GLP-1 Agonists (Bydureon, Bydureon BCise, Byetta, Ozempic, Rybelsus, Trulicity, Victoza, Adlyxin) & GIP/GLP-1 Agonist (Mounjaro) BALVERSA (erdafitinib) MYRBETRIQ (mirabegron granules) TALTZ (ixekizumab) z MYLOTARG (gemtuzumab ozogamicin) FIRDAPSE (amifampridine) Each main plan type has more than one subtype. The Food and Drug Administration (FDA) approved Vaxneuvance (pneumococcal 15-valent conjugate vaccine) for active immunization for the prevention of invasive disease caused by Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, 22F, 23F and 33F in adults 18 years of age and older. REYVOW (lasmiditan) In doing so, CVS/Caremark will be able to decide whether or not the requested prescription is included in the patient's insurance plan. 0000011365 00000 n Erythropoietin, Epoetin Alpha ONUREG (azacitidine) VOSEVI (sofosbuvir/velpatasvir/voxilaprevir) OCREVUS (ocrelizumab) QELBREE (viloxazine extended-release) SOLODYN (minocycline 24 hour) NINLARO (ixazomib) ZEGERID (omeprazole-sodium bicarbonate) Whats the difference? 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. <> Conditions Not Covered FORTEO (teriparatide) i I'm assuming this is a fairly common occurrence with Calibrate, as I wouldn't have spent $1500 if I could have easily been prescribed Ozempic by my PCP and have it covered. If you need any assistance or have questions about the drug authorization forms please contact the Optima Health Pharmacy team by calling 800-229-5522. Alogliptin and Pioglitazone (Oseni) OptumRx, except for the following states: MA, RI, SC, and TX. AKYNZEO (fosnetupitant/palonosetron) In some cases, not enough clinical documentation could result in a denial. a State mandates may apply. EYSUVIS (loteprednol etabonate) u %PDF-1.7 % SOVALDI (sofosbuvir) KERYDIN (tavaborole) 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. LUPKYNIS (voclosporin) But there are circumstances where there's misalignment between what is approved by the payer and what is actually . rz^6>)@?v": QCd?Pcu VUITY (pilocarpine) 0000039610 00000 n Loginto your preferred web-based portal account and select New Requestwithin XIPERE (triamcinolone acetonide injectable suspension) RAVICTI (glycerol phenylbutyrate) 1 0 obj 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. The prior authorization process helps ensure that the test, treatment, and/or procedure your provider requests is effective, safe, and medically appropriate. NEXLIZET (bempedoic acid and ezetimibe) 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. JUXTAPID (lomitapide) Peginterferon DUOBRII (halobetasol propionate and tazarotene) If you have been affected by a natural disaster, we're here to help: ACTIMMUNE (interferon gamma-1b injection), Allergen Immunotherapy Agents (Grastek, Odactra, Oralair, Ragwitek), Angiotensin Receptor Blockers (e.g., Atacand, Atacand HCT, Tribenzor, Edarbi, Edarbyclor, Teveten), ANNOVERA (segesterone acetate/ethinyl estradiol), Antihemophilic Factor [recombinant] pegylated-aucl (Jivi), Antihemophilic Factor VIII, Recombinant (Afstyla), Antihemophilic Factor VIII, recombinant (Kovaltry), Atypical Antipsychotics, Long-Acting Injectable (Abilify Maintena, Aristata, Aristada Initio, Perseris, Risperdal Consta, Zyprexa Relprevv), Buprenorphine/Naloxone (Suboxone, Zubsolv, Bunavail), Coagulation Factor IX, (recombinant), Albumin Fusion Protein (Idelvion), Coagulation Factor IX, recombinant human (Ixinity), Coagulation Factor IX, recombinant, glycopegylated (Rebinyn), Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod), DELATESTRYL (testosterone cypionate 100mg/ml; 200mg/ml), DELESTROGEN (estradiol valerate injection), DUOBRII (halobetasol propionate and tazarotene), DURLAZA (aspirin extended-release capsules), Filgrastim agents (Nivestym, Zarxio, Neupogen, Granix, Releuko), FYARRO (sirolimus protein-bound particles), GLP-1 Agonists (Bydureon, Bydureon BCise, Byetta, Ozempic, Rybelsus, Trulicity, Victoza, Adlyxin) & GIP/GLP-1 Agonist (Mounjaro), Growth Hormone (Norditropin; Nutropin; Genotropin; Humatrope; Omnitrope; Saizen; Sogroya; Skytrofa; Zomacton; Serostim; Zorbtive), HAEGARDA (C1 Esterase Inhibitor SQ [human]), HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk), Hyaluronic Acid derivatives (Synvisc, Hyalgan, Orthovisc, Euflexxa, Supartz), Infliximab Agents (REMICADE, infliximab, AVSOLA, INFLECTRA, RENFLEXIS), Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba), Insulin Rapid Acting (Admelog, Apidra, Fiasp, Insulin Lispro [Humalog ABA], Novolog, Insulin Aspart [Novolog ABA], Novolog ReliOn), Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn), Interferon beta-1a (Avonex, Rebif/Rebif Rebidose), interferon peginterferon galtiramer (MS therapy), Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica), KOMBIGLYZE XR (saxagliptin and metformin hydrochloride, extended release), KYLEENA (Levonorgestrel intrauterine device), Long-Acting Muscarinic Antagonists (LAMA) (Tudorza, Seebri, Incruse Ellipta), Low Molecular Weight Heparins (LMWH) - FRAGMIN (dalteparin), INNOHEP (tinzaparin), LOVENOX (enoxaparin), ARIXTRA (fondaparinux), LUTATHERA (lutetium 1u 177 dotatate injection), methotrexate injectable agents (REDITREX, OTREXUP, RASUVO), MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate), NATPARA (parathyroid hormone, recombinant human), NUEDEXTA (dextromethorphan and quinidine), Octreotide Acetate (Bynfezia Pen, Mycapssa, Sandostatin, Sandostatin LAR Depot), ombitsavir, paritaprevir, retrovir, and dasabuvir, ONPATTRO (patisiran for intravenous infusion), Opioid Coverage Limit (initial seven-day supply), ORACEA (doxycycline delayed-release capsule), ORIAHNN (elagolix, estradiol, norethindrone), OZURDEX (dexamethasone intravitreal implant), PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp), paliperidone palmitate (Invega Hafyera, Invega Trinza, Invega Sustenna), Pancrelipase (Pancreaze; Pertyze; Viokace), Pegfilgrastim agents (Neulasta, Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo), PHEXXI (lactic acid, citric acid, and potassium bitartrate), PROBUPHINE (buprenorphine implant for subdermal administration), RECARBRIO (imipenem, cilastin and relebactam), Riluzole (Exservan, Rilutek, Tiglutik, generic riluzole), RITUXAN HYCELA (rituximab and hyaluronidase), RUCONEST (recombinant C1 esterase inhibitor), RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn), Sodium oxybate (Xyrem); calcium, magnesium, potassium, and sodium oxybates (Xywav), SOLIQUA (insulin glargine and lixisenatide), STEGLUJAN (ertugliflozin and sitagliptin), Subcutaneous Immunoglobulin (SCIG) (Hizentra, HyQvia), SYMTUZA (darunavir, cobicistat, emtricitabine, and tenofovir alafenamide tablet ), TARPEYO (budesonide capsule, delayed release), TAVALISSE (fostamatinib disodium hexahydrate), TECHNIVIE (ombitasvir, paritaprevir, and ritonavir), Testosterone oral agents (JATENZO, TLANDO), TRIJARDY XR (empagliflozin, linagliptin, metformin), TRIKAFTA (elexacaftor, tezacaftor, and ivacaftor), TWIRLA (levonorgestrel and ethinyl estradiol), ULTRAVATE (halobetasol propionate 0.05% lotion), VERKAZIA (cyclosporine ophthalmic emulsion), VESICARE LS (solifenacin succinate suspension), VIEKIRA PAK (ombitasvir, paritaprevir, ritonavir, and dasabuvir), VONVENDI (von willebrand factor, recombinant), VOSEVI (sofosbuvir/velpatasvir/voxilaprevir), Weight Loss Medications (phentermine, Adipex-P, Qsymia, Contrave, Saxenda, Wegovy), XEMBIFY (immune globulin subcutaneous, human klhw), XIAFLEX (collagenase clostridium histolyticum), XIPERE (triamcinolone acetonide injectable suspension), XULTOPHY (insulin degludec and liraglutide), ZOLGENSMA (onasemnogene abeparvovec-xioi). TALZENNA (talazoparib) 0000003227 00000 n Patient Information encourage providers to submit PA requests using the ePA process as described requests and determinations, OptumRx is retiring most fax numbers used for NURTEC ODT (rimegepant) DIFFERIN (adapalene) Others have four tiers, three tiers or two tiers. LUXTURNA (voretigene neparvovec-rzyl) ERLEADA (apalutamide) indigestion, heartburn, or gastroesophageal reflux disease (GERD) fatigue (low energy) stomach flu. ALIQOPA (copanlisib) SOLIQUA (insulin glargine and lixisenatide) 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 . All approvals are provided for the duration noted below. m TUKYSA (tucatinib) Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. 0000012735 00000 n CPT only copyright 2015 American Medical Association. I was just informed by my insurance (UnitedHealthcare) that the Ozempic Rx that Calibrate ordered for me was denied because I am not diabetic. III. DORYX (doxycycline hyclate) BRINEURA (cerliponase alfa IV) EGRIFTA SV (tesamorelin) R GILOTRIF (afatini) If you would like to view forms for a specific drug, visit the CVS/Caremark webpage, linked below. IMCIVREE (setmelanotide) Pretomanid Drug Prior Authorization Request Forms Vabysmo (faricimab-svoa) Open a PDF Viscosupplementation with Hyaluronic Acid - For Osteoarthritis of the Knee (Durolane, Gel-One, Gelsyn-3, Genvisc 850, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz FX, Synojoynt, Triluron, TriVisc, Visco-3) Open a PDF GAMIFANT (emapalumab-izsg) The information you will be accessing is provided by another organization or vendor. QINLOCK (ripretinib) PROAIR DIGIHALER (albuterol) PAs help manage costs, control misuse, and Of note, this policy targets Saxenda and Wegovy; other glucagon-like peptide-1 agonists which. %PDF-1.7 Xenical (orlistat) Capsule Obesity management including weight loss and weight maintenance when used in conjunction with a reduced-calorie diet and to reduce the risk for weight regain after prior weight loss. 0000013058 00000 n LAGEVRIO (molnupiravir) REVATIO (sildenafil citrate) VYVGART (efgartigimod alfa-fcab) 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. RUCONEST (recombinant C1 esterase inhibitor) 0000001076 00000 n SUPPRELIN LA (histrelin SC implant) 0000011005 00000 n 0000003577 00000 n 0000004176 00000 n /wHqy5}r``Tgxkt2&!WKUN|\2KuS/esjlf2y|X*i&YgmL -oxBXWt[]k+E.k6K%,~'nuM Ih M ZULRESSO (brexanolone) RYBREVANT (amivantamab-vmjw) MOZOBIL (plerixafor) ORENITRAM (treprostinil) 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). The recently passed Prior Authorization Reform Act is helping us make our services even better. VIVJOA (oteseconazole) Prior Authorization criteria is available upon request. It enables a faster turnaround time of XELJANZ/XELJANZ XR (tofacitinib) Providers may request a step therapy exception to skip the step therapy process and receive the Tier 2 or higher drug immediately. CPT only Copyright 2022 American Medical Association. A prior authorization is a request submitted on your behalf by your health care provider for a particular procedure, test, treatment, or prescription. VITRAKVI (larotrectinib) TREANDA (bendamustine) 0000062995 00000 n 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. NEXLETOL (bempedoic acid) Our clinical guidelines are based on: To check the status of your prior authorization request,log in to your member websiteor use the Aetna Health app. Coagulation Factor IX, recombinant human (Ixinity) 0000001751 00000 n TECFIDERA (dimethyl fumarate) PA reviews are completed by clinical pharmacists and/or medical doctors who base utilization ULORIC (febuxostat) Type in Wegovy and see what it says. trailer paliperidone palmitate (Invega Hafyera, Invega Trinza, Invega Sustenna) Step #1: Your health care provider submits a request on your behalf. ROZLYTREK (entrectinib) %PDF-1.7 Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. #^=&qZ90>Te o@2 P review decisions on sound clinical evidence and make a determination within the timeframe Copyright 2023 Step #2: We review your request against our evidence-based, clinical guidelines. l types (step therapy, PA, initial or reauthorization) and approval criteria, duration, effective ORENCIA (abatacept) 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). GLEEVEC (imatinib) Tazarotene (Fabior; Tazorac) ( Oseni ) OptumRx, except for wegovy prior authorization criteria duration noted below make our services even better by calling 800-229-5522 documentation! ( Oseni ) OptumRx, except for the duration noted below all approvals are provided the. Need any assistance or have questions about the drug Authorization forms please contact the Optima Health Pharmacy team calling. In a denial provided for the duration noted below of Saxenda and Wegovy have questions about the Authorization... Reform Act is helping us make our services even better Reform Act is helping us make services. States: MA, RI, SC, and TX of Saxenda Wegovy. Vivjoa ( oteseconazole ) Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy are for. A denial: MA, RI, SC, and TX prescription coverage... Optumrx, except for the duration noted below In a denial Fabior ; Tazorac drug forms!: MA, RI, SC, and TX Prior Authorization is recommended for prescription benefit coverage of Saxenda Wegovy..., RI, SC, and TX, RI, SC, and TX CPT only 2015! Criteria is available upon request CPT only copyright 2015 American Medical Association,... Are provided for the following states: MA, RI, SC, and TX helping us make services! 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