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LUCENTIS (ranibizumab)
Gardasil 9
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Infliximab Agents (REMICADE, infliximab, AVSOLA, INFLECTRA, RENFLEXIS)
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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.
SCENESSE (afamelanotide)
OXLUMO (lumasiran)
0000011411 00000 n
DAYVIGO (lemborexant)
VERKAZIA (cyclosporine ophthalmic emulsion)
0000002704 00000 n
ONGLYZA (saxagliptin)
0000069186 00000 n
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authorization (PA) guidelines* to encompass assessment of drug indications, set guideline ), 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.
Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits.
KORSUVA (difelikefalin)
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.
0000000016 00000 n
An exception can be requested following a denial of a prior authorization or can be submitted at the onset of the request.
CRESEMBA (isavuconazonium)
(Hours: 5am PST to 10pm PST, Monday through Friday. ULTOMIRIS (ravulizumab)
This list is subject to change.
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 . Medicare Plans. VOXZOGO (vosoritide)
NEXLETOL (bempedoic acid)
BREXAFEMME (ibrexafungerp)
LAGEVRIO (molnupiravir)
RYBREVANT (amivantamab-vmjw)
The number of medically necessary visits . ARALEN (chloroquine phosphate)
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 . MEPSEVII (vestronidase alfa-vjbk)
Pretomanid
ORKAMBI (lumacaftor/ivacaftor)
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. types (step therapy, PA, initial or reauthorization) and approval criteria, duration, effective This page includes important information for MassHealth providers about prior authorizations. Unlisted, unspecified and nonspecific codes should be avoided.
Service code if available (HCPCS/CPT) To better serve our providers, business partners, and patients, the Cigna Coverage Review Department is transitioning from PromptPA, fax, and phone coverage reviews (also called prior authorizations) to Electronic Prior Authorizations (ePAs).
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.
ORTIKOS (budesonide ER)
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.
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0000039610 00000 n
[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 . 3 0 obj
0000004176 00000 n
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prior authorization (PA), to ensure that they are medically necessary and appropriate for the your Dashboard to submit your PA request. Hepatitis C
Submitting an electronic prior authorization (ePA) request to OptumRx ZILXI (minocycline 1.5% foam)
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Drug list prices are set by the manufacturer, whereas cash prices fluctuate based on distribution costs that impact the pharmacies that fill the prescriptions. 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. OptumRx, except for the following states: MA, RI, SC, and TX. Lack of information may delay %PDF-1.7
This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. The prior authorization process helps ensure that you are receiving quality, effective, safe, and timely care that is medically necessary. 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). You may also view the prior approval information in the Service Benefit Plan Brochures. MAVENCLAD (cladribine)
prescription drug benefit coverage under his/her health insurance plan or call OptumRx.
ZOMETA (zoledronic acid)
In the event that a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision. ORACEA (doxycycline delayed-release capsule)
Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". BAFIERTAM (monomethyl fumarate)
- 30 kg/m (obesity), or. B"_?jB+K DAkM5Zq\!rmLlIyn1vH _`a8,hks\Bsr\\MnNLs4d.mp
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SENSIPAR (cinacalcet)
REVATIO (sildenafil citrate)
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QUVIVIQ (daridorexant)
Please select a letter to see drugs listed by that letter, or enter the name of the drug you wish to search for.
NUZYRA (omadacycline tosylate)
Off-label and Administrative Criteria
ROZLYTREK (entrectinib)
RYDAPT (midostaurin)
Wegovy launched with a list price of $1,350 per 28-day supply before insurance.
If a patient does not tolerate the maintenance 2.4 mg once weekly dose, the dose can be temporarily decreased to 1.7 . 0000001794 00000 n
Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn)
Please . STRENSIQ (asfotase alfa)
Please call us at 800.753.2851 to submit a verbal prior authorization request if you are unable to use Electronic Prior Authorization. TAFINLAR (dabrafenib)
Any federal regulatory requirements and the member specific benefit plan coverage may also impact coverage criteria.
GLYXAMBI (empagliflozin-linagliptin)
VYONDYS 53 (golodirsen)
BRUKINSA (zanubrutinib)
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PAs help manage costs, control misuse, and
The maintenance dose of Wegovy is 2.4 mg injected subcutaneously once weekly. 0000003936 00000 n
DELATESTRYL (testosterone cypionate 100mg/ml; 200mg/ml)
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The OptumRx Pharmacy Utilization Management (UM) Program utilizes drug-specific prior
TALZENNA (talazoparib)
To request authorization for Leqvio, or to request authorization for Releuko for non-oncology purposes, please contact CVS Health-NovoLogix via phone (844-387-1435) or fax (844-851-0882).
SUNOSI (solriamfetol)
DUEXIS (ibuprofen and famotidine)
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All services deemed "never effective" are excluded from coverage.
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. RADICAVA (edaravone)
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.
INBRIJA (levodopa)
XEPI (ozenoxacin)
See multiple tabs of linked spreadsheet for Select, Premium & UM Changes.
REBLOZYL (luspatercept)
0000005021 00000 n
ZOLGENSMA (onasemnogene abeparvovec-xioi)
Applicable FARS/DFARS apply. 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.
Subcutaneous Immunoglobulin (SCIG) (Hizentra, HyQvia)
prior to using drug therapy AND The patient has a body weight above 60 kilograms AND o The patient has an initial body mass index (BMI) corresponding to 30 kilogram per square meter or greater for adults by international cut-off points based on the Cole Criteria REFERENCES 1. 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.
2>7_0ns]+hVaP{}A dates and more. So far, all weight loss drugs are 'excluded' from coverage for my specific employer's contracted plan.
SUBLOCADE (buprenorphine ER)
Loginto your preferred web-based portal account and select New Requestwithin AUVI-Q (epinephrine)
AUBAGIO (teriflunomide)
x=rF?#%=J,9R 0h/t7nH&tJ4=3}_-u~UqT/^Vu]x>W.XUuX/J"IxQbqqB iq(.n-?$bz')m>~H? PENNSAID (diclofenac)
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SYMTUZA (darunavir, cobicistat, emtricitabine, and tenofovir alafenamide tablet )
FYARRO (sirolimus protein-bound particles)
UKONIQ (umbralisib)
Go to the American Medical Association Web site. SYMDEKO (tezacaftor-ivacaftor)
Angiotensin Receptor Blockers (e.g., Atacand, Atacand HCT, Tribenzor, Edarbi, Edarbyclor, Teveten)
As part of an ongoing effort to increase security, accuracy, and timeliness of PA AVEED (testosterone undecanoate)
VYZULTA (latanoprostene bunod)
TIVDAK (tisotumab vedotin-tftv)
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. QTERN (dapagliflozin and saxagliptin)
e
Step #2: We review your request against our evidence-based, clinical guidelines.These clinical guidelines are frequently reviewed and updated to reflect best practices. 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. This excerpt is provided for use in connection with the review of a claim for benefits and may not be reproduced or used for any other purpose.
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.
0000001416 00000 n
FASENRA (benralizumab)
NEXVIAZYME (avalglucosidase alfa-ngpt)
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.
If denied, the provider may choose to prescribe a less costly but equally effective, alternative SYLVANT (siltuximab)
If you wish to request a Medicare Part Determination (Prior Authorization or Exception request), please see your plan's website for the appropriate form and instructions on how to submit your request.
VONVENDI (von willebrand factor, recombinant)
Step #1: Your health care provider submits a request on your behalf. Aetna has reached these conclusions based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). CAMZYOS (mavacamten)
The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. LETAIRIS (ambrisentan)
All Rights Reserved. This Agreement will terminate upon notice if you violate its terms. HARVONI (sofosbuvir/ledipasvir)
LUMOXITI (moxetumomab pasudotox-tdfk)
ROCKLATAN (netarsudil and latanoprost)
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.
0000011178 00000 n
0000069611 00000 n
Of note, Saxenda (liraglutide subcutaneous injection) and Wegovy (semaglutide subcutaneous injection) are indicated for chronic weight . x
INCIVEK (telaprevir)
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0000004021 00000 n
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BREYANZI (lisocabtagene maraleucel)
6\
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yV)GH"4LGAK`h9c&3yzGX/EN5~jx6g"nk!{`=(`\MNUokEfOnJ "1 KRINTAFEL (tafenoquine)
It is . ONZETRA XSAIL (sumatriptan nasal)
patients were required to have a prior unsuccessful dietary weight loss attempt. BRAFTOVI (encorafenib)
Has lost at least 5% of baseline (prior to the initiation of Wegovy) body weight (only required once) 4. REZUROCK (belumosudil)
RUBRACA (rucaparib)
The member's benefit plan determines coverage.
RUZURGI (amifampridine)
S
EPSOLAY (benzoyl peroxide cream)
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. Whats the difference? <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>>
But there are circumstances where there's misalignment between what is approved by the payer and what is actually . STROMECTOL (ivermectin)
0000008635 00000 n
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TAZVERIK (tazematostat)
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MassHealth Pharmacy Initiatives and Clinical Information.
interferon peginterferon galtiramer (MS therapy)
Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations. CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. BEVYXXA (betrixaban)
NOCTIVA (desmopressin)
GAMIFANT (emapalumab-izsg)
TIVORBEX (indomethacin)
III. You can review prior authorization criteria for Releuko for oncology indications, as well as any recent coding updates, on the OncoHealth website.
ALUNBRIG (brigatinib)
Insulin Rapid Acting (Admelog, Apidra, Fiasp, Insulin Lispro [Humalog ABA], Novolog, Insulin Aspart [Novolog ABA], Novolog ReliOn)
SPRIX (ketorolac nasal spray)
OPZELURA (ruxolitinib cream)
XCOPRI (cenobamate)
GLP-1 Agonists (Bydureon, Bydureon BCise, Byetta, Ozempic, Rybelsus, Trulicity, Victoza, Adlyxin) & GIP/GLP-1 Agonist (Mounjaro)
NULIBRY (fosdenopterin)
XELJANZ/XELJANZ XR (tofacitinib)
IBRANCE (palbociclib)
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Under certain plans, if more than one service can be used to treat a covered person's dental condition, Aetna may decide to authorize coverage only for a less costly covered service provided that certain terms are met.
XGEVA (denosumab)
INQOVI (decitabine and cedazuridine)
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.
ZOSTAVAX (zoster vaccine live)
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The Dental Clinical Policy Bulletins (DCPBs) describe Aetna's current determinations of whether certain services or supplies are medically necessary, based upon a review of available clinical information. 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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VIJOICE (alpelisib)
WAKIX (pitolisant)
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RECARBRIO (imipenem, cilastin and relebactam)
HAEGARDA (C1 Esterase Inhibitor SQ [human])
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