HALAVEN (eribulin)
Wegovy prior authorization criteria united healthcare. %%EOF
ANNOVERA (segesterone acetate/ethinyl estradiol)
LIBTAYO (cemiplimab-rwlc)
ZEJULA (niraparib)
APOKYN (apomorphine)
TECHNIVIE (ombitasvir, paritaprevir, and ritonavir)
POMALYST (pomalidomide)
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. 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). XEMBIFY (immune globulin subcutaneous, human klhw)
REBLOZYL (luspatercept)
CABOMETYX (cabozantinib)
JUBLIA (efinaconazole)
You are now being directed to CVS Caremark site. 3. 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. Visit the secure website, available through www.aetna.com, for more information. ORENCIA (abatacept)
See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. If the submitted form contains complete information, it will be compared to the criteria for . Sodium oxybate (Xyrem); calcium, magnesium, potassium, and sodium oxybates (Xywav)
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ARALEN (chloroquine phosphate)
BONIVA (ibandronate)
0000004176 00000 n
ONPATTRO (patisiran for intravenous infusion)
KLISYRI (tirbanibulin)
0000055963 00000 n
ESBRIET (pirfenidone)
LUMAKRAS (sotorasib)
There should also be a book you can download that will show you the pre-authorization criteria, if that is required.
TARGRETIN (bexarotene)
prior authorization (PA), to ensure that they are medically necessary and appropriate for the LONHALA MAGNAIR (glycopyrrolate)
This bill took effect January 1, 2022. 0000002222 00000 n
AMEVIVE (alefacept)
RYBREVANT (amivantamab-vmjw)
LONSURF (trifluridine and tipiracil)
Botulinum Toxin Type A and Type B
This page includes important information for MassHealth providers about prior authorizations. 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. PAs help manage costs, control misuse, and
NURTEC ODT (rimegepant)
INFINZI (durvalumab IV)
TRACLEER (bosentan)
To ensure that a PA determination is provided to you in a timely
Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica)
CARBAGLU (carglumic acid)
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.
NATPARA (parathyroid hormone, recombinant human)
Please . - 27 kg/m to <30 kg/m (overweight) in the presence of at least one .
AKLIEF (trifarotene)
DOPTELET (avatrombopag)
SUTENT (sunitinib)
JEMPERLI (dostarlimab-gxly)
SEGLENTIS (celecoxib/tramadol)
endobj
OFEV (nintedanib)
Or, call us at the number on your ID card. Riluzole (Exservan, Rilutek, Tiglutik, generic riluzole)
Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". Angiotensin Receptor Blockers (e.g., Atacand, Atacand HCT, Tribenzor, Edarbi, Edarbyclor, Teveten)
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. CAMBIA (diclofenac)
XOLAIR (omalizumab)
OXLUMO (lumasiran)
XIFAXAN (rifaximin)
a
DELESTROGEN (estradiol valerate injection)
RUBRACA (rucaparib)
MYRBETRIQ (mirabegron granules)
NERLYNX (neratinib)
CEQUA (cyclosporine)
Initial approval duration is up to 7 months . RITUXAN (rituximab)
When conditions are met, we will authorize the coverage of Wegovy. NEXAVAR (sorafenib)
Type in Wegovy and see what it says.
nausea *.
ADBRY (tralokinumab-ldrm)
SKYRIZI (risankizumab-rzaa)
EPCLUSA (sofosbuvir/velpatasvir)
Please use the updated forms found below and take note of the fax number referenced within the Drug Authorization Forms.
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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. ENBREL (etanercept)
hA 04Fv\GczC. 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 . If you have questions, you can reach out to your health care provider. the OptumRx UM Program. endobj
In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. BREYANZI (lisocabtagene maraleucel)
QELBREE (viloxazine extended-release)
N
TAGRISSO (osimertinib)
CAPLYTA (lumateperone)
headache. TAZVERIK (tazematostat)
FULYZAQ (crofelemer)
ZOLGENSMA (onasemnogene abeparvovec-xioi)
Interferon beta-1a (Avonex, Rebif/Rebif Rebidose)
ENDARI (l-glutamine oral powder)
HAEGARDA (C1 Esterase Inhibitor SQ [human])
EYLEA (aflibercept)
How to access the OptumRx PA guidelines: Reference the OptumRx electronic prior authorization ( ePA ) and (fax ) forms. TYMLOS (abaloparatide)
Octreotide Acetate (Bynfezia Pen, Mycapssa, Sandostatin, Sandostatin LAR Depot)
Step #1: Your health care provider submits a request on your behalf. SCENESSE (afamelanotide)
RHOFADE (oxymetazoline)
This search will use the five-tier subtype. <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>>
0000003755 00000 n
The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona.
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TEZSPIRE (tezepelumab-ekko)
Discontinue WEGOVY if the patient cannot tolerate the 2.4 mg dose.
0000013029 00000 n
ACTIMMUNE (interferon gamma-1b injection)
0000003227 00000 n
CARVYKTI (ciltacabtagene autoleucel)
ENJAYMO (sutimlimab-jome)
Please consult with or refer to the Evidence of Coverage or Certificate of Insurance document for a list of exclusions and limitations. Low Molecular Weight Heparins (LMWH) - FRAGMIN (dalteparin), INNOHEP (tinzaparin), LOVENOX (enoxaparin), ARIXTRA (fondaparinux)
Wegovy should be used with a reduced calorie meal plan and increased physical activity. HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk)
In some cases, not enough clinical documentation could result in a denial. ADUHELM (aducanumab-avwa)
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Others have four tiers, three tiers or two tiers. 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).
Service code if available (HCPCS/CPT) To better serve our providers, business partners, and patients, the Cigna Coverage Review Department is transitioning from PromptPA, fax, and phone coverage reviews (also called prior authorizations) to Electronic Prior Authorizations (ePAs).
VOSEVI (sofosbuvir/velpatasvir/voxilaprevir)
GAVRETO (pralsetinib)
0000045302 00000 n
Western Health Advantage. Testosterone pellets (Testopel)
VILTEPSO (viltolarsen)
LYNPARZA (olaparib)
0000002392 00000 n
Do you want to continue? Authorization will be issued for 12 months. Alogliptin and Pioglitazone (Oseni)
reason prescribed before they can be covered.
0000005011 00000 n
FLECTOR (diclofenac)
HEMLIBRA (emicizumab-kxwh)
0000011178 00000 n
Coagulation Factor IX, recombinant, glycopegylated (Rebinyn)
- 30 kg/m (obesity), or. 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 peginterferon galtiramer (MS therapy)
Wegovy should be used with a reduced calorie meal plan and increased physical activity.
Z
Pharmacy Prior Authorization Guidelines. Prior Authorization for MassHealth Providers.
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