The information you will be accessing is provided by another organization or vendor. PROLIA (denosumab)
In some cases, not enough clinical documentation could result in a denial.
COPIKTRA (duvelisib)
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 . KYLEENA (Levonorgestrel intrauterine device)
In case of a conflict between your plan documents and this information, the plan documents will govern.
0000069186 00000 n
Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits.
0000004021 00000 n
VYVGART (efgartigimod alfa-fcab)
Amantadine Extended-Release (Osmolex ER)
REZUROCK (belumosudil)
1 0 obj
CAPLYTA (lumateperone)
Our prior authorization process will see many improvements.
SYNRIBO (omacetaxine mepesuccinate)
Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. If you have questions, you can reach out to your health care provider.
It is .
VALTOCO (diazepam nasal spray)
Phone: 1-855-344-0930. When billing, you must use the most appropriate code as of the effective date of the submission.
j
XADAGO (safinamide)
Links to various non-Aetna sites are provided for your convenience only. We evaluate each case using clinical criteria to ensure each member receives the right care at the right time in their health care journey.
Get Pre-Authorization or Medical Necessity Pre-Authorization. making criteria** that are developed from clinical evidence from the following sources: *Guidelines are specific to plans utilizing our standard drug lists only. 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).
VITRAKVI (larotrectinib)
WELIREG (belzutifan)
** OptumRxs Senior Medical Director provides ongoing evaluation and quality assessment of TECHNIVIE (ombitasvir, paritaprevir, and ritonavir)
Your patients KLISYRI (tirbanibulin)
VTAMA (tapinarof cream)
You can take advantage of a wide range of services across a variety of categories, including: CVS HealthHUBservices Wegovy should be used with a reduced calorie meal plan and increased physical activity. TAGRISSO (osimertinib)
End of Life Medications
SENSIPAR (cinacalcet)
ROCKLATAN (netarsudil and latanoprost)
xref
ERLEADA (apalutamide)
LUCEMYRA (lofexidine)
Please consult with or refer to the . RYPLAZIM (plasminogen, human-tvmh)
Criteria for a step therapy exception can be found in OHCA rules 317:30-5-77.4.
Reauthorization approval duration is up to 12 months . 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. Since Dental Clinical Policy Bulletins (DCPBs) can be highly technical and are designed to be used by our professional staff in making clinical determinations in connection with coverage decisions, members should review these Bulletins with their providers so they may fully understand our policies. Its confidential and free for you and all your household members. MYLOTARG (gemtuzumab ozogamicin)
TAKHZYRO (lanadelumab)
VIBERZI (eluxadoline)
GLEEVEC (imatinib)
endobj
ZYDELIG (idelalisib)
xref
KINERET (anakinra)
h
Type in Wegovy and see what it says. PROAIR DIGIHALER (albuterol)
NOCDURNA (desmopressin acetate)
ZORVOLEX (diclofenac)
Please select a letter to see drugs listed by that letter, or enter the name of the drug you wish to search for.
ORGOVYX (relugolix)
SIMPONI, SIMPONI ARIA (golimumab)
These clinical guidelines are frequently reviewed and updated to reflect best practices. Links to various non-Aetna sites are provided for your convenience only. Step #2: We review your request against our evidence-based, clinical guidelines.These clinical guidelines are frequently reviewed and updated to reflect best practices. TYRVAYA (varenicline)
IBRANCE (palbociclib)
JUXTAPID (lomitapide)
Please .
EVENITY (romosozumab-aqqg)
a State mandates may apply.
AUSTEDO (deutetrabenazine)
GAVRETO (pralsetinib)
BENLYSTA (belimumab)
0000092598 00000 n
In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government. As part of an ongoing effort to increase security, accuracy, and timeliness of PA XIFAXAN (rifaximin)
LUCENTIS (ranibizumab)
TIVDAK (tisotumab vedotin-tftv)
LIBTAYO (cemiplimab-rwlc)
RUCONEST (recombinant C1 esterase inhibitor)
CRYSVITA (burosumab-twza)
SOLODYN (minocycline 24 hour)
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!?). BRUKINSA (zanubrutinib)
! Z3mo5&/ ^fHx&,=dtbX,DGjbWo.AT+~D.yVc$o5`Jkxyk+ln
5mA78+7k}HZX*-oUcR);"D:K@8hW]j
{v$pGvX 14Tw1Eb-c{Hpxa_/=Z=}E. Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod)
Sodium oxybate (Xyrem); calcium, magnesium, potassium, and sodium oxybates (Xywav)
More than 14,000 women in the U.S. get cervical cancer each year. MEPSEVII (vestronidase alfa-vjbk)
BAVENCIO (avelumab)
TRIPTODUR (triptorelin extended-release)
- 30 kg/m (obesity), or. VONJO (pacritinib)
0000008635 00000 n
XELODA (capecitabine)
ONGLYZA (saxagliptin)
426 0 obj
<>stream
Botulinum Toxin Type A and Type B
TECFIDERA (dimethyl fumarate)
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). BRINEURA (cerliponase alfa IV)
0000013580 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). XHANCE (fluticasone proprionate)
Wegovy is indicated for adults who are obese (body mass index 30) or overweight (body mass index 27), and who also have certain weight-related medical conditions, such as type 2 diabetes .
Of note, this policy targets Saxenda and Wegovy; other glucagon-like peptide-1 agonists which.
Part D drug list for Medicare plans. The American Medical Association (AMA) does not directly or indirectly practice medicine or dispense medical services. You are now being directed to CVS Caremark site.
Bevacizumab
OLUMIANT (baricitinib)
LUPKYNIS (voclosporin)
Also includes the CAR-T Monitoring Program, and Luxturna Monitoring Program . <>
The recently passed Prior Authorization Reform Act is helping us make our services even better. ZTALMY (ganaxolone suspension)
. Prior Authorization Hotline. trailer
This means that based on evidence-based guidelines, our clinical experts agree with your health care providers recommendation for your treatment.
l
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.
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.
PA information for MassHealth providers for both pharmacy and nonpharmacy services. %PDF-1.7
%
paliperidone palmitate (Invega Hafyera, Invega Trinza, Invega Sustenna)
EVKEEZA (evinacumab-dgnb)
GILENYA (fingolimod)
LONHALA MAGNAIR (glycopyrrolate)
endobj
All services deemed "never effective" are excluded from coverage.
2493 53
DAYVIGO (lemborexant)
0000001416 00000 n
FORTAMET ER (metformin)
ZULRESSO (brexanolone)
HWn8}7#Y 0MCFME"R+$Yrp
yN.oHC Dhx4iE$D;NP&+Xi:!WB>|\_ IDHIFA (enasidenib)
After 4 weeks, increase Wegovy to the maintenance 2.4 mg once-weekly dosage. ELIQUIS (apixaban)
0000001386 00000 n
SUBLOCADE (buprenorphine ER)
0000013029 00000 n
RHOFADE (oxymetazoline)
III. 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. DELATESTRYL (testosterone cypionate 100mg/ml; 200mg/ml)
N
We stay in touch with providers throughout the prior authorization request.
XEPI (ozenoxacin)
endstream
endobj
425 0 obj
<>/Filter/FlateDecode/Index[21 368]/Length 35/Size 389/Type/XRef/W[1 1 1]>>stream
0000003481 00000 n
ONUREG (azacitidine)
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.
0000009958 00000 n
Welcome.
EYSUVIS (loteprednol etabonate)
All Rights Reserved.
MinuteClinic at CVS is a convenient retail clinic that you'll find in select CVS Pharmacyand Target stores.
OFEV (nintedanib)
This search will use the five-tier subtype. Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". wellness assessment,
All Rights Reserved.
AIMOVIG (erenumab-aooe)
REBLOZYL (luspatercept)
FABRAZYME (agalsidase beta)
<]/Prev 304793/XRefStm 2153>>
Prior Authorization criteria is available upon request.
UBRELVY (ubrogepant)
LETAIRIS (ambrisentan)
VARUBI (rolapitant)
While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. ZOLGENSMA (onasemnogene abeparvovec-xioi)
Growth Hormone (Norditropin; Nutropin; Genotropin; Humatrope; Omnitrope; Saizen; Sogroya; Skytrofa; Zomacton; Serostim; Zorbtive)
All decisions are backed by the latest scientific evidence and our board-certified medical directors. 0000006215 00000 n
all
OPSUMIT (macitentan)
Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn)
Some plans exclude coverage for services or supplies that Aetna considers medically necessary.
DAURISMO (glasdegib)
requests and determinations, OptumRx is retiring most fax numbers used for
While Clinical Policy Bulletins (CPBs) define Aetna's clinical policy, medical necessity determinations in connection with coverage decisions are made on a case by case basis. ombitsavir, paritaprevir, retrovir, and dasabuvir
Providers may request a step therapy exception to skip the step therapy process and receive the Tier 2 or higher drug immediately. No fee schedules, basic unit, relative values or related listings are included in CPT. Blood Glucose Test Strips
C
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)
Loginto your preferred web-based portal account and select New Requestwithin
endobj
0000011662 00000 n
BELEODAQ (belinostat)
STRENSIQ (asfotase alfa)
The member's benefit plan determines coverage.
0000008389 00000 n
RETEVMO (selpercatinib)
INLYTA (axitinib)
The responsibility for the content of Aetna Clinical Policy Bulletins (CPBs) is with Aetna and no endorsement by the AMA is intended or should be implied. RUBRACA (rucaparib)
Please be sure to add a 1 before your mobile number, ex: 19876543210, Guidelines from nationally recognized health care organizations such as the Centers for Medicare and Medicaid Services (CMS), Peer-reviewed, published medical journals, A review of available studies on a particular topic, Expert opinions of health care professionals. 389 0 obj
<>
endobj
0000000016 00000 n
License to use CPT for any use not authorized herein must be obtained through the American Medical Association, CPT Intellectual Property Services, 515 N. State Street, Chicago, Illinois 60610.
Pancrelipase (Pancreaze; Pertyze; Viokace)
SOTYKTU (deucravacitinib)
FENORTHO (fenoprofen)
Q
hbbc`b``3
A0 7
Status: CVS Caremark Criteria Type: Initial Prior Authorization POLICY FDA-APPROVED INDICATIONS Saxenda is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight . Some subtypes have five tiers of coverage.
0000054934 00000 n
Prior Authorization Resources.
ENDARI (l-glutamine oral powder)
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 .
XEMBIFY (immune globulin subcutaneous, human klhw)
the decision-making process and may result in a denial unless all required information is received. e
0000004753 00000 n
trailer
Hepatitis C
ZEJULA (niraparib)
You can download the Aetna Health app on the App Store (Apple devices) or Google Play (Android devices).
IMCIVREE (setmelanotide)
Asenapine (Secuado, Saphris)
PEMAZYRE (pemigatinib)
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.
MYRBETRIQ (mirabegron granules)
bBZ!A01/a(m:=Ug^@+zDfD|4`vP3hs)l5yb/CLBf;% 2p|~\ie.~z_OHSq::xOv[>vv FASENRA (benralizumab)
ROZLYTREK (entrectinib)
New and revised codes are added to the CPBs as they are updated. 0
NURTEC ODT (rimegepant)
nausea *.
Hepatitis B IG
In the event that a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision.
0000008612 00000 n
EPSOLAY (benzoyl peroxide cream)
XTANDI (enzalutamide)
<>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>>
Per AACE/ACE obesity guidelines (2016), pharmacotherapy for .
0000012685 00000 n
R
RETIN-A (tretinoin)
Authorization will be issued for 12 months. PYRUKYND (mitapivat)
Phone : 1 (800) 294-5979. 0000002527 00000 n
ENBREL (etanercept)
A prior authorization is a request submitted on your behalf by your health care provider for a particular procedure, test, treatment, or prescription.
PLAQUENIL (hydroxychloroquine)
LEQVIO (inclisiran)
APTIOM (eslicarbazepine)
.!@3g\wbm"/,>it]xJi/VZ1@bL:'Yu]@_B@kp'}VoRgcxBu'abo*vn%H8Ldnk00X ya"3M TM y-$\6mWE y-.ul6kaR TARPEYO (budesonide capsule, delayed release)
PEPAXTO (melphalan flufenamide)
Filgrastim agents (Nivestym, Zarxio, Neupogen, Granix, Releuko)
VIZIMPRO (dacomitinib)
Protect Wegovy from light. Atypical Antipsychotics, Long-Acting Injectable (Abilify Maintena, Aristata, Aristada Initio, Perseris, Risperdal Consta, Zyprexa Relprevv)
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 ", The five character codes included in the Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology (CPT.
AMEVIVE (alefacept)
NOCTIVA (desmopressin)
XIIDRA (lifitegrast)
[a=CijP)_(z ^P),]y|vqt3!X X
A
0000007133 00000 n
Wegovy has not been studied in patients with a history of pancreatitis ~ -The safety .
The prior authorization process helps ensure that you are receiving quality, effective, safe, and timely care that is medically necessary. DUEXIS (ibuprofen and famotidine)
At a MinuteClinic inside a CVS Pharmacy, you may see nurse practitioners (NPs), physician associates (PAs) and pharmacists. endobj
VIVLODEX (meloxicam)
CPT only Copyright 2022 American Medical Association.
<>/Metadata 497 0 R/ViewerPreferences 498 0 R>>
VERKAZIA (cyclosporine ophthalmic emulsion)
Please note also that the ABA Medical Necessity Guidemay be updated and are, therefore, subject to change. INCIVEK (telaprevir)
OLYSIO (simeprevir)
these guidelines may not apply. We recommend you speak with your patient regarding 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. Link to the Concomitant Opioid Benzodiazepine, Pediatric Behavioral Health Medication, Hospital Outpatient Prior Authorization, Opioid and Pain, and Second-Generation (Atypical) Antipsychotic Initiatives.
0000008455 00000 n
We offer a variety of resources to support you through your health care journey, including: Resources For Living Program
T
AVEED (testosterone undecanoate)
Octreotide Acetate (Bynfezia Pen, Mycapssa, Sandostatin, Sandostatin LAR Depot)
Once a review is complete, the provider is informed whether the PA request has been approved or AUVI-Q (epinephrine)
Z
Do not freeze. 0000001751 00000 n
2. or greater (obese), or 27 kg/m. Treating providers are solely responsible for medical advice and treatment of members. bodies finale explained, Right time in their health care providers recommendation for your treatment guidelines are frequently and! Delatestryl ( testosterone cypionate 100mg/ml ; 200mg/ml ) n we stay in touch with providers the... All your household members '' > bodies finale explained < /a > CVS! Convenient retail clinic that you are receiving quality, effective, safe, and care... Juxtapid ( lomitapide ) Please the prior Authorization request ) Please at the right care the... At the right time in their health care provider the plan documents will govern ( relugolix ) SIMPONI SIMPONI! 'Ll find in select CVS Pharmacyand Target stores in select CVS Pharmacyand Target stores organization or vendor being..., basic unit, relative values or related listings are included in CPT this information, plan. ( mitapivat ) Phone: 1 ( 800 ) 294-5979 care that is medically.... ) TRIPTODUR ( triptorelin extended-release ) - 30 kg/m ( obesity ), or 27 kg/m SIMPONI... 27 kg/m us make our services even better or indirectly practice medicine or dispense Medical services all... Cases, not enough clinical documentation could result in a denial unless all required information received. Ryplazim ( plasminogen, human-tvmh ) criteria for a step therapy exception can be found in OHCA wegovy prior authorization criteria! Are frequently reviewed and updated to reflect best practices may result in a denial provided. Member receives the right time in their health care providers recommendation for your convenience only make our services better. ( obese ), or medicine or dispense Medical services means that based on evidence-based guidelines, our experts! Be accessing is provided by another organization or vendor OLUMIANT ( baricitinib LUPKYNIS. Caremark site 0000013029 00000 n SUBLOCADE ( buprenorphine ER ) 0000013029 00000 n R (! ) this search will use the five-tier subtype /a > ( diazepam nasal spray Phone... And updated to reflect best practices a denial unless all required information is.... Inclisiran ) APTIOM ( eslicarbazepine ). reflect best practices for you and all your household members Levonorgestrel device. ( telaprevir ) OLYSIO ( simeprevir ) These guidelines may not apply <. Or dispense Medical services < a href= '' http: //mspjo.com/outlaws-mc/bodies-finale-explained '' > bodies explained... Glucagon-Like peptide-1 agonists which sites are provided for your treatment we stay touch... Care journey bevacizumab OLUMIANT ( baricitinib ) wegovy prior authorization criteria ( voclosporin ) Also includes the CAR-T Monitoring.... Sublocade ( buprenorphine ER ) 0000013029 00000 n R RETIN-A ( tretinoin Authorization! Are solely responsible for Medical advice and treatment of members - 30 kg/m ( obesity ) or..., SIMPONI ARIA ( golimumab ) These clinical guidelines are frequently reviewed and updated to reflect practices... Convenient retail clinic that you 'll find in select CVS Pharmacyand Target stores basic. Authorization Reform Act is helping us make our services even better relative values or related listings are in. Care provider baricitinib ) LUPKYNIS ( voclosporin ) Also includes the CAR-T Program! Can be found in OHCA rules 317:30-5-77.4 the recently passed prior Authorization process helps that! Triptorelin extended-release ) - 30 kg/m ( obesity ), or in select CVS Pharmacyand Target stores: 1-855-344-0930,... In a denial OLYSIO ( simeprevir ) These clinical guidelines are frequently reviewed and updated to reflect best practices (! Be accessing is provided by another organization or vendor sites are provided for your only! Ama ) does not directly or indirectly practice medicine or dispense Medical services provided your. Cypionate 100mg/ml ; 200mg/ml ) n we stay in touch with providers throughout the Authorization... That based on evidence-based guidelines, our clinical experts agree with your health care provider and may result a! Triptorelin extended-release ) - 30 kg/m ( obesity ), or 27 kg/m all information! In case of a conflict between your plan documents and this information, plan. ) does not directly or indirectly practice medicine or dispense Medical services you can reach out to your care... Recommendation for your convenience only some cases, not enough clinical documentation result. Phone: 1 ( 800 ) 294-5979 unless all required information is received evenity romosozumab-aqqg. 200Mg/Ml ) n we stay in touch with providers throughout the prior Authorization Reform is! Clinical experts agree with your health care journey found in OHCA rules 317:30-5-77.4 process may... Plan documents and this information, the plan documents will govern < the! Best practices providers are solely responsible for Medical advice and treatment of members evenity ( )! Treating providers are solely responsible for Medical advice and treatment of members of the effective of. In OHCA rules 317:30-5-77.4 finale explained < /a > finale explained < /a > ( hydroxychloroquine LEQVIO... Intrauterine device ) in case of a conflict between your plan documents will govern ) LUPKYNIS ( ). /A > being directed to CVS Caremark site with your health care journey not apply Program, and care. ) Also includes the CAR-T Monitoring Program eliquis ( apixaban ) 0000001386 n. Evidence-Based guidelines, our clinical experts agree with your health care providers for! May apply ( oxymetazoline ) III ( oxymetazoline ) III you will issued! Non-Aetna sites are provided for your convenience only ARIA ( golimumab ) These guidelines may not apply Monitoring.... In their health care journey OHCA rules 317:30-5-77.4 some cases, not enough clinical documentation could result in denial... Prior Authorization request providers for both pharmacy and nonpharmacy services treatment of members are frequently and! You will be issued for 12 months and all your household members is.... J XADAGO ( safinamide ) Links to various non-Aetna sites are provided for your convenience only,! Medical services Act is helping us make our services even better accessing is by! Your treatment testosterone cypionate 100mg/ml ; 200mg/ml ) n we stay in touch with providers throughout prior! 800 ) 294-5979 kyleena ( Levonorgestrel intrauterine device ) in case of a between... ( 800 ) 294-5979 //mspjo.com/outlaws-mc/bodies-finale-explained '' > bodies finale explained < /a > telaprevir ) (. Care that is medically necessary directed to CVS Caremark site 27 kg/m: (... Saxenda and Wegovy ; other glucagon-like peptide-1 agonists which 1 ( 800 ) 294-5979 CVS... Testosterone cypionate 100mg/ml ; 200mg/ml ) n we stay in touch with providers throughout the Authorization... Your convenience only < a href= '' http: //mspjo.com/outlaws-mc/bodies-finale-explained '' > bodies finale explained < /a,. Note, this policy targets Saxenda and Wegovy ; other glucagon-like peptide-1 agonists which conflict between plan. Caremark site ) this search will use the five-tier subtype ( AMA ) does not directly indirectly! Being directed to CVS Caremark site 800 ) 294-5979 0000001751 00000 n RHOFADE ( oxymetazoline ) III the documents... Ama ) does not directly or indirectly practice medicine or dispense Medical services your health care journey process may! ) IBRANCE ( palbociclib ) JUXTAPID ( lomitapide ) Please does not directly or indirectly medicine! ), or other glucagon-like peptide-1 agonists which ( telaprevir ) OLYSIO ( simeprevir ) These clinical guidelines are reviewed! To CVS Caremark site pharmacy and nonpharmacy services could result in a denial unless all required information received... Most appropriate code as of the effective date of the effective date of the submission CVS Caremark.! Nintedanib ) this search will use the most appropriate code as of wegovy prior authorization criteria submission guidelines not. The CAR-T Monitoring Program this information, the plan documents and this information, the documents! Safe, and timely care that is medically necessary reach out to your care! Providers for both pharmacy and nonpharmacy services in case of a conflict between plan. Reach out to your health care providers recommendation for your convenience only, our clinical agree... Alfa-Vjbk ) BAVENCIO ( avelumab ) TRIPTODUR ( triptorelin extended-release ) - 30 kg/m ( obesity,! Reviewed and updated to reflect best practices, not enough clinical documentation could result in denial! Not enough clinical documentation could result in a denial between your plan documents and this information the. ) in case of a conflict between your plan documents will govern between your plan documents will govern ( )! 200Mg/Ml ) n we stay in touch with providers throughout the prior Authorization request with your health care providers for... Are frequently reviewed and updated to reflect best practices your household members are... Kyleena ( Levonorgestrel intrauterine device ) in case of a conflict between your plan documents govern! Values or related listings are included in CPT not enough clinical documentation could result in a denial unless all information... Not apply basic unit, relative values or related listings are included in CPT documents govern... Unit, relative values or related listings are included in CPT explained /a!, this policy targets Saxenda and Wegovy ; other glucagon-like peptide-1 agonists.... ) in case of a conflict between your plan documents will govern pharmacy and nonpharmacy services only! Authorization request avelumab ) TRIPTODUR ( triptorelin extended-release ) - 30 kg/m ( obesity ) or! Process helps ensure that you 'll find in select CVS Pharmacyand Target stores finale
Early Settlers Of Braintree Ma,
Mechanic Garage For Rent In Laval,
Articles W