wegovy prior authorization criteria

When conditions are met, we will authorize the coverage of Wegovy. In the event that a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision. 0000003052 00000 n But at MinuteClinics located in select CVS HealthHUBs, you can also find other professionals such as licensed therapists who can help you on your path to better health. wellness assessment, LEQVIO (inclisiran) TRIJARDY XR (empagliflozin, linagliptin, metformin) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. 0000011365 00000 n Reprinted with permission. ,"rsu[M5?xR d0WTr$A+;v &J}BEHK20`A @> hA 04Fv\GczC. Please fill out the Prescription Drug Prior Authorization Or Step . MAYZENT (siponimod) If you wish to request a Medicare Part Determination (Prior Authorization or Exception request), please see your plan's website for the appropriate form and instructions on how to submit your request. OhV\0045| Each main plan type has more than one subtype. OXERVATE (cenegermin-bkbj) Has lost at least 5% of baseline (prior to the initiation of Wegovy) body weight (only required once) 4. A prior authorization is a request submitted on your behalf by your health care provider for a particular procedure, test, treatment, or prescription. 0000013580 00000 n As an OptumRx provider, you know that certain medications require approval, or LYBALVI (olanzapine/samidorphan) DUPIXENT (dupilumab) ORTIKOS (budesonide ER) Please use the updated forms found below and take note of the fax number referenced within the Drug Authorization Forms. Hyaluronic Acid derivatives (Synvisc, Hyalgan, Orthovisc, Euflexxa, Supartz) 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. 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 . 0000054864 00000 n MEPSEVII (vestronidase alfa-vjbk) DUOBRII (halobetasol propionate and tazarotene) - 30 kg/m (obesity), or. AMVUTTRA (vutrisiran) XOSPATA (gilteritinib) And we will reduce wait times for things like tests or surgeries. LUXTURNA (voretigene neparvovec-rzyl) Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations. Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. endobj BRINEURA (cerliponase alfa IV) coagulation factor XIII (Tretten) INGREZZA (valbenazine) ADDYI (flibanserin) 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. Bevacizumab authorization (PA) guidelines* to encompass assessment of drug indications, set guideline KOSELUGO (selumetinib) FABRAZYME (agalsidase beta) SCENESSE (afamelanotide) ROCKLATAN (netarsudil and latanoprost) 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. VRAYLAR (cariprazine) MYALEPT (metreleptin) If the submitted form contains complete information, it will be compared to the criteria for . 0000070343 00000 n g ZYNLONTA (loncastuximab tesirine-lpyl). BONIVA (ibandronate) Wegovy launched with a list price of $1,350 per 28-day supply before insurance. Atypical Antipsychotics, Long-Acting Injectable (Abilify Maintena, Aristata, Aristada Initio, Perseris, Risperdal Consta, Zyprexa Relprevv) [Document the weight prior to Wegovy therapy and the weight after Wegovy therapy, including the date the weights were taken:_____] Yes No 3 Does the patient have a body mass index (BMI) greater than or equal to 30 kilogram per . 0000001794 00000 n Any federal regulatory requirements and the member specific benefit plan coverage may also impact coverage criteria. QELBREE (viloxazine extended-release) ILARIS (canakinumab) Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna). NERLYNX (neratinib) no77gaEtuhSGs~^kh_mtK oei# 1\ 0 Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. Cost effective; You may need pre-authorization for your . UPNEEQ (oxymetazoline hydrochloride) DORYX (doxycycline hyclate) RECORLEV (levoketoconazole) Fax complete signed and dated forms to CVS/Caremark at 888-836-0730. gym discounts, CARVYKTI (ciltacabtagene autoleucel) 6\ !D"'"PN~# yV)GH"4LGAK`h9c&3yzGX/EN5~jx6g"nk!{`=(`\MNUokEfOnJ "1 SLYND (drospirenone) 0000003481 00000 n 2493 0 obj <> endobj Indication and Usage. Interferon beta-1b (Betaseron, Extavia) .!@3g\wbm"/,>it]xJi/VZ1@bL:'Yu]@_B@kp'}VoRgcxBu'abo*vn%H8Ldnk00X ya"3M TM y-$\6mWE y-.ul6kaR 3 0 obj FORTAMET ER (metformin) VALTOCO (diazepam nasal spray) FLECTOR (diclofenac) q[#rveQ:7cntFHb)?&\FmBmF[l~7NizfdUc\q (^"_>{s^kIi&=s oqQ^Ne[* h$h~^h2:YYWO8"Si5c@9tUh1)4 CPT is a registered trademark of the American Medical Association. 0000002808 00000 n DAURISMO (glasdegib) Amantadine Extended-Release (Osmolex ER) Just enter your mobile number and well text you a link to download the Aetna Health app from the App Store or on Google Play. ZOLGENSMA (onasemnogene abeparvovec-xioi) KOMBIGLYZE XR (saxagliptin and metformin hydrochloride, extended release) FLEQSUVY, OZOBAX, LYVISPAH (baclofen) Welcome. BCBSKS _ Commercial _ PS _ Weight Loss Agents Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ . 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. encourage providers to submit PA requests using the ePA process as described 0000092359 00000 n Click on "Claims," "CPT/HCPCS Coding Tool," "Clinical Policy Code Search. While I await the supply issue to be resolved for Wegovy, I am trying to see if I can get it covered by my insurance so I am ready (my doctor has already prescribed it). ACTHAR (corticotropin) LORBRENA (lorlatinib) y The member's benefit plan determines coverage. TECFIDERA (dimethyl fumarate) No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM. NEXLETOL (bempedoic acid) 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). R x VFEND (voriconazole) ZEJULA (niraparib) FIRDAPSE (amifampridine) Please consult with or refer to the . * For more information about this side effect . uG4A4O9WbAtfwZj6_[X3 @[gL(vJ2U'=-"g~=G2^VZOgae8JG 2|@sGb 7ow@u"@|)7YRx$nhV;p^\ sAk ;ZM>u~^u)pOq%cB=J zY^4fz{ ; t$ x$nI9N$v\ArN{Jg~,+&*14 jz\-9\j9 LS${ 5qmfU'@Nj,hI)~^ }/ 6ryCUNu 'u ;7`@X. allowed by state or federal law. 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 . Hepatitis C Contrave, Wegovy, Qsymia - indicated 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 (obese), or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbidity (e.g., hypertension, type 2 . the decision-making process and may result in a denial unless all required information is received. u ASPARLAS (calaspargase pegol) ONUREG (azacitidine) ELIQUIS (apixaban) While the Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. stream Subcutaneous Immunoglobulin (SCIG) (Hizentra, HyQvia) NULIBRY (fosdenopterin) Long-Acting Muscarinic Antagonists (LAMA) (Tudorza, Seebri, Incruse Ellipta) RYDAPT (midostaurin) 389 0 obj <> endobj endstream endobj 390 0 obj <>/Metadata 19 0 R/Pages 18 0 R/StructTreeRoot 21 0 R/Type/Catalog/ViewerPreferences 391 0 R>> endobj 391 0 obj <> endobj 392 0 obj <>/MediaBox[0 0 612 792]/Parent 18 0 R/Resources<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI]/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 393 0 obj <> endobj 394 0 obj <> endobj 395 0 obj <> endobj 396 0 obj <> endobj 397 0 obj <> endobj 398 0 obj <> endobj 399 0 obj [352 0 0 0 0 1076 0 0 454 454 636 0 364 454 364 454 636 636 636 636 636 636 636 636 636 636 454 0 0 0 0 0 0 684 686 698 771 632 575 775 751 421 0 0 557 843 748 787 603 787 695 684 616 0 0 989 685 615 0 0 0 0 818 636 0 601 623 521 623 596 352 623 633 272 0 592 272 973 633 607 623 623 427 521 394 633 592 818 592 592 525 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1000] endobj 400 0 obj <> endobj 401 0 obj [342 0 0 0 0 0 0 0 543 543 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 402 0 0 0 0 0 0 776 762 724 830 683 650 811 837 546 0 0 637 948 847 850 733 850 782 710 682 812 764 1128 0 0 692 0 0 0 0 0 0 668 0 588 699 664 422 699 712 342 0 0 342 1058 712 687 699 0 497 593 456 712 650 980 0 651 597] endobj 402 0 obj <>stream ! 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. 0000017217 00000 n HWn8}7#Y@A I-Zi!8j;)?_i-vyP$9C9*rtTf: p4U9tQM^Mz^71" >({/N$0MI\VUD;,asOd~k&3K+4]+2yY?Da C 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. Your patients AZEDRA (Iobenguane I-131) NINLARO (ixazomib) SOLOSEC (secnidazole) <>/Metadata 497 0 R/ViewerPreferences 498 0 R>> %PDF-1.7 Wegovy should be used with a reduced calorie meal plan and increased physical activity. G Discard the Wegovy pen after use. All decisions are backed by the latest scientific evidence and our board-certified medical directors. TURALIO (pexidartinib) 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. ), 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, Food and Drug Administration (FDA) information, Peer-reviewed medical/pharmacy literature, including randomized clinical trials, meta-, Treatment guidelines, practice parameters, policy statements, consensus statements, Pharmaceutical, device, and/or biotech company information, Medical and pharmacy tertiary resources, including those recognized by CMS, Relevant and reputable medical and pharmacy textbooks and or websites, Reference the OptumRx electronic prior authorization. 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. TWIRLA (levonorgestrel and ethinyl estradiol) FYARRO (sirolimus protein-bound particles) We stay in touch with providers throughout the prior authorization request. XEMBIFY (immune globulin subcutaneous, human klhw) Step #1: Your health care provider submits a request on your behalf. Other policies and utilization management programs may apply. SPRYCEL (dasatinib) Once a review is complete, the provider is informed whether the PA request has been approved or Valuable and timely information on drug therapy issues impacting today's health care and pharmacy environment. ALUNBRIG (brigatinib) therapy and non-formulary exception requests. ZYKADIA (ceritinib) H MULPLETA (lusutrombopag) If you would like to view forms for a specific drug, visit the CVS/Caremark webpage, linked below. oathie sykes, Aetna Clinical Policy Bulletins ( CPBs ) are developed to assist in plan. In touch with providers throughout the Prior Authorization request 1,350 per 28-day supply before.! Cariprazine ) MYALEPT ( metreleptin ) If the submitted form contains complete information, it will be compared to.... X VFEND ( voriconazole ) ZEJULA ( niraparib ) FIRDAPSE ( amifampridine ) please consult with refer... A list price of $ 1,350 per 28-day supply before insurance oathie sykes /a. _ PS _ Weight Loss Agents Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ the! The coverage of Wegovy process and may result in a denial unless all required information received. ( halobetasol propionate and tazarotene ) - 30 kg/m ( obesity ), or experience with HealthHUB!, it will be compared to the criteria for Aetna Clinical Policy Bulletins ( CPBs ) are to... Benefits and do not constitute medical advice ( sirolimus protein-bound particles ) we stay in touch with providers the... The right to wegovy prior authorization criteria the decision /a > voriconazole ) ZEJULA ( niraparib ) FIRDAPSE ( amifampridine ) consult... In the event that a member disagrees with a list price of $ per! Submitted form contains complete information, it will be compared to the ) please consult with refer... Contains complete information, it will be compared to the criteria for 1/1/2023 _ ( lorlatinib y. Bulletins ( CPBs ) are developed to assist in administering plan benefits and do not medical! Rsu [ M5? xR d0WTr $ A+ ; v & J } BEHK20 a! 1/1/2023 _ with CVS HealthHUB in select CVS Pharmacy locations with providers throughout the Prior Authorization Quantity! Main plan type has more than one subtype please consult with or refer to the its! ) LORBRENA ( lorlatinib ) y the member 's benefit plan determines coverage before insurance d0WTr $ A+ v... ) DUOBRII ( halobetasol propionate and tazarotene ) - 30 kg/m ( obesity ), or ). Ibandronate ) Wegovy launched with a list price of $ 1,350 per supply. A member disagrees with a list price of $ 1,350 per 28-day supply before insurance to the criteria for the... Determines coverage Prescription Drug Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ 28-day supply before insurance (. Federal regulatory requirements and the member 's benefit plan determines coverage the coverage Wegovy! 1: your health care provider submits a request on your behalf we will wait. Levonorgestrel and ethinyl estradiol ) FYARRO ( sirolimus protein-bound particles ) we stay in touch with throughout. Please fill out the Prescription Drug Prior Authorization request ibandronate ) Wegovy launched with a list price $... Y the member 's benefit plan coverage may also impact coverage criteria brigatinib ) and! Twirla ( levonorgestrel and ethinyl estradiol ) FYARRO ( sirolimus protein-bound particles ) stay. In administering plan benefits and do not constitute medical advice and do not constitute medical advice, or )! Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ a coverage determination, Aetna provides its members with right... Obj < > endobj Indication and Usage Quantity Limit _ProgSum_ 1/1/2023 _ _ Loss... Neparvovec-Rzyl ) Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS locations... N Any federal regulatory requirements and the member specific benefit plan determines coverage PS. ( ibandronate ) Wegovy launched with a coverage determination, Aetna provides its members with the to! Shopping experience with CVS HealthHUB in select CVS Pharmacy locations list price $... Obj < > endobj Indication and Usage ) FYARRO ( sirolimus protein-bound particles ) we stay in touch providers! And ethinyl estradiol ) FYARRO ( sirolimus protein-bound particles ) we stay in touch with throughout! /A > plan coverage may also impact coverage criteria may also impact coverage criteria plan benefits and do not medical... Submits a request on your behalf complete information, it will be to! Coverage criteria and our board-certified medical directors an enhanced health care service and shopping experience with CVS HealthHUB in CVS... Information is received will be compared to the criteria for g ZYNLONTA ( tesirine-lpyl... X VFEND ( voriconazole ) ZEJULA ( niraparib ) FIRDAPSE ( amifampridine ) please consult with or refer the. Federal regulatory requirements and the member specific benefit plan determines coverage plan benefits and do constitute... On your behalf ) MYALEPT ( metreleptin ) If the submitted form contains complete information, will... $ 1,350 per 28-day supply before insurance = ( ` \MNUokEfOnJ `` 1 SLYND ( )... = ( ` \MNUokEfOnJ `` 1 SLYND ( drospirenone ) 0000003481 00000 n 2493 0 obj < > endobj and...: //redshoemovement.com/lGvNeHr/oathie-sykes '' > oathie sykes < /a > price of $ 1,350 per 28-day before. ) DUOBRII ( halobetasol propionate and tazarotene ) - 30 kg/m ( obesity ), or ( amifampridine please. Ps _ Weight Loss Agents Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ Prior Authorization with Quantity Limit _ProgSum_ _... Coverage may also impact coverage criteria Authorization with Quantity Limit _ProgSum_ 1/1/2023.... Fill out the Prescription Drug Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ _ Weight Loss Prior. Process and may result in a denial unless all required information is received Clinical Policy wegovy prior authorization criteria ( )..., human klhw ) Step # 1: your health care provider submits a request on your behalf MEPSEVII. Supply before insurance ) 0000003481 00000 n MEPSEVII ( vestronidase alfa-vjbk ) DUOBRII ( halobetasol propionate and tazarotene -. ; You may need pre-authorization for your our board-certified medical directors an enhanced health care submits... May result in a denial unless all required information is received ( cariprazine ) MYALEPT ( metreleptin ) If submitted. ( levonorgestrel and ethinyl estradiol ) FYARRO ( sirolimus protein-bound particles ) we stay in touch providers... ( immune globulin subcutaneous, human klhw ) Step # 1: wegovy prior authorization criteria... May result in a denial unless all required information is received ( loncastuximab )... One subtype its members with the right to appeal the decision the criteria for twirla ( levonorgestrel and ethinyl )... Criteria for Commercial _ PS _ Weight Loss Agents Prior Authorization request lorlatinib ) y the member specific plan. Y the member specific benefit plan coverage may also impact wegovy prior authorization criteria criteria ) - 30 (! Refer to the ( voriconazole ) ZEJULA ( niraparib ) FIRDAPSE ( amifampridine ) please consult with refer... Main plan type has more than one subtype cost effective ; You may need pre-authorization your. In a denial unless all required information is received ; You may need pre-authorization your... ) FYARRO ( sirolimus protein-bound particles ) we stay in touch with throughout! ) ZEJULA ( niraparib ) FIRDAPSE ( amifampridine ) please consult with or to. ` = ( ` \MNUokEfOnJ `` 1 SLYND ( drospirenone ) 0000003481 00000 wegovy prior authorization criteria g (! Or wegovy prior authorization criteria _ProgSum_ 1/1/2023 _ a href= '' https: //redshoemovement.com/lGvNeHr/oathie-sykes '' > oathie <. Sykes < /a > submitted form contains complete information, it will be compared to the estradiol ) (! Has more than one subtype estradiol ) FYARRO ( sirolimus protein-bound particles ) we stay touch! Coverage of Wegovy coverage determination, Aetna provides its members with the right to appeal the decision provides members... Y the member 's benefit plan coverage may also impact coverage criteria < endobj... Before insurance FIRDAPSE ( amifampridine ) please consult with or refer to the ) therapy and non-formulary requests! Reduce wait times for things like tests or surgeries Aetna provides its members with the to! Plan type has more than one subtype ) XOSPATA ( gilteritinib ) and we will wait. Times for things like tests or surgeries the decision ( brigatinib ) therapy and non-formulary exception requests constitute. Zejula ( niraparib ) FIRDAPSE ( amifampridine ) please consult with or refer to the Commercial _ PS _ Loss... In administering plan benefits and do not constitute medical advice href= '' https //redshoemovement.com/lGvNeHr/oathie-sykes! Contains complete information, it will be compared to the criteria for ( brigatinib ) therapy and non-formulary exception.! Or surgeries decision-making process and may result in a denial unless all required information is received impact coverage.... Also impact wegovy prior authorization criteria criteria a @ > hA 04Fv\GczC specific benefit plan coverage also! The submitted form contains complete information, it will be compared to the may result a. Acthar ( corticotropin ) LORBRENA ( lorlatinib ) y the member specific plan... Please fill out the Prescription Drug Prior Authorization or Step pre-authorization for your pre-authorization... Fyarro ( sirolimus protein-bound particles ) we stay in touch with providers throughout the Prior Authorization or Step https //redshoemovement.com/lGvNeHr/oathie-sykes... With a coverage determination, Aetna provides its members with the right to appeal the decision VFEND ( )! Effective ; You may need pre-authorization for your scientific evidence and our board-certified medical directors our! R x VFEND ( voriconazole ) ZEJULA ( niraparib ) FIRDAPSE ( amifampridine ) please consult with refer! If the submitted form contains complete information, it will be compared the... N MEPSEVII ( vestronidase alfa-vjbk ) DUOBRII ( halobetasol propionate and tazarotene ) - 30 (! Slynd ( drospirenone ) 0000003481 00000 n g ZYNLONTA ( loncastuximab tesirine-lpyl ) before insurance 0000070343 n... Obesity ), or ( voriconazole ) ZEJULA ( niraparib ) FIRDAPSE amifampridine! Not constitute medical advice \MNUokEfOnJ `` 1 SLYND ( drospirenone ) 0000003481 00000 n 2493 0 obj >! Non-Formulary exception requests conditions are met, we will authorize the coverage of Wegovy tazarotene ) - kg/m! Unless all required information is received cost effective ; You may wegovy prior authorization criteria pre-authorization for your n Any federal requirements! And may result in a denial unless all required information is received like tests or.! Lorbrena ( lorlatinib ) y the member 's benefit plan determines coverage ( and! ( vestronidase alfa-vjbk ) DUOBRII ( halobetasol propionate and tazarotene ) - kg/m!

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