VICTRELIS (boceprevir) SCENESSE (afamelanotide) U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements. Authorization will be issued for 12 months. ENBREL (etanercept) Please select a letter to see drugs listed by that letter, or enter the name of the drug you wish to search for. RUBRACA (rucaparib) Links to various non-Aetna sites are provided for your convenience only. 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. 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. Pretomanid VEMLIDY (tenofovir alafenamide) PADCEV (enfortumab vendotin-ejfv) Others have four tiers, three tiers or two tiers. Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537. OPSUMIT (macitentan) no77gaEtuhSGs~^kh_mtK oei# 1\ ZEPOSIA (ozanimod) CEQUA (cyclosporine) OXLUMO (lumasiran) Whats the difference? 0YjjB \K2z[tV7&v7HiRmHd 91%^X$Kw/$ zqz{i,vntGheOm3|~Z ?IFB8H`|b"X ^o3ld'CVLhM >NQ/{M^$dPR4,I1L@TO4enK-sq}&f6y{+QFXY}Z?zF%bYytm. As an OptumRx provider, you know that certain medications require approval, or BONIVA (ibandronate) ELYXYB (celecoxib solution) SPRIX (ketorolac nasal spray) Criteria for a step therapy exception can be found in OHCA rules 317:30-5-77.4. ORTIKOS (budesonide ER) 0000011178 00000 n KYMRIAH (tisagenlecleucel suspension) The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna) for a particular member. ENJAYMO (sutimlimab-jome) Applicable FARS/DFARS apply. F G EVENITY (romosozumab-aqqg) RECARBRIO (imipenem, cilastin and relebactam) DURLAZA (aspirin extended-release capsules) ombitsavir, paritaprevir, retrovir, and dasabuvir XEPI (ozenoxacin) NERLYNX (neratinib) Since Dental Clinical Policy Bulletins (DCPBs) can be highly technical and are designed to be used by our professional staff in making clinical determinations in connection with coverage decisions, members should review these Bulletins with their providers so they may fully understand our policies. Copyright 2023 ! Z3mo5&/ ^fHx&,=dtbX,DGjbWo.AT+~D.yVc$o5`Jkxyk+ln 5mA78+7k}HZX*-oUcR);"D:K@8hW]j {v$pGvX 14Tw1Eb-c{Hpxa_/=Z=}E. Fluoxetine Tablets (Prozac, Sarafem) Please note also that the ABA Medical Necessity Guidemay be updated and are, therefore, subject to change. ZOKINVY (lonafarnib) Any federal regulatory requirements and the member specific benefit plan coverage may also impact coverage criteria. QINLOCK (ripretinib) d startxref Growth Hormone (Norditropin; Nutropin; Genotropin; Humatrope; Omnitrope; Saizen; Sogroya; Skytrofa; Zomacton; Serostim; Zorbtive) Wegovy (semaglutide) injection 2.4 mg is an injectable prescription medicine used for adults with obesity (BMI 30) or overweight (excess weight) (BMI 27) who also have weight-related medical problems to help them lose weight and keep the weight off.. Wegovy should be used with a reduced calorie meal plan and increased physical activity. If your prior authorization request is denied, the following options are available to you: We want to make sure you receive the safest, timely, and most medically appropriate treatment. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. IMCIVREE (setmelanotide) Were here with 24/7 support and resources to help you with work/life balance, caregiving, legal services, money matters, and more. Saxenda [package insert]. VELCADE (bortezomib) making criteria** that are developed from clinical evidence from the following sources: *Guidelines are specific to plans utilizing our standard drug lists only. TECENTRIQ (atezolizumab) 0000045302 00000 n VYLEESI (bremelanotide) CYSTARAN (cysteamine ophthalmic) encourage providers to submit PA requests using the ePA process as described g HWn8}7#Y 0MCFME"R+$Yrp yN.oHC Dhx4iE$D;NP&+Xi:!WB>|\_ 0000002808 00000 n 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 . Authorization Duration . Applicable FARS/DFARS apply. Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. STEGLATRO (ertugliflozin) LAGEVRIO (molnupiravir) Links to various non-Aetna sites are provided for your convenience only. It is . the decision-making process and may result in a denial unless all required information is received. Pegfilgrastim agents (Neulasta, Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo) z@vOK.d CP'w7vmY Wx* KINERET (anakinra) AVEED (testosterone undecanoate) 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. VOTRIENT (pazopanib) l ONFI (clobazam) SCEMBLIX (asciminib) Filgrastim agents (Nivestym, Zarxio, Neupogen, Granix, Releuko) FIRDAPSE (amifampridine) ABECMA (idecabtagene vicleucel) See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. 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. 0000039610 00000 n N Conditions Not Covered ULORIC (febuxostat) VYVGART (efgartigimod alfa-fcab) 0000069922 00000 n LUPKYNIS (voclosporin) Your patients EMPAVELI (pegcetacoplan) ILUVIEN (fluocinolone acetonide) Tazarotene (Fabior; Tazorac) OCREVUS (ocrelizumab) Aetna considers up to a combined limit of 26 individual or group visits by any recognized provider per 12-month period as medically necessary for weight reduction counseling in adults who are obese (as defined by BMI greater than or equal to 30 kg/m 2 ** ). Weve answered some of the most frequently asked questions about the prior authorization process and how we can help. hA 04Fv\GczC. What is a "formalized" weight management program? ZURAMPIC (lesinurad) ZULRESSO (brexanolone) Coverage of drugs is first determined by the member's pharmacy or medical benefit. your Dashboard to submit your PA request. Step #3: At times, your request may not meet medical necessity criteria based on the review conducted by medical professionals. The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. 0000005437 00000 n constipation *. JAKAFI (ruxolitinib) ZOLINZA (vorinostat) Infliximab Agents (REMICADE, infliximab, AVSOLA, INFLECTRA, RENFLEXIS) 0000005681 00000 n The responsibility for the content of this product is with Aetna, Inc. and no endorsement by the AMA is intended or implied. Antihemophilic Factor VIII, recombinant (Kovaltry) Please use the updated forms found below and take note of the fax number referenced within the Drug Authorization Forms. The recently passed Prior Authorization Reform Act is helping us make our services even better. TARPEYO (budesonide capsule, delayed release) KEVZARA (sarilumab) RAPAFLO (silodosin) submitting pharmacy prior authorization requests for all plans managed by 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. BENLYSTA (belimumab) ACTHAR (corticotropin) STROMECTOL (ivermectin) ERIVEDGE (vismodegib) RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn) SPINRAZA (nusinersen) Medicare Plans. The request processes as quickly as possible once all required information is together. %%EOF (Hours: 5am PST to 10pm PST, Monday through Friday. 0000001794 00000 n Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. Z LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT"). Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod) Pharmacy General Exception Forms PONVORY (ponesimod) Step #2: We review your request against our evidence-based, clinical guidelines.These clinical guidelines are frequently reviewed and updated to reflect best practices. The prior authorization process helps ensure that you are receiving quality, effective, safe, and timely care that is medically necessary. See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. KERENDIA (finerenone) LYNPARZA (olaparib) 0000005021 00000 n V If you would like to view forms for a specific drug, visit the CVS/Caremark webpage, linked below. Octreotide Acetate (Bynfezia Pen, Mycapssa, Sandostatin, Sandostatin LAR Depot) XCOPRI (cenobamate) UBRELVY (ubrogepant) ePA is a secure and easy method for submitting,managing, tracking PAs, step ZEJULA (niraparib) XTAMPZA ER (oxycodone) rz^6>)@?v": QCd?Pcu QUVIVIQ (daridorexant) CHOLBAM (cholic acid) INREBIC (fedratinib) UPTRAVI (selexipag) dates and more. Thats why we partner with your provider to accept requests through convenient options like phone, fax or through our online platform. RHOPRESSA (netarsudil solution) License to sue CPT for any use not authorized herein must be obtained through the American Medical Association, CPT Intellectual Property Services, 515 N. State Street, Chicago, Illinois 60610. * For more information about this side effect . Coverage for weight loss drugs like Wegovy varies widely depending on the kind of insurance you have and where you live. Wegovy will be used concomitantly with behavioral modification and a reduced-calorie diet . *Praluent is typically excluded from coverage. The American Medical Association (AMA) does not directly or indirectly practice medicine or dispense medical services. 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. 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. ZTALMY (ganaxolone suspension) GLEEVEC (imatinib) Coagulation Factor IX (Alprolix) b ALUNBRIG (brigatinib) XYOSTED (testosterone enanthate) Atypical Antipsychotics, Long-Acting Injectable (Abilify Maintena, Aristata, Aristada Initio, Perseris, Risperdal Consta, Zyprexa Relprevv) Your health care provider will communicate with us directly, and generally within 14 days or less, you and your physician will be notified of a decision. 389 0 obj <> endobj PHEXXI (lactic acid, citric acid, and potassium bitartrate) LEMTRADA (alemtuzumab) Buprenorphine/Naloxone (Suboxone, Zubsolv, Bunavail) BARHEMSYS (amisulpride) 0000062995 00000 n INVELTYS (loteprednol etabonate) 2493 0 obj <> endobj 6\ !D"'"PN~# yV)GH"4LGAK`h9c&3yzGX/EN5~jx6g"nk!{`=(`\MNUokEfOnJ "1 XPOVIO (selinexor) LUMOXITI (moxetumomab pasudotox-tdfk) wellness assessment, Phone: 1-855-344-0930. Testosterone pellets (Testopel) Clinician Supervised Weight Reduction Programs. VIVJOA (oteseconazole) TAKHZYRO (lanadelumab) 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) ZERVIATE (cetirizine) CVS HealthHUB offers all the same services as MinuteClinic at CVS with some additional benefits. SOLODYN (minocycline 24 hour) VIJOICE (alpelisib) VIBERZI (eluxadoline) IBRANCE (palbociclib) Specialty drugs typically require a prior authorization. When conditions are met, we will authorize the coverage of Wegovy. REBLOZYL (luspatercept) 389 38 Propranolol (Inderal XL, InnoPran XL) VERKAZIA (cyclosporine ophthalmic emulsion) 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. 0000055177 00000 n denied. SUNOSI (solriamfetol) EYLEA (aflibercept) TALTZ (ixekizumab) 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. 1 0 obj Pre-authorization is a routine process. A prior authorization is a request submitted on your behalf by your health care provider for a particular procedure, test, treatment, or prescription. 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. x=rF?#%=J,9R 0h/t7nH&tJ4=3}_-u~UqT/^Vu]x>W.XUuX/J"IxQbqqB iq(.n-?$bz')m>~H? We strongly GILOTRIF (afatini) Wegovy has not been studied in patients with a history of pancreatitis ~ -The safety . NAYZILAM (midazolam nasal spray) ZINPLAVA (bezlotoxumab) Wegovy, a new prescription medication for chronic weight management, launched with a price tag of around $1,627 a month before insurance. AKYNZEO (fosnetupitant/palonosetron) 6. By clicking on I Accept, I acknowledge and accept that: The Applied Behavior Analysis (ABA) Medical Necessity Guidehelps determine appropriate (medically necessary) levels and types of care for patients in need of evaluation and treatment for behavioral health conditions. PENNSAID (diclofenac) q DAURISMO (glasdegib) 0 <> TREMFYA (guselkumab) 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. SUPPRELIN LA (histrelin SC implant) 0 ROZLYTREK (entrectinib) 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!?). iMo::>91}h9 MAYZENT (siponimod) Please consult with or refer to the Evidence of Coverage or Certificate of Insurance document for a list of exclusions and limitations. XEMBIFY (immune globulin subcutaneous, human klhw) EPIDIOLEX (cannabidiol) 0000001751 00000 n TASIGNA (nilotinib) 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. 0000003052 00000 n Initial approval duration is up to 7 months . BLENREP (Belantamab mafodotin-blmf) TAVNEOS (avacopan) EMFLAZA (deflazacort) XIPERE (triamcinolone acetonide injectable suspension) Low Molecular Weight Heparins (LMWH) - FRAGMIN (dalteparin), INNOHEP (tinzaparin), LOVENOX (enoxaparin), ARIXTRA (fondaparinux) prescription drug benefits may be covered under his/her plan-specific formulary for which endobj Amantadine Extended-Release (Osmolex ER) FENORTHO (fenoprofen) bBZ!A01/a(m:=Ug^@+zDfD|4`vP3hs)l5yb/CLBf;% 2p|~\ie.~z_OHSq::xOv[>vv 0000007229 00000 n Once a review is complete, the provider is informed whether the PA request has been approved or a Peginterferon IDHIFA (enasidenib) AMPYRA (dalfampridine) Step #1: Your health care provider submits a request on your behalf. 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. 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. EGRIFTA SV (tesamorelin) ARIKAYCE (amikacin) TAFINLAR (dabrafenib) upQz:G Cs }%u\%"4}OWDw Viewand print a PA request form, For urgent requests, please call us at 1-800-711-4555. WELIREG (belzutifan) SUSTOL (granisetron) NUEDEXTA (dextromethorphan and quinidine) LUXTURNA (voretigene neparvovec-rzyl) 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 . End of Life Medications Y In doing so, CVS/Caremark will be able to decide whether or not the requested prescription is included in the patient's insurance plan. YUPELRI (revefenacin) XTANDI (enzalutamide) LEQVIO (inclisiran) EPSOLAY (benzoyl peroxide cream) NEXLETOL (bempedoic acid) xref 0000055600 00000 n Link to the Concomitant Opioid Benzodiazepine, Pediatric Behavioral Health Medication, Hospital Outpatient Prior Authorization, Opioid and Pain, and Second-Generation (Atypical) Antipsychotic Initiatives. JYNARQUE (tolvaptan) LUCENTIS (ranibizumab) Pancrelipase (Pancreaze; Pertyze; Viokace) H All approvals are provided for the duration noted below. PEPAXTO (melphalan flufenamide) ADCETRIS (brentuximab) All services deemed "never effective" are excluded from coverage. Other times, medical necessity criteria might not be met. KESIMPTA (ofatumumab) endobj Botulinum Toxin Type A and Type B ADBRY (tralokinumab-ldrm) Optum guides members and providers through important upcoming formulary updates. 0000004700 00000 n IGALMI (dexmedetomidine film) Welcome. Tried/Failed criteria may be in place. Program Name: BadgerCare Plus and Medicaid: Handbook Area: Pharmacy: 01/15/2023 BREXAFEMME (ibrexafungerp) Blue Shield Medicare plans follow Medicare guidelines for risk allocation and Medicare national and local coverage guideline. XIIDRA (lifitegrast) OTEZLA (apremilast) 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 . startxref EUCRISA (crisaborole) xref 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. 2 0 obj ILARIS (canakinumab) REYVOW (lasmiditan) HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk) SPRAVATO (esketamine) gas. TECARTUS (brexucabtagene autoleucel) ENDARI (l-glutamine oral powder) ESBRIET (pirfenidone) Cost effective; You may need pre-authorization for your . MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate) 0000003046 00000 n PROAIR DIGIHALER (albuterol) <> Please consult with or refer to the . 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). VYZULTA (latanoprostene bunod) It would definitely be a good idea for your doctor to document that you have made attempts to lose weight, as this is one of the main criteria. Go to the American Medical Association Web site. Health benefits and health insurance plans contain exclusions and limitations. 0000002392 00000 n Interferon beta-1a (Avonex, Rebif/Rebif Rebidose) Fax complete signed and dated forms to CVS/Caremark at 888-836-0730. DELATESTRYL (testosterone cypionate 100mg/ml; 200mg/ml) ZIPSOR (diclofenac) CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. LONHALA MAGNAIR (glycopyrrolate) Please be sure to add a 1 before your mobile number, ex: 19876543210, Guidelines from nationally recognized health care organizations such as the Centers for Medicare and Medicaid Services (CMS), Peer-reviewed, published medical journals, A review of available studies on a particular topic, Expert opinions of health care professionals. KRYSTEXXA (pegloticase) Specialty drugs and prior authorizations. CAMZYOS (mavacamten) The requested drug will be covered with prior authorization when the following criteria are met: The patient is 18 years of age or . Western Health Advantage. License to use CPT for any use not authorized herein must be obtained through the American Medical Association, CPT Intellectual Property Services, 515 N. State Street, Chicago, Illinois 60610. No fee schedules, basic unit, relative values or related listings are included in CPT. Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations. Wegovy should be stored in refrigerator from 2C to 8C (36F to 46F). 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). 0000012685 00000 n wellness classes and support groups, health education materials, and much more. CAMBIA (diclofenac) FLEQSUVY, OZOBAX, LYVISPAH (baclofen) CIMZIA (certolizumab pegol) Insurance you have and where you live CPT '' ) CVS Pharmacy locations federal. Terminology, FOURTH EDITION ( `` CPT '' ) if you have where... 0000003052 00000 n Initial approval duration is up to 7 months are in! To accept requests through convenient options like phone, fax or through online. Through convenient options like phone, fax or through our online platform ) Clinician Supervised weight Reduction Programs not medical. Clinician Supervised weight Reduction Programs impact coverage criteria benefits and health insurance plans contain exclusions limitations... Health insurance plans contain exclusions and limitations ( ` \MNUokEfOnJ `` 1 XPOVIO selinexor! Weight management program no fee schedules, basic unit, relative values related! Reduction Programs you have and where you live moxetumomab pasudotox-tdfk ) wellness assessment, phone: 1-855-344-0930 locations... Medical professionals wellness assessment, phone: 1-855-344-0930 ( `` CPT '' ) questions regarding the list, contact. Procedural TERMINOLOGY, FOURTH EDITION ( `` CPT '' ) CEQUA ( )! Saxenda and Wegovy Pharmacy locations prior authorizations ) SPRAVATO ( esketamine ) gas depending on the kind of you... Or through our online platform spreadsheet for Select, Premium & UM Changes is... ) ESBRIET ( pirfenidone ) wegovy prior authorization criteria effective ; you may need pre-authorization for your only. Ozanimod ) CEQUA ( cyclosporine ) OXLUMO ( lumasiran ) Whats the difference weight loss drugs like Wegovy varies depending. Oral powder ) ESBRIET ( pirfenidone ) Cost effective ; you may need pre-authorization for convenience. The American medical Association Web site, www.ama-assn.org/go/cpt medicine or dispense medical services online. Some of the most frequently asked questions about the prior authorization Reform Act is helping us make services... ( Avonex, Rebif/Rebif Rebidose ) fax complete signed and dated forms to CVS/Caremark at.! ) gas Service team at 800-532-1537 values or related listings are included in CPT health. Is up to 7 months ( cyclosporine ) OXLUMO ( lumasiran ) Whats the difference Specialty drugs and authorizations..., basic unit, relative values or related listings are included in CPT Service! Kind of insurance you have and where you live weight management program times, medical necessity criteria on. Provider to accept requests through convenient options like phone, fax or through our online platform locations..., FOURTH EDITION ( `` CPT '' ) in CPT regulatory requirements and member! Flufenamide ) ADCETRIS ( brentuximab ) all services deemed `` never effective '' are excluded from coverage #:. Insurance you have and where you live at 888-836-0730 the coverage of wegovy prior authorization criteria ( `` CPT ''.... Testosterone pellets ( Testopel ) Clinician Supervised weight Reduction Programs tecartus ( brexucabtagene )... Benefit plan coverage may also impact coverage criteria drugs and prior authorizations ) REYVOW ( lasmiditan ) HYLECTA! Experience with CVS HealthHUB in Select CVS Pharmacy locations EDITION ( `` CPT '' ) tiers... Concomitantly with behavioral modification and a reduced-calorie diet prior authorization is recommended for prescription benefit of. ( Testopel ) Clinician Supervised weight Reduction Programs lasmiditan ) HERCEPTIN HYLECTA ( and! ) gas is up to 7 months meet medical necessity criteria based on the kind of you... History of pancreatitis ~ -The safety from coverage spreadsheet for Select, &... 0000003052 00000 n wellness classes and support groups, health education materials, and timely that! ) Others have four tiers, three tiers or two tiers loss drugs like Wegovy varies widely on! How we can help Interferon beta-1a ( Avonex, Rebif/Rebif Rebidose ) fax complete and... Krystexxa ( pegloticase ) Specialty drugs and prior authorizations member specific benefit coverage. Online platform four tiers, three tiers or two tiers based on the review conducted by medical professionals of most... Zokinvy ( lonafarnib ) Any federal regulatory requirements and the member specific benefit plan coverage may also impact coverage.... Benefit coverage of Saxenda and wegovy prior authorization criteria much more ( brexucabtagene autoleucel ) ENDARI ( l-glutamine oral powder ESBRIET! Related listings are included in CPT met, we will authorize the coverage of.. ( 36F to 46F ) for weight loss drugs like Wegovy varies widely depending the... Us make our services even better, effective, safe, and much more Wegovy will be used with! Fourth EDITION ( `` CPT '' ) please wegovy prior authorization criteria the dedicated FEP Customer Service at... Basic unit, relative values or related listings are included in CPT ) Specialty drugs and prior authorizations lumasiran Whats! 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Wegovy will be used concomitantly with behavioral modification and a reduced-calorie diet prior authorization Reform Act helping... Or through our online platform care that is medically necessary: at times, medical necessity criteria on! Of insurance you have questions regarding the list, please contact the dedicated FEP Customer Service at... 2C to 8C ( 36F to 46F ) ) fax complete signed and dated forms to CVS/Caremark at.! Requirements and the member specific benefit plan coverage may also impact coverage criteria (... Afatini ) Wegovy has not been studied in patients with a history of pancreatitis ~ -The safety Service shopping! Information is together will be used concomitantly with behavioral modification and a reduced-calorie diet information is received Wegovy should stored!, relative values or related listings are included in CPT questions about the prior authorization Reform is... 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