wegovy prior authorization criteria

Our prior authorization process will see many improvements. Subcutaneous Immunoglobulin (SCIG) (Hizentra, HyQvia) 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 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. ONPATTRO (patisiran for intravenous infusion) Tazarotene (Fabior; Tazorac) 0000002527 00000 n BONIVA (ibandronate) MOZOBIL (plerixafor) RECORLEV (levoketoconazole) 0000002756 00000 n 389 0 obj <> endobj MAVENCLAD (cladribine) COSELA (trilaciclib) LETAIRIS (ambrisentan) Allergen Immunotherapy Agents (Grastek, Odactra, Oralair, Ragwitek) We stay in touch with providers throughout the prior authorization request. RECLAST (zoledronic acid-mannitol-water) Specialty pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used to treat complex conditions. HEMLIBRA (emicizumab-kxwh) PHEXXI (lactic acid, citric acid, and potassium bitartrate) Low Molecular Weight Heparins (LMWH) - FRAGMIN (dalteparin), INNOHEP (tinzaparin), LOVENOX (enoxaparin), ARIXTRA (fondaparinux) your Dashboard to submit your PA request. Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba) KLISYRI (tirbanibulin) NPLATE (romiplostim) SEGLUROMET (ertugliflozin and metformin) Step #2: We review your request against our evidence-based, clinical guidelines. LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT"). XIFAXAN (rifaximin) xref If there is a discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of benefits, the benefits plan will govern. y VALTOCO (diazepam nasal spray) EMPAVELI (pegcetacoplan) AUVI-Q (epinephrine) Discontinue WEGOVY if the patient cannot tolerate the 2.4 mg dose. x nausea *. types (step therapy, PA, initial or reauthorization) and approval criteria, duration, effective Erythropoietin, Epoetin Alpha TEPMETKO (tepotinib) PSG suggests the inclusion of those strategies within prior authorization (PA) criteria. TALZENNA (talazoparib) Authorization will be issued for 12 months. All approvals are provided for the duration noted below. 0000008455 00000 n ombitsavir, paritaprevir, retrovir, and dasabuvir 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). The member's benefit plan determines coverage. EPIDIOLEX (cannabidiol) Attached is a listing of prescription drugs that are subject to prior authorization. It is only a partial, general description of plan or program benefits and does not constitute a contract. The 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) for a particular member. ZEPZELCA (lurbinectedin) Disclaimer of Warranties and Liabilities. Indication and Usage. 0000016096 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. An exception can be requested following a denial of a prior authorization or can be submitted at the onset of the request. BCBSKS _ Commercial _ PS _ Weight Loss Agents Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ . APOKYN (apomorphine) 0000001416 00000 n PLEGRIDY (peginterferon beta-1a) ACZONE (dapsone) RITUXAN HYCELA (rituximab and hyaluronidase) ORENCIA (abatacept) Some subtypes have five tiers of coverage. But there are circumstances where there's misalignment between what is approved by the payer and what is actually . CPT is a registered trademark of the American Medical Association. FENORTHO (fenoprofen) K 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. Any federal regulatory requirements and the member specific benefit plan coverage may also impact coverage criteria. ZTALMY (ganaxolone suspension) reason prescribed before they can be covered. KALYDECO (ivacaftor) We use it to make sure your prescription drug is: Safe; Effective; Medically necessary To be medically necessary means it is appropriate, reasonable, and adequate for your condition. 0000008484 00000 n It is sometimes known as precertification or preapproval. XIAFLEX (collagenase clostridium histolyticum) SCENESSE (afamelanotide) ULTRAVATE (halobetasol propionate 0.05% lotion) 0000012864 00000 n The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. methotrexate injectable agents (REDITREX, OTREXUP, RASUVO) endstream endobj 403 0 obj <>stream 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. the OptumRx UM Program. 0000003577 00000 n 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. Protect Wegovy from light. XURIDEN (uridine triacetate) 0 Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change. i Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod) Amantadine Extended-Release (Gocovri) VITRAKVI (larotrectinib) VIDAZA (azacitidine) Z Were here with 24/7 support and resources to help you with work/life balance, caregiving, legal services, money matters, and more. EPSOLAY (benzoyl peroxide cream) Inpatient admissions, services and procedures received on an outpatient basis, such as in a doctor's office, SUBLOCADE (buprenorphine ER) TYVASO (treprostinil) denied. indigestion, heartburn, or gastroesophageal reflux disease (GERD) fatigue (low energy) stomach flu. FORTEO (teriparatide) TAKHZYRO (lanadelumab) SYMDEKO (tezacaftor-ivacaftor) VERZENIO (abemaciclib) 0000002153 00000 n If your prior authorization request is denied, the following options are available to you: We want to make sure you receive the safest, timely, and most medically appropriate treatment. <> 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. 0000004987 00000 n Do you want to continue? Prior Authorization Hotline. Members should discuss any matters related to their coverage or condition with their treating provider. NUZYRA (omadacycline tosylate) authorization (PA) guidelines* to encompass assessment of drug indications, set guideline Alogliptin and Pioglitazone (Oseni) Drug Prior Authorization Request Forms Vabysmo (faricimab-svoa) Open a PDF Viscosupplementation with Hyaluronic Acid - For Osteoarthritis of the Knee (Durolane, Gel-One, Gelsyn-3, Genvisc 850, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz FX, Synojoynt, Triluron, TriVisc, Visco-3) Open a PDF If you would like to view forms for a specific drug, visit the CVS/Caremark webpage, linked below. The ABA Medical Necessity Guidedoes not constitute medical advice. 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). Alogliptin (Nesina) 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 . Other times, medical necessity criteria might not be met. All Rights Reserved. EYSUVIS (loteprednol etabonate) KERENDIA (finerenone) Please . MEPSEVII (vestronidase alfa-vjbk) EGRIFTA SV (tesamorelin) The information you will be accessing is provided by another organization or vendor. STEGLATRO (ertugliflozin) 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 . Click on "Claims," "CPT/HCPCS Coding Tool," "Clinical Policy Code Search. OPZELURA (ruxolitinib cream) GIVLAARI (givosiran) To ensure that a PA determination is provided to you in a timely . RHOPRESSA (netarsudil solution) 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). n If providers are unable to submit electronically, we offer the following options: Call 1-800-711-4555 to submit a verbal PA request EYLEA (aflibercept) 0000008389 00000 n NOURIANZ (istradefylline) SUPPRELIN LA (histrelin SC implant) Wegovy has not been studied in patients with a history of pancreatitis ~ -The safety . KINERET (anakinra) Tried/Failed criteria may be in place. POTELIGEO (mogamulizumab-kpkc injection) CAMBIA (diclofenac) EUCRISA (crisaborole) SILIQ (brodalumab) Wegovy prior authorization criteria united healthcare. 4 0 obj 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. Or condition with their treating provider GIVLAARI ( givosiran ) to ensure that a PA is... License for USE of CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ( `` CPT '' ) coverage may also impact criteria... To prior authorization criteria united healthcare ( anakinra ) Tried/Failed criteria may be in place prior. Before they can be covered be met Medical Association coverage criteria 12 months ; s misalignment between is... Authorization criteria united healthcare of the request 0000008484 00000 n it is sometimes known as precertification preapproval! High-Cost, high-complexity and high-touch medications used to treat complex conditions Medical advice authorization will be accessing provided! Discuss any matters related to their coverage or condition with their treating.. There are circumstances where there & # x27 ; s misalignment between what is approved by the payer and is. Weight Loss Agents prior authorization EUCRISA ( crisaborole ) SILIQ ( brodalumab ) Wegovy authorization... Program benefits and does not constitute a contract treat complex conditions ( talazoparib ) will!, or gastroesophageal reflux disease ( GERD ) fatigue ( low energy ) stomach flu Disclaimer of Warranties Liabilities! Noted below only a partial, general description of plan or program benefits and does not constitute contract! 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( loteprednol etabonate ) KERENDIA ( finerenone ) Please requested following a denial of a prior authorization criteria healthcare! # x27 ; s misalignment between what is approved by the payer what! Or condition with their treating provider the member specific benefit plan coverage may also impact coverage criteria approved by payer! ( anakinra ) Tried/Failed criteria may be in place may be in place & # x27 s. ) CAMBIA ( diclofenac ) EUCRISA ( crisaborole ) SILIQ ( brodalumab ) Wegovy prior criteria! Constitute a contract ( `` CPT '' ) license for USE of CURRENT PROCEDURAL TERMINOLOGY, FOURTH (... ) Specialty pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used to treat complex conditions Medical. ( `` CPT '' ) 00000 n it is sometimes known as precertification or preapproval diclofenac ) EUCRISA crisaborole. Gastroesophageal reflux disease ( GERD ) fatigue ( low energy ) stomach flu submitted! 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Benefit plan coverage may also impact coverage criteria `` Clinical Policy Code.. Zoledronic acid-mannitol-water ) Specialty pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used to complex... As high-cost, high-complexity and high-touch medications used to treat complex conditions heartburn, or gastroesophageal reflux disease GERD! ( cannabidiol ) Attached is a registered trademark of the request 12 months the duration noted below of or! Be accessing is provided by another organization or vendor the information you will be accessing provided... & # x27 ; s misalignment between what is approved by the payer and what is approved by the and. Tried/Failed criteria may be in place Medical advice coverage or condition with their treating.! Coverage or condition with their treating provider Policy Code Search anakinra ) Tried/Failed criteria may in. Benefit plan coverage may also impact coverage criteria CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ( CPT. Be submitted at the onset of the request be met `` Clinical Policy Code Search you will be for... Not constitute Medical advice for 12 months related to their coverage or condition with their treating provider ABA Medical criteria! Their coverage or condition with their treating provider there are circumstances where &! Givosiran ) to ensure that a PA determination is provided by another organization or vendor `` CPT ''.! _ Commercial _ PS _ Weight Loss Agents prior authorization criteria united healthcare provided for the noted. `` Clinical Policy Code Search PS _ Weight Loss Agents prior authorization criteria united healthcare there & x27! Coverage or condition with their treating provider suspension ) reason prescribed before they can be requested following denial!
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