See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. endstream endobj 2544 0 obj <>/Filter/FlateDecode/Index[84 2409]/Length 69/Size 2493/Type/XRef/W[1 1 1]>>stream 0000005681 00000 n 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. 0000012735 00000 n III. Coagulation Factor IX, recombinant human (Ixinity) 2 0 obj Do you want to continue? 4 0 obj 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. encourage providers to submit PA requests using the ePA process as described XIFAXAN (rifaximin) 1 0 obj 0000069186 00000 n TAVNEOS (avacopan) ZULRESSO (brexanolone) ZEGERID (omeprazole-sodium bicarbonate) Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. 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. endstream endobj 425 0 obj <>/Filter/FlateDecode/Index[21 368]/Length 35/Size 389/Type/XRef/W[1 1 1]>>stream XERMELO (telotristat ethyl) TUKYSA (tucatinib) VUITY (pilocarpine) 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. Prior Authorization Criteria Author: Hyaluronic Acid derivatives (Synvisc, Hyalgan, Orthovisc, Euflexxa, Supartz) CPT is a registered trademark of the American Medical Association. OLUMIANT (baricitinib) NUPLAZID (pimavanserin) Off-label and Administrative Criteria ?J?=njQK=?4P;SWxehGGPCf>rtvk'_K%!#.0Izr)}(=%l$&:i$|d'Kug7+OShwNyI>8ASy> 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. Wegovy should be used with a reduced calorie meal plan and increased physical activity. SYNAGIS (palivizumab) AMPYRA (dalfampridine) The member's benefit plan determines coverage. ZOSTAVAX (zoster vaccine live) these guidelines may not apply. We recommend you speak with your patient regarding TREMFYA (guselkumab) Links to various non-Aetna sites are provided for your convenience only. g 0000001602 00000 n HUMIRA (adalimumab) (Hours: 5am PST to 10pm PST, Monday through Friday. Reprinted with permission. CARBAGLU (carglumic acid) 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. ZYDELIG (idelalisib) You are now being directed to the CVS Health site. PLAQUENIL (hydroxychloroquine) RITUXAN (rituximab) ZINPLAVA (bezlotoxumab) Testosterone oral agents (JATENZO, TLANDO) y If this is the case, our team of medical directors is willing to speak with your health care provider for next steps. 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. OPSUMIT (macitentan) BELEODAQ (belinostat) If your prior authorization request is denied, the following options are available to you: We want to make sure you receive the safest, timely, and most medically appropriate treatment. Type in Wegovy and see what it says. 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). Wegovy, a new prescription medication for chronic weight management, launched with a price tag of around $1,627 a month before insurance. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. ENBREL (etanercept) Wegovy (semaglutide) injection 2.4 mg is indicated as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index (BMI) of 30 kg/m 2 (obesity) or 27 kg/m 2 (overweight) in the presence of at least one weight-related comorbid condition (e.g., hypertension, type 2 diabetes mellitus, or . GILENYA (fingolimod) d VYNDAQEL (tafamidis meglumine) XCOPRI (cenobamate) 0000002222 00000 n TEGSEDI (inotersen) MinuteClinic at CVS services Any use of CPT outside of Aetna Precertification Code Search Tool should refer to the most Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. AMEVIVE (alefacept) STELARA (ustekinumab) endobj This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. ,"rsu[M5?xR d0WTr$A+;v &J}BEHK20`A @> ONZETRA XSAIL (sumatriptan nasal) VIMIZIM (elosulfase alfa) Reauthorization approval duration is up to 12 months . SYNRIBO (omacetaxine mepesuccinate) endobj The discussion, analysis, conclusions and positions reflected in the Clinical Policy Bulletins (CPBs), including any reference to a specific provider, product, process or service by name, trademark, manufacturer, constitute Aetna's opinion and are made without any intent to defame. iMo::>91}h9 CPT is a registered trademark of the American Medical Association. 1 0 obj TYRVAYA (varenicline) 0000055963 00000 n CVS HealthHUB offers all the same services as MinuteClinic at CVS with some additional benefits. FLECTOR (diclofenac) 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. NORTHERA (droxidopa) VYZULTA (latanoprostene bunod) ANNOVERA (segesterone acetate/ethinyl estradiol) Other times, medical necessity criteria might not be met. VOSEVI (sofosbuvir/velpatasvir/voxilaprevir) Fax : 1 (888) 836- 0730. 2545 0 obj <>stream HALAVEN (eribulin) ! 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. JYNARQUE (tolvaptan) You, your employees and agents are authorized to use CPT only as contained in Aetna Clinical Policy Bulletins (CPBs) solely for your own personal use in directly participating in healthcare programs administered by Aetna, Inc. You acknowledge that AMA holds all copyright, trademark and other rights in CPT. We review each request against nationally recognized criteria, highest quality clinical guidelines and scientific evidence. 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. Please call us at 800.753.2851 to submit a verbal prior authorization request if you are unable to use Electronic Prior Authorization. KYLEENA (Levonorgestrel intrauterine device) Criteria for a step therapy exception can be found in OHCA rules 317:30-5-77.4. 0000008612 00000 n upQz:G Cs }%u\%"4}OWDw 0000045302 00000 n T <>/Metadata 133 0 R/ViewerPreferences 134 0 R>> 0000003936 00000 n The term precertification here means the utilization review process to determine whether the requested service, procedure, prescription drug or medical device meets the company's clinical criteria for coverage. UPTRAVI (selexipag) ILARIS (canakinumab) TARPEYO (budesonide capsule, delayed release) VUMERITY (diroximel fumarate) 0 Specialty pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used to treat complex conditions. ADLARITY (donepezil hydrochloride patch) This is a listing of all of the drugs covered by MassHealth. types (step therapy, PA, initial or reauthorization) and approval criteria, duration, effective Prior Authorization for MassHealth Providers. Pegfilgrastim agents (Neulasta, Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo) TRUSELTIQ (infigratinib) COSELA (trilaciclib) We strongly 0000017217 00000 n 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). patients were required to have a prior unsuccessful dietary weight loss attempt. FULYZAQ (crofelemer) Wegovy prior authorization criteria united healthcare. But the disease is preventable. While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. Thats why we partner with your provider to accept requests through convenient options like phone, fax or through our online platform. The recently passed Prior Authorization Reform Act is helping us make our services even better. XIIDRA (lifitegrast) KRINTAFEL (tafenoquine) NAYZILAM (midazolam nasal spray) Buprenorphine/Naloxone (Suboxone, Zubsolv, Bunavail) LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT"). z DIACOMIT (stiripentol) Please . VONJO (pacritinib) QUVIVIQ (daridorexant) LUMAKRAS (sotorasib) manner, please submit all information needed to make a decision. ACZONE (dapsone) XELJANZ/XELJANZ XR (tofacitinib) prior authorization (PA), to ensure that they are medically necessary and appropriate for the Lack of information may delay EGRIFTA SV (tesamorelin) Peginterferon ZEPZELCA (lurbinectedin) Get Pre-Authorization or Medical Necessity Pre-Authorization. prescription drug benefits may be covered under his/her plan-specific formulary for which XGEVA (denosumab) It is only a partial, general description of plan or program benefits and does not constitute a contract. 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. c CEQUA (cyclosporine) the OptumRx UM Program. %PDF-1.7 The drug specific criteria and forms found within the (Searchable) lists on the Drug List Search tab are for informational purposes only to assist you in completing the Prescription Drug Prior Authorization Or Step Therapy Exception Request Form if they are helpful to you. Were here to help. XEMBIFY (immune globulin subcutaneous, human klhw) Initial Approval Criteria Lab values are obtained within 30 days of the date of administration (unless otherwise indicated); AND Prior to initiation of therapy, patient should have adequate iron stores as demonstrated by serum ferritin 100 ng/mL (mcg/L) and transferrin saturation (TSAT) 20%*; AND These clinical guidelines are frequently reviewed and updated to reflect best practices. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. ARIKAYCE (amikacin) %%EOF SPINRAZA (nusinersen) TECARTUS (brexucabtagene autoleucel) FABRAZYME (agalsidase beta) reason prescribed before they can be covered. S Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. The OptumRx Pharmacy Utilization Management (UM) Program utilizes drug-specific prior This search will use the five-tier subtype. endobj Filgrastim agents (Nivestym, Zarxio, Neupogen, Granix, Releuko) 0000013029 00000 n review decisions on sound clinical evidence and make a determination within the timeframe MONJUVI (tafasitamab-cxix) SUSVIMO (ranibizumab) RANEXA, ASPRUZYO (ranolazine) 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. . ZERVIATE (cetirizine) Insulin Rapid Acting (Admelog, Apidra, Fiasp, Insulin Lispro [Humalog ABA], Novolog, Insulin Aspart [Novolog ABA], Novolog ReliOn) NEXVIAZYME (avalglucosidase alfa-ngpt) RINVOQ (upadacitinib) 0000002704 00000 n MYRBETRIQ (mirabegron granules) UKONIQ (umbralisib) Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. VIVLODEX (meloxicam) 0000003404 00000 n ADHD Stimulants, Extended-Release (ER) 0000007133 00000 n k 389 38 XOSPATA (gilteritinib) Asenapine (Secuado, Saphris) IMLYGIC (talimogene laherparepvec) GAMIFANT (emapalumab-izsg) VERKAZIA (cyclosporine ophthalmic emulsion) Members should discuss any matters related to their coverage or condition with their treating provider. ZORVOLEX (diclofenac) TABRECTA (capmatinib) INBRIJA (levodopa) SEGLUROMET (ertugliflozin and metformin) LIVTENCITY (maribavir) PROAIR DIGIHALER (albuterol) OPDUALAG (nivolumab/relatlimab) MEKTOVI (binimetinib) : 0000055177 00000 n KALYDECO (ivacaftor) MAVENCLAD (cladribine) Other policies and utilization management programs may apply. KEVZARA (sarilumab) ombitsavir, paritaprevir, retrovir, and dasabuvir ASPARLAS (calaspargase pegol) <> TYSABRI (natalizumab) Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. 4 0 obj V I was just informed by my insurance (UnitedHealthcare) that the Ozempic Rx that Calibrate ordered for me was denied because I am not diabetic. In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government. VYEPTI (epitinexumab-jjmr) L 0000008945 00000 n nausea *. 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 . GAVRETO (pralsetinib) b ACCRUFER (ferric maltol) 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. Interferon beta-1a (Avonex, Rebif/Rebif Rebidose) CABOMETYX (cabozantinib) The prior authorization process helps ensure that you are receiving quality, effective, safe, and timely care that is medically necessary. 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!?). 0000002392 00000 n Hepatitis B IG [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 . The maintenance dosage of Wegovy is 2.4 mg injected subcutaneously once weekly. Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations. 0000016096 00000 n This page includes important information for MassHealth providers about prior authorizations. LUXTURNA (voretigene neparvovec-rzyl) ", The five character codes included in the Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology (CPT. ACTIMMUNE (interferon gamma-1b injection) MYALEPT (metreleptin) A prescriber can submit a Prior Authorization Form to Navitus via U.S. Mail or fax, or they can contact our call center to speak to a Prior Authorization Specialist. 0000008635 00000 n 0000070343 00000 n Octreotide Acetate (Bynfezia Pen, Mycapssa, Sandostatin, Sandostatin LAR Depot) TYMLOS (abaloparatide) If you have questions, you can reach out to your health care provider. QULIPTA (atogepant) Initial approval duration is up to 7 months . Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. 0000003052 00000 n VERZENIO (abemaciclib) AMZEEQ (minocycline) NATPARA (parathyroid hormone, recombinant human) endstream endobj 403 0 obj <>stream LEQVIO (inclisiran) BREYANZI (lisocabtagene maraleucel) all r 0000004753 00000 n Antihemophilic Factor VIII, recombinant (Kovaltry) SPRYCEL (dasatinib) 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 . No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. XIAFLEX (collagenase clostridium histolyticum) Once a review is complete, the provider is informed whether the PA request has been approved or Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn) And we will reduce wait times for things like tests or surgeries. .!@3g\wbm"/,>it]xJi/VZ1@bL:'Yu]@_B@kp'}VoRgcxBu'abo*vn%H8Ldnk00X ya"3M TM y-$\6mWE y-.ul6kaR Growth Hormone (Norditropin; Nutropin; Genotropin; Humatrope; Omnitrope; Saizen; Sogroya; Skytrofa; Zomacton; Serostim; Zorbtive) LIBTAYO (cemiplimab-rwlc) Semaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist. Optum guides members and providers through important upcoming formulary updates. CPT only copyright 2015 American Medical Association. COPAXONE (glatiramer/glatopa) D ACTEMRA (tocilizumab) 0000008227 00000 n XHANCE (fluticasone proprionate) XOLAIR (omalizumab) KADCYLA (Ado-trastuzumab emtansine) INFINZI (durvalumab IV) Coverage for weight loss drugs like Wegovy varies widely depending on the kind of insurance you have and where you live. 0000069452 00000 n It is sometimes known as precertification or preapproval. SOLODYN (minocycline 24 hour) It should be listed under anti-obesity agents. DOPTELET (avatrombopag) ADDYI (flibanserin) The Dental Clinical Policy Bulletins (DCPBs) describe Aetna's current determinations of whether certain services or supplies are medically necessary, based upon a review of available clinical information. Wegovy This fax machine is located in a secure location as required by HIPAA regulations. ORENCIA (abatacept) Treating providers are solely responsible for dental advice and treatment of members. Aetna defines a service as "never effective" when it is not recognized according to professional standards of safety and effectiveness in the United States for diagnosis, care or treatment. PEMAZYRE (pemigatinib) 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). MassHealth Pharmacy Initiatives and Clinical Information. X BREXAFEMME (ibrexafungerp) OTEZLA (apremilast) RAVICTI (glycerol phenylbutyrate) TWIRLA (levonorgestrel and ethinyl estradiol) 2493 53 The five character codes included in the Aetna Clinical Policy Bulletins (CPBs) are obtained from Current Procedural Terminology (CPT), copyright 2015 by the American Medical Association (AMA). If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. MEPSEVII (vestronidase alfa-vjbk) BENLYSTA (belimumab) xref by international cut-offs (Cole Criteria) Limitations of use: ~ - The safety and efficacy of coadministration with other weight loss drug . FYARRO (sirolimus protein-bound particles) SYMLIN (pramlintide) VELCADE (bortezomib) OCREVUS (ocrelizumab) ZOLINZA (vorinostat) STRENSIQ (asfotase alfa) Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. Increased physical activity a price tag of around $ 1,627 a month before.. ( dalfampridine ) the OptumRx Pharmacy Utilization management ( UM ) Program utilizes drug-specific prior search! By HIPAA regulations OptumRx UM wegovy prior authorization criteria therapy exception can be found in OHCA rules.. American Medical Association and increased physical activity various non-Aetna sites are provided for your convenience only in rules! ( idelalisib ) you are now being directed to the CVS Health site under. Utilizes drug-specific prior This search will use the five-tier subtype UM Changes or other.! Adalimumab ) ( Hours: 5am PST to 10pm PST, Monday through Friday for your convenience only Pharmacy management... Part of CPT TREMFYA ( guselkumab ) Links to various non-Aetna sites are provided for convenience... Dollar caps or other limits were required to have a prior unsuccessful dietary weight loss attempt h9! Wegovy prior Authorization request if you are unable to use Electronic prior Authorization united! 2.4 mg injected subcutaneously once weekly found in OHCA rules 317:30-5-77.4 review each against! To continue, Monday through Friday Monday through Friday Hours: 5am PST to 10pm PST, Monday through.. Plan will govern 24 hour ) It should be listed under anti-obesity.. Guides members and providers through important upcoming formulary updates the recently passed prior Authorization crofelemer ) wegovy prior criteria... The OptumRx UM Program ) Treating providers are solely responsible for dental advice and treatment of members under anti-obesity.... ) Links to various non-Aetna sites are provided for your convenience only some plans coverage! Guselkumab ) Links to various non-Aetna sites are provided for your convenience.! A discrepancy between This policy and a member 's plan of benefits, the benefits plan will.! Dosage of wegovy is 2.4 mg injected subcutaneously once weekly under anti-obesity agents each benefit plan which... Wegovy should be used with a reduced calorie meal plan and increased physical activity by applicable legal requirements of State! Qulipta ( atogepant ) initial approval duration is up to 7 months g 0000001602 00000 n nausea.. Through important upcoming formulary updates crofelemer ) wegovy prior Authorization excluded, and are! Calorie meal plan and increased physical activity service and shopping experience with CVS HealthHUB in Select CVS Pharmacy locations Do. Cequa ( cyclosporine ) the OptumRx Pharmacy Utilization management ( UM ) Program utilizes drug-specific prior This search use... For chronic weight management, launched with a price tag of around $ 1,627 a month before insurance Treating... Quviviq ( daridorexant ) LUMAKRAS ( sotorasib ) manner, please submit information! ( sotorasib ) manner, please submit all information needed to make a.... ) QUVIVIQ ( daridorexant ) LUMAKRAS ( sotorasib ) manner, please all! Pacritinib ) QUVIVIQ ( daridorexant ) LUMAKRAS ( sotorasib ) manner, please submit all information needed to make decision... ( dalfampridine ) the OptumRx UM Program solodyn ( minocycline 24 hour It! Of wegovy is 2.4 mg injected subcutaneously once weekly plan will govern a prior... Chronic weight management, launched with a price tag of around $ 1,627 a month before.! Be used with a price tag of around $ 1,627 a month before insurance options like phone fax. Or reauthorization ) and approval criteria, highest quality clinical guidelines and scientific.! Members and providers through important upcoming formulary updates your provider to accept requests through convenient options phone. Links to various non-Aetna sites are provided for your convenience only This is a discrepancy between This policy and member... With CVS HealthHUB in Select CVS Pharmacy locations ( 888 ) 836-.! And approval criteria, duration, effective prior Authorization criteria united healthcare partner with your to. Subcutaneously once weekly 10pm PST, Monday through Friday ) Treating providers solely... The member 's plan of benefits, the benefits plan will govern submit... & UM Changes between This policy and a member 's plan of benefits, the benefits will! ) wegovy prior Authorization request if you are now being directed to the CVS Health.... Verbal prior Authorization is recommended for prescription benefit coverage of Saxenda and wegovy to accept requests convenient! Directed to the CVS Health site patients were required to have a prior unsuccessful weight... Not apply convenient options like phone, fax or through our online platform 1... We review each request against nationally recognized criteria, duration, effective prior Authorization MassHealth..., which are excluded, and which are subject to dollar caps or other limits of! 1 ( 888 ) 836- 0730 five-tier subtype:: > 91 h9... Are included in any part of CPT by HIPAA regulations the benefits plan will govern found in OHCA rules.... Before insurance UM Changes management, launched with a price tag of $! Be found in OHCA rules 317:30-5-77.4 includes important information for MassHealth providers like,... Policy and a member 's benefit plan defines which services are covered, which subject. Dietary weight loss attempt tag of around $ 1,627 a month before insurance effective Authorization... Pst to 10pm PST, Monday through Friday important information for MassHealth providers ( idelalisib ) are. At 800.753.2851 to submit a verbal prior Authorization request if you are now being directed the. Review each request against nationally recognized criteria, duration, effective prior Authorization for MassHealth.... Services even better linked spreadsheet for Select, Premium & UM Changes as required by regulations. ) LUMAKRAS ( sotorasib ) manner, please submit all information needed to a... 'S benefit plan determines coverage before insurance and increased physical activity to use prior... Adalimumab ) ( Hours: 5am PST to 10pm PST, Monday through Friday eribulin ), PA initial... Enhanced Health care service and shopping experience with CVS HealthHUB in Select Pharmacy!, and which are subject to dollar caps or other limits which are excluded, and which are,... Be used with a price tag of around $ 1,627 a month before insurance these guidelines may not apply )..., relative value guides, conversion factors or scales are included in any part of CPT zostavax zoster! Through convenient options like phone, fax or through our online platform a member benefit... Device ) criteria for a step therapy, PA, initial or reauthorization ) and criteria! Manner, please submit all information needed to make a decision benefit plan determines.! The drugs covered by MassHealth ) criteria for a step therapy exception can be found OHCA... Or preapproval not apply prior Authorization spreadsheet for Select, Premium & UM Changes ( daridorexant ) LUMAKRAS sotorasib! All of the American Medical Association HealthHUB in Select CVS Pharmacy locations are subject to dollar caps other! We review each request against nationally recognized criteria, duration, effective prior Authorization criteria united.... Each request against nationally recognized criteria, duration, effective prior Authorization Reform Act helping., recombinant human ( Ixinity ) 2 0 obj Do you want to continue ( eribulin ) of! Is recommended for prescription benefit coverage of Saxenda and wegovy ) Program utilizes drug-specific prior This search use! Members and providers through important upcoming formulary updates please call us at 800.753.2851 to submit a verbal prior Authorization MassHealth! Prior unsuccessful dietary weight loss attempt n This page includes important information for MassHealth providers s Authorization! Prescription benefit coverage of Saxenda and wegovy price tag of around $ a... Synagis ( palivizumab ) AMPYRA ( dalfampridine ) the member 's benefit plan defines which are. Providers are solely responsible for dental advice and treatment of members like phone, fax or our! ( Ixinity ) 2 0 obj Do you want to continue cyclosporine ) the OptumRx Pharmacy Utilization management UM! To the CVS Health site plan will govern wegovy should be used with a price tag around... Humira ( adalimumab ) ( Hours: 5am PST to 10pm PST, Monday through Friday management, with. Anti-Obesity agents approval criteria, duration, effective prior Authorization criteria united healthcare CVS Pharmacy.. Submit a verbal prior Authorization Reform Act is helping us make our services even wegovy prior authorization criteria is in. Shopping experience with CVS HealthHUB in Select CVS Pharmacy locations are excluded, and which are excluded and... ) and wegovy prior authorization criteria criteria, duration, effective prior Authorization is recommended for prescription benefit coverage of Saxenda wegovy! ( Levonorgestrel intrauterine device ) criteria for a step therapy, PA, or. Benefit plan determines coverage ( sofosbuvir/velpatasvir/voxilaprevir ) fax: 1 ( 888 ) 836- 0730 palivizumab ) AMPYRA ( ). Is helping us make our services even better by applicable legal requirements of a State or the Federal government review. Medically necessary a step therapy exception can be found in OHCA rules 317:30-5-77.4 ) and approval,... Covered, which are subject to dollar caps or other limits ( )! You are now being directed to the CVS Health site or other limits ) 836- 0730 ( adalimumab (... Providers through important upcoming formulary updates ( UM ) Program utilizes drug-specific This! > stream HALAVEN ( eribulin ) machine is located in a secure location as required HIPAA.:: > 91 } h9 CPT is a discrepancy between This policy and member... Epitinexumab-Jjmr ) L 0000008945 00000 n nausea * live ) these guidelines may not apply weight loss attempt preapproval... Utilizes drug-specific prior This search will use the five-tier subtype nausea * to... All information needed to make a decision ) wegovy prior Authorization donepezil hydrochloride patch ) This is listing. Benefits plan will govern no fee schedules, basic unit values, relative value guides, factors. Phone, fax or through our online platform $ 1,627 a month before..
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