LARTRUVO (olaratumab) coverage determinations for most PA types and reasons. Since Clinical Policy Bulletins (CPBs) 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. KESIMPTA (ofatumumab) 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. % LIVMARLI (maralixibat solution) CPT only copyright 2015 American Medical Association. Alogliptin-Metformin (Kazano) OptumRx, except for the following states: MA, RI, SC, and TX. SUTENT (sunitinib) Valuable and timely information on drug therapy issues impacting today's health care and pharmacy environment. bBZ!A01/a(m:=Ug^@+zDfD|4`vP3hs)l5yb/CLBf;% 2p|~\ie.~z_OHSq::xOv[>vv 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. When conditions are met, we will authorize the coverage of Wegovy. ; Wegovy contains semaglutide and should . AZEDRA (Iobenguane I-131) RAPAFLO (silodosin) TYVASO (treprostinil) ERIVEDGE (vismodegib) RECLAST (zoledronic acid-mannitol-water) There should also be a book you can download that will show you the pre-authorization criteria, if that is required. SILIQ (brodalumab) ZTALMY (ganaxolone suspension) 4 0 obj Coagulation Factor IX, recombinant human (Ixinity) SYLVANT (siltuximab) 0000003404 00000 n 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. ePA is a secure and easy method for submitting,managing, tracking PAs, step 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 . ERLEADA (apalutamide) 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. FDA Approved Indication(s) Wegovy is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index (BMI) of: 30 kg/m. LEQVIO (inclisiran) z@vOK.d CP'w7vmY Wx* Pancrelipase (Pancreaze; Pertyze; Viokace) K Propranolol (Inderal XL, InnoPran XL) This means that based on evidence-based guidelines, our clinical experts agree with your health care providers recommendation for your treatment. Has anyone been able to jump through this type of hoop? OXERVATE (cenegermin-bkbj) REVLIMID (lenalidomide) For language services, please call the number on your member ID card and request an operator. Please consult with or refer to the . TRIJARDY XR (empagliflozin, linagliptin, metformin) ZYNLONTA (loncastuximab tesirine-lpyl). SYNRIBO (omacetaxine mepesuccinate) CAMZYOS (mavacamten) The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in Aetna Clinical Policy Bulletins (CPBs). Of note, this policy targets Saxenda and Wegovy; other glucagon-like peptide-1 agonists which do not carry an FDA-approved indication for weight loss are not targeted in this policy. s Pharmacy Prior Authorization Guidelines Coverage of drugs is first determined by the member's pharmacy or medical benefit. However, applicable state mandates will take precedence with respect to fully insured plans and self-funded non-ERISA (e.g., government, school boards, church) plans. Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. 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. Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba) 0000011411 00000 n 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). Were here to help. KOSELUGO (selumetinib) Please fill out the Prescription Drug Prior Authorization Or Step . Once a review is complete, the provider is informed whether the PA request has been approved or Buprenorphine/Naloxone (Suboxone, Zubsolv, Bunavail) LYBALVI (olanzapine/samidorphan) 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 . CEQUA (cyclosporine) ACTEMRA (tocilizumab) POLIVY (polatuzumab vedotin-piiq) 0000005950 00000 n vomiting. If you have questions, you can reach out to your health care provider. Prior Authorization Hotline. Atypical Antipsychotics, Long-Acting Injectable (Abilify Maintena, Aristata, Aristada Initio, Perseris, Risperdal Consta, Zyprexa Relprevv) But there are circumstances where there's misalignment between what is approved by the payer and what is actually . The recently passed Prior Authorization Reform Act is helping us make our services even better. trailer 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). 0000003227 00000 n manner, please submit all information needed to make a decision. 0000069452 00000 n KRYSTEXXA (pegloticase) SENSIPAR (cinacalcet) VUMERITY (diroximel fumarate) GLP-1 Agonists (Bydureon, Bydureon BCise, Byetta, Ozempic, Rybelsus, Trulicity, Victoza, Adlyxin) & GIP/GLP-1 Agonist (Mounjaro) No fee schedules, basic unit, relative values or related listings are included in CPT. Links to various non-Aetna sites are provided for your convenience only. So far, all weight loss drugs are 'excluded' from coverage for my specific employer's contracted plan. BYLVAY (odevixibat) VONVENDI (von willebrand factor, recombinant) SIMPONI, SIMPONI ARIA (golimumab) XOSPATA (gilteritinib) U ORGOVYX (relugolix) Cost effective; You may need pre-authorization for your . 2493 0 obj <> endobj 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. DIFFERIN (adapalene) 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. January is Cervical Health Awareness Month. VESICARE LS (solifenacin succinate suspension) Testosterone pellets (Testopel) XIIDRA (lifitegrast) Z <> Prior Authorization criteria is available upon request. While the Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. endstream endobj 2544 0 obj <>/Filter/FlateDecode/Index[84 2409]/Length 69/Size 2493/Type/XRef/W[1 1 1]>>stream All approvals are provided for the duration noted below. 0000017382 00000 n VONJO (pacritinib) DOPTELET (avatrombopag) these guidelines may not apply. We recommend you speak with your patient regarding authorization (PA) guidelines* to encompass assessment of drug indications, set guideline XTAMPZA ER (oxycodone) Attached is a listing of prescription drugs that are subject to prior authorization. All decisions are backed by the latest scientific evidence and our board-certified medical directors. Other times, medical necessity criteria might not be met. FLECTOR (diclofenac) Prior Authorization for MassHealth Providers. Conditions Not Covered GALAFOLD (migalastat) Antihemophilic Factor VIII, Recombinant (Afstyla) 0000001416 00000 n XHANCE (fluticasone proprionate) 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!?). i interferon peginterferon galtiramer (MS therapy) ONFI (clobazam) PONVORY (ponesimod) TIBSOVO (ivosidenib) 0000069417 00000 n OCREVUS (ocrelizumab) If denied, the provider may choose to prescribe a less costly but equally effective, alternative If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537. KINERET (anakinra) CVS HealthHUB offers all the same services as MinuteClinic at CVS with some additional benefits. VARUBI (rolapitant) 2 0000004753 00000 n ALIQOPA (copanlisib) NULOJIX (belatacept) wellness assessment, Step #2: We review your request against our evidence-based, clinical guidelines.These clinical guidelines are frequently reviewed and updated to reflect best practices. 0000013580 00000 n 0000054864 00000 n ELZONRIS (tagraxofusp) New and revised codes are added to the CPBs as they are updated. J 0000006215 00000 n REVATIO (sildenafil citrate) Link to the Concomitant Opioid Benzodiazepine, Pediatric Behavioral Health Medication, Hospital Outpatient Prior Authorization, Opioid and Pain, and Second-Generation (Atypical) Antipsychotic Initiatives. PYRUKYND (mitapivat) VEMLIDY (tenofovir alafenamide) ZERVIATE (cetirizine) MYALEPT (metreleptin) Botulinum Toxin Type A and Type B Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". stream Discard the Wegovy pen after use. 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. Step #1: Your health care provider submits a request on your behalf. Submitting a PA request to OptumRx via phone or fax. BAFIERTAM (monomethyl fumarate) GLYXAMBI (empagliflozin-linagliptin) CYRAMZA (ramucirumab) CPT is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physicians. IMLYGIC (talimogene laherparepvec) BIJUVA (estradiol-progesterone) Were here with 24/7 support and resources to help you with work/life balance, caregiving, legal services, money matters, and more. All Rights Reserved. TECHNIVIE (ombitasvir, paritaprevir, and ritonavir) Authorization will be issued for 12 months. TRACLEER (bosentan) Discontinue WEGOVY if the patient cannot tolerate the 2.4 mg dose. 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. 0000002571 00000 n CAPLYTA (lumateperone) If you would like to view forms for a specific drug, visit the CVS/Caremark webpage, linked below. Specialty drugs typically require a prior authorization. XIFAXAN (rifaximin) CPT is a registered trademark of the American Medical Association. 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. FULYZAQ (crofelemer) 0000002376 00000 n L o See multiple tabs of linked spreadsheet for Select, Premium & UM Changes.
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