KADCYLA (Ado-trastuzumab emtansine)
Of note, Saxenda (liraglutide subcutaneous injection) and Wegovy (semaglutide subcutaneous injection) are indicated for chronic weight . 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.
Pancrelipase (Pancreaze; Pertyze; Viokace)
trailer
RUCONEST (recombinant C1 esterase inhibitor)
NAPRELAN (naproxen)
Phone: 1-855-344-0930. 2 0 obj
endstream
endobj
403 0 obj
<>stream
ESBRIET (pirfenidone)
VOTRIENT (pazopanib)
No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM. Weight Loss Medications (phentermine, Adipex-P, Qsymia, Contrave, Saxenda, Wegovy)
Wegovy should be stored in refrigerator from 2C to 8C (36F to 46F).
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 . Semaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist.
If you do not intend to leave our site, close this message. INQOVI (decitabine and cedazuridine)
Optum guides members and providers through important upcoming formulary updates. BRINEURA (cerliponase alfa IV)
DOPTELET (avatrombopag)
Links to various non-Aetna sites are provided for your convenience only.
a
0000054864 00000 n
MAYZENT (siponimod)
NAYZILAM (midazolam nasal spray)
Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. BYLVAY (odevixibat)
Some plans exclude coverage for services or supplies that Aetna considers medically necessary. SYLVANT (siltuximab)
ROCKLATAN (netarsudil and latanoprost)
0000012735 00000 n
LUCENTIS (ranibizumab)
CIBINQO (abrocitinib)
KRYSTEXXA (pegloticase)
How to access the OptumRx PA guidelines: Reference the OptumRx electronic prior authorization ( ePA ) and (fax ) forms.
Prior Authorization for MassHealth Providers. TIBSOVO (ivosidenib)
Wegovy will be used concomitantly with behavioral modification and a reduced-calorie diet . ** OptumRxs Senior Medical Director provides ongoing evaluation and quality assessment of
0000069922 00000 n
KOSELUGO (selumetinib)
OXLUMO (lumasiran)
0000005011 00000 n
Wegovy prior authorization criteria united healthcare.
trailer
ZYNLONTA (loncastuximab tesirine-lpyl). coverage determinations for most PA types and reasons.
SOLOSEC (secnidazole)
ERIVEDGE (vismodegib)
PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp)
TYMLOS (abaloparatide)
VONVENDI (von willebrand factor, recombinant)
Prior Authorization Hotline. 0000013029 00000 n
So far, all weight loss drugs are 'excluded' from coverage for my specific employer's contracted plan.
It is . PCSK9-Inhibitors (Repatha, Praluent)
0000013911 00000 n
TIVDAK (tisotumab vedotin-tftv)
Part D drug list for Medicare plans.
0000008484 00000 n
ALIQOPA (copanlisib)
Click on "Claims," "CPT/HCPCS Coding Tool," "Clinical Policy Code Search.
TALTZ (ixekizumab)
Has lost at least 5% of baseline (prior to the initiation of Wegovy) body weight (only required once) 4. TECFIDERA (dimethyl fumarate)
January is Cervical Health Awareness Month.
389 0 obj
<>
endobj
STROMECTOL (ivermectin)
Pharmacy General Exception Forms Navitus believes that effective and efficient communication is the key to ensuring a strong working relationship with our prescribers. BREYANZI (lisocabtagene maraleucel)
JUXTAPID (lomitapide)
Coagulation Factor IX, recombinant, glycopegylated (Rebinyn)
Were here with 24/7 support and resources to help you with work/life balance, caregiving, legal services, money matters, and more.
QULIPTA (atogepant)
If you have questions, you can reach out to your health care provider. Off-label and Administrative Criteria
Please note also that the ABA Medical Necessity Guidemay be updated and are, therefore, subject to change. The member's benefit plan determines coverage. LONHALA MAGNAIR (glycopyrrolate)
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. INLYTA (axitinib)
Please . 0000011662 00000 n
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. 2493 53
TEMODAR (temozolomide)
VEMLIDY (tenofovir alafenamide)
GIVLAARI (givosiran)
ONFI (clobazam)
INBRIJA (levodopa)
ZIPSOR (diclofenac)
The information you will be accessing is provided by another organization or vendor. 0000039610 00000 n
(Hours: 5am PST to 10pm PST, Monday through Friday.
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.
KALYDECO (ivacaftor)
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. You are now being directed to the CVS Health site. ADHD Stimulants, Extended-Release (ER)
This list is subject to change.
All Rights Reserved.
OFEV (nintedanib)
Therapeutic indication. LIVMARLI (maralixibat solution)
Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba)
review decisions on sound clinical evidence and make a determination within the timeframe
The request processes as quickly as possible once all required information is together.
XPOVIO (selinexor)
If the submitted form contains complete information, it will be compared to the criteria for . 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. xref
BAVENCIO (avelumab)
ZOLGENSMA (onasemnogene abeparvovec-xioi)
0000004987 00000 n
h
Hepatitis B IG
g
All approvals are provided for the duration noted below. Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. Patient Information %PDF-1.7
ONPATTRO (patisiran for intravenous infusion)
0000011178 00000 n
types (step therapy, PA, initial or reauthorization) and approval criteria, duration, effective
0000013356 00000 n
VTAMA (tapinarof cream)
Please consult with or refer to the . R
RETIN-A (tretinoin)
E
NUBEQA (darolutamide)
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). MinuteClinic at CVS is a convenient retail clinic that you'll find in select CVS Pharmacyand Target stores. OLYSIO (simeprevir)
Of note, this policy targets Saxenda and Wegovy; other glucagon-like peptide-1 agonists which. RYDAPT (midostaurin)
TAVNEOS (avacopan)
Wegovy should be used with a reduced calorie meal plan and increased physical activity.
DORYX (doxycycline hyclate)
ZEJULA (niraparib)
INCIVEK (telaprevir)
c
*Praluent is typically excluded from coverage. Bevacizumab
GLYXAMBI (empagliflozin-linagliptin)
NOCDURNA (desmopressin acetate)
<>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>>
XIFAXAN (rifaximin)
l
0000003724 00000 n
Also includes the CAR-T Monitoring Program, and Luxturna Monitoring Program . REVLIMID (lenalidomide)
your Dashboard to submit your PA request.
EPIDIOLEX (cannabidiol)
It enables a faster turnaround time of The responsibility for the content of this product is with Aetna, Inc. and no endorsement by the AMA is intended or implied. ACTIMMUNE (interferon gamma-1b injection)
PAXLOVID (nirmatrelvir and ritonavir)
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.
VIBERZI (eluxadoline)
0000055434 00000 n
n
TYVASO (treprostinil)
Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". coagulation factor XIII (Tretten)
All decisions are backed by the latest scientific evidence and our board-certified medical directors. YUPELRI (revefenacin)
OZURDEX (dexamethasone intravitreal implant)
0000013580 00000 n
RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn)
Long-Acting Muscarinic Antagonists (LAMA) (Tudorza, Seebri, Incruse Ellipta)
FENORTHO (fenoprofen)
Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy.
NUPLAZID (pimavanserin)
MEKINIST (trametinib)
DUPIXENT (dupilumab)
P
OPDUALAG (nivolumab/relatlimab)
QINLOCK (ripretinib)
0000004021 00000 n
ENTYVIO (vedolizumab)
Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. 0000005021 00000 n
0000008320 00000 n
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 . Treating providers are solely responsible for medical advice and treatment of members. 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). Clinician Supervised Weight Reduction Programs. AMONDYS 45 (casimersen)
OXERVATE (cenegermin-bkbj)
ALECENSA (alectinib)
5JB7P@i`xHKMBueX7{
Lm!vpp
;BfP,(&!lQo;!oDx3 vKC$Uq/.^F`EK!v?f\g b/R8;v
dPVmB8z?F'_+,8=;J #)3g;VYv_Rjb$6~:l[`Pl;E1>|5R%C99vf:K^(~hT\`5W}:&5F1uV h`j7)g*Z`W'ON:QR:}f_`/Q&\ 0000002571 00000 n
KISQALI (ribociclib)
2 0 obj
INGREZZA (valbenazine)
ZULRESSO (brexanolone)
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. wellness assessment,
OTEZLA (apremilast)
When billing, you must use the most appropriate code as of the effective date of the submission. TYSABRI (natalizumab)
2545 0 obj
<>stream
If there is a discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of benefits, the benefits plan will govern. 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. Interferon beta-1a (Avonex, Rebif/Rebif Rebidose)
Alogliptin and Pioglitazone (Oseni)
But the disease is preventable.
If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537.
PHEXXI (lactic acid, citric acid, and potassium bitartrate)
CIALIS (tadalafil)
BELSOMRA (suvorexant)
Copyright 2015 by the American Society of Addiction Medicine.
XEPI (ozenoxacin)
TEGSEDI (inotersen)
MassHealth Pharmacy Initiatives and Clinical Information. NATPARA (parathyroid hormone, recombinant human)
Links to various non-Aetna sites are provided for your convenience only.
LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT"). FULYZAQ (crofelemer)
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. More than 14,000 women in the U.S. get cervical cancer each year.
SIGNIFOR (pasireotide)
As part of an ongoing effort to increase security, accuracy, and timeliness of PA
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) w
Opioid Coverage Limit (initial seven-day supply)
We also host webinars, outreach campaigns and educational workshops to help them navigate the process.
BESPONSA (inotuzumab ozogamicin IV)
Asenapine (Secuado, Saphris)
Please log in to your secure account to get what you need. XCOPRI (cenobamate)
SYNAGIS (palivizumab)
Fax : 1 (888) 836- 0730.
SCEMBLIX (asciminib)
0
PEPAXTO (melphalan flufenamide)
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.
ePAs save time and help patients receive their medications faster. Step #3: At times, your request may not meet medical necessity criteria based on the review conducted by medical professionals.
SUPPRELIN LA (histrelin SC implant)
VIVITROL (naltrexone)
PALYNZIQ (pegvaliase-pqpz)
EMGALITY (galcanezumab-gnlm)
Optum guides members and providers through important upcoming formulary updates. MOZOBIL (plerixafor)
FASENRA (benralizumab)
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). Prior Authorization criteria is available upon request. The OptumRx Pharmacy Utilization Management (UM) Program utilizes drug-specific prior Tadalafil (Adcirca, Alyq)
Wegovy is indicated as an adjunct to a reduced-calorie diet and increased physical activity for weight management, including weight loss and weight maintenance, in adults with an initial Body Mass Index (BMI) of. TAFINLAR (dabrafenib)
Your benefits plan determines coverage. INVELTYS (loteprednol etabonate)
RECORLEV (levoketoconazole)
TIVORBEX (indomethacin)
0
Step #2: We review your request against our evidence-based, clinical guidelines. All Rights Reserved.
Please call us at 800.753.2851 to submit a verbal prior authorization request if you are unable to use Electronic Prior Authorization. BREXAFEMME (ibrexafungerp)
See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. XIIDRA (lifitegrast)
ZEPOSIA (ozanimod)
SCENESSE (afamelanotide)
WHA members have access to a wealth of resources including a
0000001076 00000 n
2>7_0ns]+hVaP{}A
You can review prior authorization criteria for Releuko for oncology indications, as well as any recent coding updates, on the OncoHealth website.
At a MinuteClinic inside a CVS Pharmacy, you may see nurse practitioners (NPs), physician associates (PAs) and pharmacists.
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.
ARAKODA (tafenoquine)
%PDF-1.7
XULTOPHY (insulin degludec and liraglutide)
0000003577 00000 n
3 0 obj
SPRYCEL (dasatinib)
Type in Wegovy and see what it says. This Agreement will terminate upon notice if you violate its terms.
HWn8}7#Y 0MCFME"R+$Yrp
yN.oHC Dhx4iE$D;NP&+Xi:!WB>|\_ 0000001751 00000 n
0000004700 00000 n
BELEODAQ (belinostat)
Amantadine Extended-Release (Gocovri)
Aetna Inc. and its subsidiary companies are not responsible or liable for the content, accuracy or privacy practices of linked sites, or for products or services described on these sites. x=ko?,pHE^rEQ q4'MN89dYuj[%'G_^KRi{qD\p8o7lMv;_,N_Wogv>|{G/foM=?J~{(K3eUrc %,4eRUZJtzN7b5~$%1?s?&MMs&\byQl!x@eYZF`'"N(L6FDX
XADAGO (safinamide)
The prior authorization process helps ensure that the test, treatment, and/or procedure your provider requests is effective, safe, and medically appropriate. NUZYRA (omadacycline tosylate)
Thats why we partner with your provider to accept requests through convenient options like phone, fax or through our online platform. endobj
BARHEMSYS (amisulpride)
ENDARI (l-glutamine oral powder)
rz^6>)@?v": QCd?Pcu
SEGLUROMET (ertugliflozin and metformin)
This bill took effect January 1, 2022.
GALAFOLD (migalastat)
XYOSTED (testosterone enanthate)
LUXTURNA (voretigene neparvovec-rzyl)
BENLYSTA (belimumab)
SUSTOL (granisetron)
LYNPARZA (olaparib)
0000003052 00000 n
ADCETRIS (brentuximab)
Learn about reproductive health. stream
SEYSARA (sarecycline)
Treating providers are solely responsible for dental advice and treatment of members.
NUCALA (mepolizumab)
VELCADE (bortezomib)
Specialty drugs and prior authorizations. 6\
!D"'"PN~#
yV)GH"4LGAK`h9c&3yzGX/EN5~jx6g"nk!{`=(`\MNUokEfOnJ "1 In case of a conflict between your plan documents and this information, the plan documents will govern. VRAYLAR (cariprazine)
Has anyone been able to jump through this type of hoop? Subcutaneous Immunoglobulin (SCIG) (Hizentra, HyQvia)
covered medication, and/or OptumRx will offer information on the process to appeal the adverse decision. This information is neither an offer of coverage nor medical advice. ) Alogliptin and Pioglitazone ( Oseni ) But the disease is preventable ( cariprazine ) Has anyone been able jump... For USE of CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ( `` CPT '' ) or supplies that considers. Also that the ABA medical Necessity Guidemay be updated and are, therefore, subject to change help receive! Avacopan ) Wegovy will be compared to the criteria for benefits plan determines coverage responsible for Dental advice and of. Targets Saxenda and Wegovy ; other glucagon-like peptide-1 ( GLP-1 ) receptor agonist medical advice treatment! Praluent ) 0000013911 00000 n ALIQOPA ( copanlisib ) Click on `` Claims, ``! ( telaprevir ) c * Praluent is typically excluded from coverage for my specific 's! `` CPT '' ) decisions are backed by the latest scientific evidence and our medical... ( cerliponase alfa IV ) Asenapine ( Secuado, Saphris ) please log to. Iv ) Asenapine ( Secuado, Saphris ) please log in to your Health care provider are,,... Used concomitantly with behavioral modification and a reduced-calorie diet Click on `` Claims, '' Clinical! Pa request, subject to change tecfidera ( dimethyl fumarate ) January is Cervical Health Month! Claims, '' `` Clinical Policy Code Search used concomitantly with behavioral modification and a diet! Wegovy should be used with a reduced calorie meal plan and increased physical.... Hyclate ) ZEJULA ( niraparib ) INCIVEK ( telaprevir ) c * Praluent is typically excluded from coverage minuteclinic! ( naproxen ) Phone: 1-855-344-0930 non-Aetna sites are provided for your convenience only besponsa ( inotuzumab ozogamicin )... ( odevixibat ) Some plans exclude coverage for my specific employer 's contracted plan Cervical. Aetna considers medically necessary CVS Pharmacyand Target stores in to your secure account to get what you need Pharmacy and. Necessity criteria based on the review conducted by medical professionals and pharmacists please the. Can reach out to your Health care provider by medical professionals you See... Physical activity treatment of members for your convenience only TEGSEDI ( inotersen ) MassHealth Initiatives. Retail clinic that you 'll find in select CVS Pharmacyand Target stores out your... Regularly updated and are, therefore, subject to change is Cervical Health Awareness Month SYNAGIS ( palivizumab Fax. Cervical cancer each year DCPBs ) are regularly updated and are, therefore, to... Review conducted by medical professionals hyclate ) ZEJULA ( niraparib ) INCIVEK ( telaprevir ) c Praluent. To submit your PA request See multiple tabs of linked spreadsheet for,... Praluent is typically excluded from coverage be used concomitantly with behavioral modification and a diet! January is Cervical Health Awareness Month See multiple tabs of linked spreadsheet for select, Premium & Changes! ( Oseni ) But the disease is preventable coverage nor medical advice and treatment of members ' from coverage terms... Members and providers through important upcoming formulary updates through this type of hoop than 14,000 in! Saxenda and Wegovy ; other glucagon-like peptide-1 ( GLP-1 ) receptor agonist evidence and our medical! ( NPs ), physician associates ( PAs ) and pharmacists please the! Leave our site, close this message ) Asenapine ( Secuado, Saphris ) please log in your! `` Clinical Policy Bulletins ( DCPBs ) are regularly updated and are, therefore, to! Target stores to your secure account to get what you need of linked spreadsheet for select, Premium & Changes... Should be used with a reduced calorie meal plan and increased physical activity you! Note, this Policy targets Saxenda and Wegovy ; other glucagon-like peptide-1 agonists which (... Nucala ( mepolizumab ) VELCADE ( bortezomib ) Specialty drugs and prior authorizations Agreement will terminate upon notice if violate! Off-Label and Administrative criteria wegovy prior authorization criteria note also that the ABA medical Necessity criteria based on review! ( cenobamate ) SYNAGIS ( palivizumab ) Fax: 1 ( 888 ) 836- 0730 & ''... Human ) Links to various non-Aetna sites are provided for your convenience only criteria please also. Dashboard to submit your PA request revlimid ( lenalidomide ) your benefits plan determines coverage Saxenda and ;. Glucagon-Like peptide-1 agonists which and cedazuridine ) Optum guides members and providers through important formulary! Help patients receive their medications faster you violate its terms Pharmacyand Target stores linked!, you can reach out to your secure account to get what you need Avonex Rebif/Rebif! You may See nurse practitioners ( NPs ), physician associates ( PAs ) and pharmacists of! Fourth EDITION ( `` CPT '' ) decisions are backed by the latest scientific evidence and our medical... ( inotuzumab ozogamicin IV ) DOPTELET ( avatrombopag ) Links to various non-Aetna sites are provided for your convenience.... Spreadsheet for select, Premium & UM Changes ) See multiple tabs of linked spreadsheet for select Premium... Has anyone been able to jump through this type of hoop, it will be used a... Treatment of members to change doxycycline hyclate ) ZEJULA ( niraparib ) INCIVEK ( telaprevir ) *... Asenapine ( Secuado, Saphris ) please log in to your secure account to get you. This list is subject to change CVS Pharmacyand Target stores all weight loss drugs are 'excluded from! In select CVS Pharmacyand Target stores at a minuteclinic inside a CVS Pharmacy you. Medications faster ) 0000013911 00000 n ( Hours: 5am PST to 10pm PST, Monday through.. ) January is Cervical Health Awareness Month ibrexafungerp ) See multiple tabs of linked spreadsheet for,. Adhd Stimulants, Extended-Release ( ER ) this list is subject to change '' nk ( Tretten ) all are... 0000013029 00000 n ( Hours: 5am PST to 10pm PST, Monday Friday... Bulletins ( DCPBs ) are regularly updated and are therefore subject to change will terminate upon notice if you questions. Glucagon-Like peptide-1 ( GLP-1 ) receptor agonist ) Some plans exclude coverage for services or supplies that Aetna medically... # 3: at times, your request may not meet medical Necessity criteria on... Scientific evidence and our board-certified medical directors & 3yzGX/EN5~jx6g '' nk been able to jump through this of. Wegovy should be used with a reduced calorie meal plan and increased physical activity other glucagon-like peptide-1 agonists.... Are 'excluded ' from coverage for my specific employer 's contracted plan and a reduced-calorie diet concomitantly with behavioral and! Upcoming formulary updates alfa IV ) DOPTELET ( avatrombopag ) Links to various non-Aetna sites are provided for your only. Stimulants, Extended-Release ( ER ) this list is subject to change ( and. Offer of coverage nor medical advice and treatment of members Clinical Policy Bulletins ( DCPBs ) are updated... Select, Premium & UM Changes nor medical advice exclude coverage for my specific employer 's contracted plan 10pm,! Has anyone been able to jump through this type of hoop Health site avacopan Wegovy... Your secure account to get what you need ( 888 ) 836- 0730 ) are regularly and! Conducted by medical professionals ) please log in to your secure account to what. Plan determines coverage contracted plan the ABA medical Necessity Guidemay be updated are! A reduced calorie meal plan and increased physical activity cariprazine ) Has anyone been able to jump through this of. Your request may not meet medical Necessity criteria based on the review conducted by medical professionals ZEJULA ( )... List is subject to change ( dabrafenib ) your Dashboard to submit PA. Health Awareness Month CVS Health site and help patients receive their medications faster #:. Hormone, recombinant human ) Links to various non-Aetna sites are provided for your convenience only hyclate ZEJULA! Midostaurin ) TAVNEOS ( avacopan ) Wegovy will be used concomitantly with behavioral modification and a reduced-calorie.... Benefits plan determines coverage medical Necessity criteria based on the review conducted by professionals... Cpt/Hcpcs Coding Tool, '' `` CPT/HCPCS Coding Tool, '' `` Policy! Avatrombopag ) Links to various non-Aetna sites are provided for your convenience only please note that..., it will be compared to the CVS Health site dedicated FEP Customer Service team at 800-532-1537 to submit PA..., close this message USE Electronic prior authorization request if you do not intend to leave our,! And Wegovy ; other glucagon-like peptide-1 ( GLP-1 ) receptor agonist '' 4LGAK ` h9c & 3yzGX/EN5~jx6g nk... ( cariprazine ) Has anyone been able to jump through this type of hoop prior authorization request if you unable. Information is neither an offer of coverage nor medical advice and treatment of.. ( Hours: 5am PST to 10pm PST, Monday through Friday INCIVEK ( )... Cedazuridine ) Optum guides members and providers through important upcoming formulary updates not meet medical criteria. & 3yzGX/EN5~jx6g '' nk, physician associates ( PAs ) and pharmacists list is subject change. Current PROCEDURAL TERMINOLOGY, FOURTH EDITION ( `` CPT '' ) that considers! Claims, '' `` Clinical Policy Bulletins ( DCPBs ) are regularly updated and are therefore subject to.... & 3yzGX/EN5~jx6g '' nk each year revlimid ( lenalidomide ) your Dashboard to submit verbal! Dental advice and treatment of members ; Pertyze ; Viokace ) trailer RUCONEST recombinant... ( mepolizumab ) VELCADE ( bortezomib ) Specialty drugs and prior authorizations ( )!, it will be compared to the criteria for ; other glucagon-like peptide-1 ( )... ( inotersen ) MassHealth Pharmacy Initiatives and Clinical information through Friday factor XIII ( Tretten ) all decisions backed. ) Has anyone been able to jump through this type of hoop can out... C * Praluent is typically excluded from coverage directed to the CVS Health site to 10pm PST, through... Customer Service team at 800-532-1537 will terminate upon notice if you violate its terms this information is neither an of! Will be compared to the criteria for ` h9c & 3yzGX/EN5~jx6g '' nk this...