RYBREVANT (amivantamab-vmjw)
manner, please submit all information needed to make a decision.
Optum guides members and providers through important upcoming formulary updates. 6\
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yV)GH"4LGAK`h9c&3yzGX/EN5~jx6g"nk!{`=(`\MNUokEfOnJ "1 Step #2: We review your request against our evidence-based, clinical guidelines. Specialty pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used to treat complex conditions. Peginterferon
It is sometimes known as precertification or preapproval. AZEDRA (Iobenguane I-131)
The recently passed Prior Authorization Reform Act is helping us make our services even better.
ADBRY (tralokinumab-ldrm)
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If denied, the provider may choose to prescribe a less costly but equally effective, alternative
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0000017382 00000 n
CYRAMZA (ramucirumab)
ZYKADIA (ceritinib)
AIMOVIG (erenumab-aooe)
Hepatitis C
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. ASPARLAS (calaspargase pegol)
INQOVI (decitabine and cedazuridine)
SHINGRIX (zoster vaccine recombinant)
RAYOS (prednisone)
You may also view the prior approval information in the Service Benefit Plan Brochures.
PRIOR AUTHORIZATION CRITERIA DRUG CLASS WEIGHT LOSS MANAGEMENT BRAND NAME* (generic) WEGOVY . QELBREE (viloxazine extended-release)
Of note, this policy targets Saxenda and Wegovy; other glucagon-like peptide-1 agonists which. Some subtypes have five tiers of coverage. CPT only Copyright 2022 American Medical Association. SYNAGIS (palivizumab)
4 0 obj
Attached is a listing of prescription drugs that are subject to prior authorization.
ZINPLAVA (bezlotoxumab)
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). Testosterone oral agents (JATENZO, TLANDO)
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VFEND (voriconazole)
If you have questions, you can reach out to your health care provider. HARVONI (sofosbuvir/ledipasvir)
XIAFLEX (collagenase clostridium histolyticum)
BIJUVA (estradiol-progesterone)
MYRBETRIQ (mirabegron granules)
TEPMETKO (tepotinib)
Unlisted, unspecified and nonspecific codes should be avoided. LEUKINE (sargramostim)
D
Inpatient admissions, services and procedures received on an outpatient basis, such as in a doctor's office, of the following: (a) Patient is 18 years of age for Wegovy (b) Patient is 12 years of age for Saxenda (3) Failure to lose > 5% of body weight through at least 6 months of lifestyle modification alone (e.g., dietary or caloric restriction, exercise, behavioral support, community .
ONGLYZA (saxagliptin)
RYPLAZIM (plasminogen, human-tvmh)
Drug list prices are set by the manufacturer, whereas cash prices fluctuate based on distribution costs that impact the pharmacies that fill the prescriptions. all
TARGRETIN (bexarotene)
PROAIR DIGIHALER (albuterol)
Wegovy, a new prescription medication for chronic weight management, launched with a price tag of around $1,627 a month before insurance.
0000092908 00000 n
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. Click on "Claims," "CPT/HCPCS Coding Tool," "Clinical Policy Code Search.
TAVALISSE (fostamatinib disodium hexahydrate)
ENJAYMO (sutimlimab-jome)
IMLYGIC (talimogene laherparepvec)
ROCKLATAN (netarsudil and latanoprost)
Tazarotene (Fabior; Tazorac)
ePA is a secure and easy method for submitting,managing, tracking PAs, step 2
TIVDAK (tisotumab vedotin-tftv)
TYMLOS (abaloparatide)
0000006215 00000 n
Low Molecular Weight Heparins (LMWH) - FRAGMIN (dalteparin), INNOHEP (tinzaparin), LOVENOX (enoxaparin), ARIXTRA (fondaparinux)
GILENYA (fingolimod)
CONTRAVE (bupropion and naltrexone)
UBRELVY (ubrogepant)
Prior Authorization for MassHealth Providers. RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn)
The OptumRx Pharmacy Utilization Management (UM) Program utilizes drug-specific prior TASIGNA (nilotinib)
End of Life Medications
FABRAZYME (agalsidase beta)
Welcome. ORENITRAM (treprostinil)
TECARTUS (brexucabtagene autoleucel)
Interferon beta-1b (Betaseron, Extavia)
0
BEVYXXA (betrixaban)
TRUSELTIQ (infigratinib)
CABOMETYX (cabozantinib)
RETIN-A (tretinoin)
BLENREP (Belantamab mafodotin-blmf)
Please use the updated forms found below and take note of the fax number referenced within the Drug Authorization Forms.
TEMODAR (temozolomide)
the OptumRx UM Program. 0000008455 00000 n
MAVYRET (glecaprevir/pibrentasvir)
WELIREG (belzutifan)
BREYANZI (lisocabtagene maraleucel)
XELJANZ/XELJANZ XR (tofacitinib)
ROZLYTREK (entrectinib)
The five character codes included in the Aetna Clinical Policy Bulletins (CPBs) are obtained from Current Procedural Terminology (CPT), copyright 2015 by the American Medical Association (AMA). 0000004021 00000 n
RANEXA, ASPRUZYO (ranolazine)
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XTANDI (enzalutamide)
GIVLAARI (givosiran)
XADAGO (safinamide)
AMEVIVE (alefacept)
SOTYKTU (deucravacitinib)
It does not mean precertification as defined by Texas law, as a reliable representation of payment of care or services to fully insured HMO and PPO members. We will be more clear with processes.
These clinical guidelines are frequently reviewed and updated to reflect best practices. XOSPATA (gilteritinib)
Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider. Therapeutic indication. I'm assuming this is a fairly common occurrence with Calibrate, as I wouldn't have spent $1500 if I could have easily been prescribed Ozempic by my PCP and have it covered.
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GILOTRIF (afatini)
NULOJIX (belatacept)
No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. 0000004987 00000 n
Phone : 1 (800) 294-5979.
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.
STRENSIQ (asfotase alfa)
BREXAFEMME (ibrexafungerp)
TAKHZYRO (lanadelumab)
XIPERE (triamcinolone acetonide injectable suspension)
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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. covered medication, and/or OptumRx will offer information on the process to appeal the adverse decision.
LIBTAYO (cemiplimab-rwlc)
CINQAIR (reslizumab)
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!?). 426 0 obj
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Initial approval duration is up to 7 months . Pretomanid
Blue Shield Medicare plans follow Medicare guidelines for risk allocation and Medicare national and local coverage guideline. DUOBRII (halobetasol propionate and tazarotene)
paliperidone palmitate (Invega Hafyera, Invega Trinza, Invega Sustenna)
C
Links to various non-Aetna sites are provided for your convenience only. LUPKYNIS (voclosporin)
ONZETRA XSAIL (sumatriptan nasal)
AUVI-Q (epinephrine)
ONPATTRO (patisiran for intravenous infusion)
How to access the OptumRx PA guidelines: Reference the OptumRx electronic prior authorization ( ePA ) and (fax ) forms.
NPLATE (romiplostim)
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. Each main plan type has more than one subtype. 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.
constipation *. 0000070343 00000 n
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INCIVEK (telaprevir)
XERMELO (telotristat ethyl)
Opioid Coverage Limit (initial seven-day supply)
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Explore differences between MinuteClinic and HealthHUB. Wegovy will be used concomitantly with behavioral modification and a reduced-calorie diet . RECARBRIO (imipenem, cilastin and relebactam)
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Coagulation Factor IX (Alprolix)
HAEGARDA (C1 Esterase Inhibitor SQ [human])
VERKAZIA (cyclosporine ophthalmic emulsion)
SIMPONI, SIMPONI ARIA (golimumab)
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submitting pharmacy prior authorization requests for all plans managed by If you do not intend to leave our site, close this message. ZURAMPIC (lesinurad)
SLYND (drospirenone)
If you would like to view forms for a specific drug, visit the CVS/Caremark webpage, linked below. WHA members have access to a wealth of resources including a
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. Alogliptin-Metformin (Kazano)
PAXLOVID (nirmatrelvir and ritonavir)
GLEEVEC (imatinib)
QBREXZA (glycopyrronium cloth 2.4%)
NATPARA (parathyroid hormone, recombinant human)
a
STELARA (ustekinumab)
REBLOZYL (luspatercept)
TYRVAYA (varenicline)
0000001416 00000 n
0000004700 00000 n
Other times, medical necessity criteria might not be met. 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 .
BAVENCIO (avelumab)
vomiting. But there are circumstances where there's misalignment between what is approved by the payer and what is actually . AMZEEQ (minocycline)
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. Coagulation Factor IX, recombinant, glycopegylated (Rebinyn)
This Agreement will terminate upon notice if you violate its terms.
%%EOF
INVELTYS (loteprednol etabonate)
PROLIA (denosumab)
?J?=njQK=?4P;SWxehGGPCf>rtvk'_K%!#.0Izr)}(=%l$&:i$|d'Kug7+OShwNyI>8ASy> Buprenorphine/Naloxone (Suboxone, Zubsolv, Bunavail)
KOSELUGO (selumetinib)
TECFIDERA (dimethyl fumarate)
0000002704 00000 n
HWn8}7#Y@A I-Zi!8j;)?_i-vyP$9C9*rtTf: p4U9tQM^Mz^71" >({/N$0MI\VUD;,asOd~k&3K+4]+2yY?Da C COTELLIC (cobimetinib)
ZOKINVY (lonafarnib)
STROMECTOL (ivermectin)
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. 0000002808 00000 n
Interferon beta-1a (Avonex, Rebif/Rebif Rebidose)
TUKYSA (tucatinib)
DUPIXENT (dupilumab)
FINTEPLA (fenfluramine)
TRACLEER (bosentan)
0000002756 00000 n
All decisions are backed by the latest scientific evidence and our board-certified medical directors. ORILISSA (elagolix)
KALYDECO (ivacaftor)
ZEPATIER (elbasvir-grazoprevir)
0000008484 00000 n
Some plans exclude coverage for services or supplies that Aetna considers medically necessary. Capsaicin Patch
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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 . BRINEURA (cerliponase alfa IV)
LONSURF (trifluridine and tipiracil)
0000012685 00000 n
HEPLISAV-B (hepatitis B vaccine)
DOJOLVI (triheptanoin liquid)
OLUMIANT (baricitinib)
Link to the Concomitant Opioid Benzodiazepine, Pediatric Behavioral Health Medication, Hospital Outpatient Prior Authorization, Opioid and Pain, and Second-Generation (Atypical) Antipsychotic Initiatives. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product.
PEMAZYRE (pemigatinib)
0000055434 00000 n
SOLIQUA (insulin glargine and lixisenatide)
When billing, you must use the most appropriate code as of the effective date of the submission. Other policies and utilization management programs may apply. reason prescribed before they can be covered. 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. uG4A4O9WbAtfwZj6_[X3 @[gL(vJ2U'=-"g~=G2^VZOgae8JG 2|@sGb 7ow@u"@|)7YRx$nhV;p^\ sAk ;ZM>u~^u)pOq%cB=J zY^4fz{ ;
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ACTIMMUNE (interferon gamma-1b injection)
The responsibility for the content of this product is with Aetna, Inc. and no endorsement by the AMA is intended or implied.
BELSOMRA (suvorexant)
Wegovy launched with a list price of $1,350 per 28-day supply before insurance.
Disclaimer of Warranties and Liabilities. VONJO (pacritinib)
ZOMETA (zoledronic acid)
VILTEPSO (viltolarsen)
0000004753 00000 n
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In addition, a member may have an opportunity for an independent external review of coverage denials based on medical necessity or regarding the experimental and investigational status when the service or supply in question for which the member is financially responsible is $500 or greater.
Indication and Usage. ANNOVERA (segesterone acetate/ethinyl estradiol)
ORTIKOS (budesonide ER)
0000001076 00000 n
0000069682 00000 n
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ARALEN (chloroquine phosphate)
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CIALIS (tadalafil)
Fax : 1 (888) 836- 0730. Atypical Antipsychotics, Long-Acting Injectable (Abilify Maintena, Aristata, Aristada Initio, Perseris, Risperdal Consta, Zyprexa Relprevv)
startxref
FIRDAPSE (amifampridine)
ULTOMIRIS (ravulizumab)
NUZYRA (omadacycline tosylate)
MYALEPT (metreleptin)
Applicable FARS/DFARS apply. PROMACTA (eltrombopag)
Tadalafil (Adcirca, Alyq)
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NOCTIVA (desmopressin)
CAMZYOS (mavacamten)
ZTALMY (ganaxolone suspension)
0000001794 00000 n
Wegovy prior authorization criteria united healthcare. prescription drug benefit coverage under his/her health insurance plan or call OptumRx. CHOLBAM (cholic acid)
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. <]/Prev 304793/XRefStm 2153>>
allowed by state or federal law. TRIKAFTA (elexacaftor, tezacaftor, and ivacaftor)
headache. A
The discussion, analysis, conclusions and positions reflected in the Clinical Policy Bulletins (CPBs), including any reference to a specific provider, product, process or service by name, trademark, manufacturer, constitute Aetna's opinion and are made without any intent to defame. ZEJULA (niraparib)
Coagulation Factor IX, recombinant, glycopegylated (Rebinyn) coagulation factor XIII (Tretten) Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod) CONTRAVE (bupropion and naltrexone) You can download the Aetna Health app on the App Store (Apple devices) or Google Play (Android devices).
I was just informed by my insurance (UnitedHealthcare) that the Ozempic Rx that Calibrate ordered for me was denied because I am not diabetic.
0000000016 00000 n
Some plans exclude coverage for services or supplies that Aetna considers medically necessary. Wegovy has not been studied in patients with a history of pancreatitis ~ -The safety . the decision-making process and may result in a denial unless all required information is received.
If this is the case, our team of medical directors is willing to speak with your health care provider for next steps. 0000003052 00000 n
Antihemophilic Factor VIII, Recombinant (Afstyla)
Off-label and Administrative Criteria
The member's benefit plan determines coverage.
NOCDURNA (desmopressin acetate)
PLAQUENIL (hydroxychloroquine)
For language services, please call the number on your member ID card and request an operator.
Weve answered some of the most frequently asked questions about the prior authorization process and how we can help. Patient Information
Wegovy should be used with a reduced calorie meal plan and increased physical activity. x=rF?#%=J,9R 0h/t7nH&tJ4=3}_-u~UqT/^Vu]x>W.XUuX/J"IxQbqqB iq(.n-?$bz')m>~H? 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 . denied. e
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LAGEVRIO (molnupiravir)
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).
Thats why we partner with your provider to accept requests through convenient options like phone, fax or through our online platform.
ZILXI (minocycline 1.5% foam)
SPRIX (ketorolac nasal spray)
BESPONSA (inotuzumab ozogamicin IV)
CALQUENCE (Acalabrutinib)
trailer
FORTAMET ER (metformin)
Visit the secure website, available through www.aetna.com, for more information.
0000007229 00000 n
The maintenance dosage of Wegovy is 2.4 mg injected subcutaneously once weekly. COPIKTRA (duvelisib)
Growth Hormone (Norditropin; Nutropin; Genotropin; Humatrope; Omnitrope; Saizen; Sogroya; Skytrofa; Zomacton; Serostim; Zorbtive)
RETEVMO (selpercatinib)
In some cases, not enough clinical documentation could result in a denial. xref
SIGNIFOR (pasireotide)
JUBLIA (efinaconazole)
0000001386 00000 n
UPNEEQ (oxymetazoline hydrochloride)
As an OptumRx provider, you know that certain medications require approval, or
XEPI (ozenoxacin)
DIACOMIT (stiripentol)
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. hb```b``{k @16=v1?Q_# tY
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You are now being directed to CVS Caremark site.
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. Please fill out the Prescription Drug Prior Authorization Or Step . VOXZOGO (vosoritide)
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