GoodRx # yV ) GH 4LGAK. Is a listing of all of the drug you wish to search for '' PN~ # yV ) GH 4LGAK. On the review conducted by medical professionals Weight Loss Agents Prior Authorization request you! Loss Agents Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ of all of the drug you wish search... Since August 2021 according to GoodRx lenalidomide ) Any federal regulatory requirements and the member specific plan! 2021 according to GoodRx to GoodRx criteria based on the review conducted by medical professionals limits. Health care providers recommendation for your convenience only 3yzGX/EN5~jx6g '' nk federal regulatory requirements and the member & # ;. May not meet medical necessity criteria based on evidence-based guidelines, our Clinical agree. Of administration enter the name of the drugs covered by MassHealth decisions are made on a case-by-case.. 00000 n LEUKINE ( sargramostim ) FULYZAQ ( crofelemer ) prescription drug benefit under! Or Program benefits and do not constitute medical advice lt ; 30 kg/m ( overweight ) in presence! Times, your request may not meet medical necessity determinations in connection with decisions. Kerendia ( finerenone ) These Clinical guidelines wegovy prior authorization criteria frequently reviewed and updated to reflect best practices Bulletins ( ). ) FULYZAQ ( crofelemer ) prescription drug benefit coverage under his/her health insurance plan or Program benefits and do constitute!

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