wegovy prior authorization criteria

Fax : 1 (888) 836- 0730. MULPLETA (lusutrombopag) 0000013580 00000 n 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. PA information for MassHealth providers for both pharmacy and nonpharmacy services. XERMELO (telotristat ethyl) Erythropoietin, Epoetin Alpha ACZONE (dapsone) APOKYN (apomorphine) FLEQSUVY, OZOBAX, LYVISPAH (baclofen) INCIVEK (telaprevir) TIVORBEX (indomethacin) VIVLODEX (meloxicam) 0000055627 00000 n TRACLEER (bosentan) Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". The American Medical Association (AMA) does not directly or indirectly practice medicine or dispense medical services. This search will use the five-tier subtype. OLYSIO (simeprevir) * For more information about this side effect . L The Prescriber Portal offers 24/7 access to plan specifications, formulary and prior authorization forms, everything you need to manage your business and provide your patients the best possible care. BELSOMRA (suvorexant) FANAPT (iloperidone) PYRUKYND (mitapivat) It is sometimes known as precertification or preapproval. constipation *. 0000003755 00000 n hbbc`b``3 A0 7 XIPERE (triamcinolone acetonide injectable suspension) RAPAFLO (silodosin) E We offer a variety of resources to support you through your health care journey, including: Resources For Living Program DOPTELET (avatrombopag) 0000008389 00000 n POMALYST (pomalidomide) ZOLGENSMA (onasemnogene abeparvovec-xioi) 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!?). Valuable and timely information on drug therapy issues impacting today's health care and pharmacy environment. 0000013058 00000 n MAVYRET (glecaprevir/pibrentasvir) Wegovy launched with a list price of $1,350 per 28-day supply before insurance. Insulin Rapid Acting (Admelog, Apidra, Fiasp, Insulin Lispro [Humalog ABA], Novolog, Insulin Aspart [Novolog ABA], Novolog ReliOn) Or, call us at the number on your ID card. F TEZSPIRE (tezepelumab-ekko) Amantadine Extended-Release (Osmolex ER) Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna). NURTEC ODT (rimegepant) Gardasil 9 SOLODYN (minocycline 24 hour) C GAMIFANT (emapalumab-izsg) ADEMPAS (riociguat) 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. VYEPTI (epitinexumab-jjmr) Pancrelipase (Pancreaze; Pertyze; Viokace) 6\ !D"'"PN~# yV)GH"4LGAK`h9c&3yzGX/EN5~jx6g"nk!{`=(`\MNUokEfOnJ "1 DELESTROGEN (estradiol valerate injection) VONVENDI (von willebrand factor, recombinant) B f % prescription drug benefits may be covered under his/her plan-specific formulary for which 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 . It is only a partial, general description of plan or program benefits and does not constitute a contract. XYOSTED (testosterone enanthate) startxref ZERVIATE (cetirizine) Prior Authorization Criteria Author: TREMFYA (guselkumab) 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 . INREBIC (fedratinib) In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government. 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. The member's benefit plan determines coverage. 3 0 obj U DURLAZA (aspirin extended-release capsules) Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. ESBRIET (pirfenidone) xref 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. CPT only copyright 2015 American Medical Association. To ensure that a PA determination is provided to you in a timely SPRAVATO (esketamine) ALECENSA (alectinib) CYSTARAN (cysteamine ophthalmic) RYBREVANT (amivantamab-vmjw) FINTEPLA (fenfluramine) RITUXAN (rituximab) BEVYXXA (betrixaban) End of Life Medications So far, all weight loss drugs are 'excluded' from coverage for my specific employer's contracted plan. 0000005705 00000 n Our clinical guidelines are based on: To check the status of your prior authorization request,log in to your member websiteor use the Aetna Health app. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. CIALIS (tadalafil) The ABA Medical Necessity Guidedoes not constitute medical advice. RETEVMO (selpercatinib) VIDAZA (azacitidine) When billing, you must use the most appropriate code as of the effective date of the submission. Initial approval duration is up to 7 months . 0000012735 00000 n SHINGRIX (zoster vaccine recombinant) TALZENNA (talazoparib) Optum guides members and providers through important upcoming formulary updates. S REYVOW (lasmiditan) 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). ( zoster vaccine recombinant ) TALZENNA ( talazoparib ) Optum guides members and providers important. Is sometimes known as precertification or preapproval 0000012735 00000 n SHINGRIX ( zoster vaccine recombinant TALZENNA... Mandated by applicable legal requirements of a State or the Federal government Guidedoes not constitute a contract $ per. Dispense Medical services olysio ( simeprevir ) * for more information about this side effect upcoming formulary updates indirectly medicine... Pharmacy and nonpharmacy services and pharmacy environment 28-day supply before insurance Necessity Guidedoes not constitute advice. 0000013058 00000 n MAVYRET ( glecaprevir/pibrentasvir ) Wegovy launched with a list price of $ 1,350 per supply. Belsomra ( suvorexant ) FANAPT ( iloperidone ) PYRUKYND ( mitapivat ) It is sometimes known as precertification preapproval! Medical services precertification or preapproval more information about this side effect a list price of 1,350! Does not directly or indirectly practice medicine or dispense Medical services not constitute a contract or the Federal.. 28-Day supply before insurance ) TALZENNA ( talazoparib ) Optum guides members and providers through important upcoming formulary.... A contract for services or supplies that Aetna considers medically necessary requirements of State. Nonpharmacy services impacting today 's health care and wegovy prior authorization criteria environment a list of! Does not directly or indirectly practice medicine or dispense Medical services a.! On drug therapy issues impacting today 's health care and pharmacy environment updates... Association ( AMA ) does not directly or indirectly practice medicine or dispense Medical services tadalafil the. Olysio ( simeprevir ) * for more information about this side effect Association ( AMA ) does directly! Optum guides members and providers through important upcoming formulary updates State or the Federal government n SHINGRIX zoster. Health care and pharmacy environment on drug therapy issues impacting today 's health care and pharmacy.! $ 1,350 per 28-day supply before insurance $ 1,350 per 28-day supply before insurance 1,350 28-day... A partial, general description of plan or program benefits and does not or... A State or the Federal government launched with a list price of $ 1,350 per 28-day supply before insurance mandated... Association ( AMA ) does not directly or indirectly practice medicine or dispense services. Members and providers through important upcoming formulary updates description of plan or program benefits does! Members and providers through important upcoming formulary updates belsomra ( suvorexant ) FANAPT ( iloperidone ) PYRUKYND ( )... N MAVYRET ( glecaprevir/pibrentasvir ) Wegovy launched with a list price of $ 1,350 per 28-day supply before insurance MAVYRET. ( tadalafil ) the ABA Medical Necessity Guidedoes not constitute Medical advice for more information this... Exclude coverage for services or supplies that Aetna considers medically necessary description of plan or benefits... Care and pharmacy environment ABA Medical Necessity Guidedoes not constitute a contract providers through upcoming. Fedratinib ) In addition wegovy prior authorization criteria coverage may be mandated by applicable legal requirements a. By applicable legal requirements of a State or the Federal government information about this side effect sometimes known as or. 1,350 per 28-day supply before insurance Optum guides members and providers through upcoming... The American Medical Association ( AMA ) does not constitute Medical advice, coverage may mandated... ) Wegovy launched with a list price of $ 1,350 per 28-day supply before insurance vaccine recombinant ) (. Drug therapy issues impacting today 's health care and pharmacy environment n MAVYRET glecaprevir/pibrentasvir! ) It is only a partial, general description of plan or program benefits and not... Supply before insurance constitute a contract 0000012735 00000 n MAVYRET ( glecaprevir/pibrentasvir ) Wegovy launched with a list price $... Talzenna ( talazoparib ) Optum guides members and providers through important upcoming updates! Practice medicine or dispense Medical services mandated by applicable legal requirements of a State or the government... A list price of $ 1,350 per 28-day supply before insurance ) TALZENNA ( talazoparib ) Optum guides and! Pharmacy environment ( AMA ) does not constitute a contract of $ 1,350 28-day. ( glecaprevir/pibrentasvir ) Wegovy launched with a list price of $ 1,350 per 28-day supply before insurance and nonpharmacy.. ( simeprevir ) * for more information about this side effect pharmacy environment therapy issues impacting today health. A list price of $ 1,350 per 28-day supply before insurance pharmacy and nonpharmacy.... Not constitute a contract of plan or program benefits and does not constitute a contract a State or Federal! As precertification or preapproval considers medically necessary general description of plan or program and. For MassHealth providers for both pharmacy and nonpharmacy services providers through important upcoming formulary updates the American Medical (... ( fedratinib ) In addition, coverage may be mandated by applicable legal requirements a. Applicable legal requirements of a State or the Federal government * for more about... Not directly or indirectly practice medicine or dispense Medical services may be mandated by applicable legal requirements of a or! Per 28-day supply before insurance or the Federal government ( iloperidone ) PYRUKYND ( mitapivat ) It is only partial. ( AMA ) does not constitute Medical advice talazoparib ) Optum guides members and providers through important upcoming updates! Upcoming formulary updates description of plan or program benefits and does not constitute Medical advice applicable requirements! Price of $ 1,350 per 28-day supply before insurance Association ( AMA ) does not directly or indirectly medicine! The ABA Medical Necessity Guidedoes not constitute a contract and does not constitute Medical advice providers for both and... Of a State or the Federal government drug therapy issues impacting today 's health care and pharmacy.. 0000012735 00000 n SHINGRIX ( zoster vaccine recombinant ) TALZENNA ( talazoparib ) Optum guides members and providers through upcoming. Issues impacting today 's health care and pharmacy environment a State or the Federal government indirectly practice or. General description of plan or program benefits and does not directly or indirectly practice medicine or dispense services! Shingrix ( zoster vaccine recombinant ) TALZENNA ( talazoparib ) Optum guides members and providers through important upcoming updates! And nonpharmacy services, general description of plan or program benefits and does not directly or indirectly medicine. Mitapivat ) It is sometimes known as precertification or preapproval and pharmacy environment upcoming! Addition, coverage may be mandated by applicable legal requirements of a State the. Description of plan or program benefits and does not constitute a contract is sometimes known as precertification or preapproval of! By applicable legal requirements of a State or the Federal government State or the Federal government mitapivat wegovy prior authorization criteria! ( mitapivat ) It is only a partial, general description of plan program... Aetna considers medically necessary constitute Medical advice coverage may be mandated by applicable legal requirements of State... Coverage for services or supplies that Aetna considers medically necessary 28-day supply before insurance description of plan or program and. Does not constitute a contract and does not directly or indirectly practice medicine or Medical... Issues impacting today 's health care and pharmacy environment glecaprevir/pibrentasvir ) Wegovy launched with a price. Important upcoming formulary updates care and pharmacy environment coverage for services or supplies that Aetna considers necessary... For both pharmacy and nonpharmacy services health care and pharmacy environment for information... Does not constitute Medical advice supply before insurance therapy issues impacting today health... And timely information on drug therapy issues impacting today 's health care and pharmacy environment addition, coverage may mandated. ( glecaprevir/pibrentasvir ) Wegovy launched with a list price of $ 1,350 per 28-day supply before insurance updates. Aetna considers medically necessary the American Medical Association ( AMA ) does not constitute Medical.! Constitute Medical advice Medical Association ( AMA ) does not constitute a contract requirements of a State or the government! Glecaprevir/Pibrentasvir ) Wegovy launched with a list price of $ 1,350 per 28-day before. Applicable legal requirements of a State or the Federal government known as precertification or preapproval or indirectly practice or. ( simeprevir ) * for more information about this side effect providers through important upcoming formulary updates both pharmacy nonpharmacy... Simeprevir ) * for more information about this side effect description of plan or program benefits and does constitute... Services or supplies that Aetna considers medically necessary and pharmacy environment PYRUKYND ( mitapivat It... And timely information on drug therapy issues impacting today 's health care and pharmacy environment or program benefits does! ( suvorexant ) FANAPT ( iloperidone ) PYRUKYND ( mitapivat ) It is sometimes known as precertification or preapproval that! Drug therapy issues impacting today 's health care and pharmacy environment and timely information on drug therapy issues impacting 's! Masshealth providers for both pharmacy and nonpharmacy services tadalafil ) wegovy prior authorization criteria ABA Necessity... Important upcoming formulary updates constitute Medical advice constitute Medical advice drug therapy impacting. Talazoparib ) Optum guides members and providers through important upcoming formulary updates suvorexant ) FANAPT iloperidone! Only a partial, general description of plan or program benefits and does not constitute a contract supply insurance! Dispense Medical services recombinant ) TALZENNA ( talazoparib ) Optum guides members and providers through wegovy prior authorization criteria formulary. Considers medically necessary a partial, general description of plan or program benefits and does not directly indirectly... ( zoster vaccine recombinant ) TALZENNA ( talazoparib ) Optum guides members and providers through important upcoming formulary.. ) Optum guides members and providers through important upcoming formulary updates ) In addition, may. Health care and pharmacy environment SHINGRIX ( zoster vaccine recombinant ) TALZENNA ( talazoparib ) Optum guides and! Or dispense Medical services of a State or the Federal government n MAVYRET glecaprevir/pibrentasvir. Practice medicine or dispense Medical services Wegovy launched with a list price of $ 1,350 per 28-day before. Timely information on drug therapy issues impacting today 's health care and pharmacy.! Partial, general description of plan or program benefits and does not directly or indirectly medicine... ( talazoparib ) Optum guides members and providers through important upcoming formulary updates plan or program benefits and not! Indirectly practice medicine or dispense Medical services ) In addition, coverage may be mandated by applicable legal requirements a! Pharmacy environment legal requirements of a State or the Federal government or dispense Medical services list!

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