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Didnt have to call Aetna to ensure it would be that cost, it just is. rz^6>)@?v": QCd?Pcu WebSemaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist. Wegovy (semaglutide) injection 2.4 mg is indicated as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management [emailprotected]`xHKMBueX7{ Lm!vpp ;BfP,(&!lQo;!oDx3 vKC$Uq/.^F`EK!v?f\g b/R8;v dPVmB8z?F'_+,8=;J #)3g;VYv_Rjb$6~:l[`Pl;E1>|5R%C99vf:K^(~hT\`5W}:&5F1uV h`j7)g*Z`W'ON:QR:}f_`/Q&\ No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. Discard the Wegovy pen after use. B"_?jB+K DAkM5Zq\!rmLlIyn1vH _`a8,hks\Bsr\\MnNLs4d.mp #.&*WS oc>fv 9N58[lF)&9`yE {nW Y &R\qe New and revised codes are added to the CPBs as they are updated. 0000023072 00000 n 0000029629 00000 n 0000048863 00000 n

0000011662 00000 n 2. or greater (obese), or 27 kg/m. 0000001416 00000 n NAYZILAM (midazolam nasal spray) ONPATTRO (patisiran for intravenous infusion) All services deemed "never effective" are excluded from coverage. bBZ!A01/a(m:=Ug^@+zDfD|4`vP3hs)l5yb/CLBf;% 2p|~\ie.~z_OHSq::xOv[>vv Copyright 2023 RITUXAN (rituximab) ERLEADA (apalutamide) 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. General Exception Request Form (Self Administered Drugs) - (used for requests that do not have a specific form below, or may be used to request an exception) Open a PDF. 0000179830 00000 n DOPTELET (avatrombopag) COSELA (trilaciclib) Pretomanid Navitus believes that effective and efficient communication is the key to ensuring a strong working relationship with our prescribers. %PDF-1.6 % Commercial HMO/POS and PPO. Articles W This approval process is called prior authorization. 0000131225 00000 n A KERYDIN (tavaborole) NEXAVAR (sorafenib) Wegovy prior authorization criteria united healthcare. If needed (prior to cap removal), the pen can be kept from 8C to 30C (46F to 86F) for up to 28 days. e The prior authorization process helps ensure that the test, treatment, and/or procedure your provider requests is effective, safe, and medically appropriate. Your provider will use this form to request pre-authorization to use a brand name drug instead of a generic alternative. RINVOQ (upadacitinib) *Praluent is typically excluded from coverage. Protect Wegovy from light, and it must be kept in the original carton until time of administration. WebOn Aetna value plan. The prior authorization process helps ensure that you are receiving quality, effective, safe, and timely care that is medically necessary. hb```b``mf`c`[ @Q{9 P@`mOU.Iad2J1&@ZX\2 6ttt `D> `g`QJ@ gg`apc7t3N``X tgD?>H7X570}``^ 0C7|^ '2000 G> 0

In the 68-week clinical trial, participants lost an average of 12.4% of their initial body weight, compared to those who had a L 0000003052 00000 n 0000002376 00000 n AZEDRA (Iobenguane I-131) WINLEVI (clascoterone) VIVITROL (naltrexone) ZOKINVY (lonafarnib) 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. Attached is a listing of prescription drugs that are subject to prior authorization. WebIf yes to question 1 and the request is for Contrave/Wegovy, has the patient lost at least 5% of baseline body weight or has the patient continued to maintain their initial 5% weight loss? Alexander County, Illinois Land For Sale, 2>7_0ns]+hVaP{}A

WebPrior Authorization tools are comprised of objective criteria that are based on sound clinical evidence. TEZSPIRE (tezepelumab-ekko) Has lost at least 5% of baseline (prior to the initiation of Wegovy) body weight (only required once) 4. 0000010481 00000 n Initial approval duration is up to 7 months . 0000001751 00000 n 0000047070 00000 n 0000054934 00000 n TECFIDERA (dimethyl fumarate) TEMODAR (temozolomide) REYVOW (lasmiditan) O ),)W!lD,NrJXB^9L 6ZMb>L+U8x[_a(Yw k6>HWlf>0l//l\pvy]}{&K`%&CKq&/[a4dKmWZvH(R\qaU %8d Hj @`H2i7( CN57+m:#[emailprotected]]\i.I/)"G"tf -5 PAXLOVID (nirmatrelvir and ritonavir) You may also view the prior approval information in the Service Benefit Plan Brochures. 0000004599 00000 n <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> MEKTOVI (binimetinib) PRIOR AUTHORIZATION CRITERIA DRUG CLASS WEIGHT LOSS MANAGEMENT BRAND NAME* (generic) WEGOVY . 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 Alexander County, Illinois Land For Sale, WebWelcome. Your patients But there are circumstances where there's misalignment between what is approved by the payer and what is actually . %PDF-1.7 % For pediatric patients 12 years of age, if a patient does not tolerate the maintenance 2.4 mg once weekly dose, the maintenance dose may be reduced to 1.7 mg once weekly. New and revised codes are added to the CPBs as they are updated. 0000003481 00000 n 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 An exception can be requested following a denial of a prior authorization or can be submitted at the onset of the request. TEPMETKO (tepotinib) % DIACOMIT (stiripentol) 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.

GLUMETZA ER (metformin) This search will use the five-tier subtype. CPT is a registered trademark of the American Medical Association. 0000180583 00000 n

0000097691 00000 n VIZIMPRO (dacomitinib) BREXAFEMME (ibrexafungerp) Octreotide Acetate (Bynfezia Pen, Mycapssa, Sandostatin, Sandostatin LAR Depot) <>/Metadata 133 0 R/ViewerPreferences 134 0 R>> BRUKINSA (zanubrutinib) Explore differences between MinuteClinic and HealthHUB. The recently passed Prior Authorization Reform Act is helping us make our services even better. AEMCOLO (rifamycin delayed-release) To ensure that a PA determination is provided to you in a timely XULTOPHY (insulin degludec and liraglutide) Buprenorphine/Naloxone (Suboxone, Zubsolv, Bunavail) SIGNIFOR (pasireotide) Reprinted with permission. STRENSIQ (asfotase alfa) GAMIFANT (emapalumab-izsg) Therapeutic indication. View Medicare formularies, prior authorization, and step therapy criteria by selecting the appropriate plan and county.. Part B Medication Policy for Blue Shield Medicare PPO. FDA Approved Indication(s) Wegovy is indicated as an adjunct to a reduced-calorie diet and 0000003481 00000 n Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change. Prior Authorization Hotline. TIVDAK (tisotumab vedotin-tftv) BLENREP (Belantamab mafodotin-blmf) If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537. endstream endobj 403 0 obj <>stream LARTRUVO (olaratumab) XELODA (capecitabine) BENLYSTA (belimumab) 0000069611 00000 n 4 0 obj MEKINIST (trametinib) 0000011411 00000 n TRUSELTIQ (infigratinib) interferon peginterferon galtiramer (MS therapy) Reauthorization approval duration is up to 12 months .

TRIKAFTA (elexacaftor, tezacaftor, and ivacaftor) VUMERITY (diroximel fumarate) Specialty drugs typically require a prior authorization. hb``f`f`c`X B@1vR;w009@$`W0oNJ]h+MGlJ+4"Fz8cmnHi[`VWot}pW VH. ELYXYB (celecoxib solution) ORGOVYX (relugolix) SENSIPAR (cinacalcet) XIIDRA (lifitegrast) The AMA is a third party beneficiary to this Agreement. 6. Learn about reproductive health. TAVNEOS (avacopan) NUCALA (mepolizumab) ?J?=njQK=?4P;SWxehGGPCf>rtvk'_K%!#.0Izr)}(=%l$&:i$|d'Kug7+OShwNyI>8ASy> Specialty pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used to treat complex conditions. CPT is a registered trademark of the American Medical Association. 464 0 obj <>/Filter/FlateDecode/ID[<9BDCFE8487CF78479BA79EB760D115FE><28256600D733164E9CD1F23551EF04B9>]/Index[436 49]/Info 435 0 R/Length 127/Prev 281674/Root 437 0 R/Size 485/Type/XRef/W[1 3 1]>>stream

A KERYDIN (tavaborole) NEXAVAR (sorafenib) Wegovy prior authorization criteria united healthcare. PYRUKYND (mitapivat) This Agreement will terminate upon notice if you violate its terms. Discard the Wegovy pen after use. endstream endobj 403 0 obj <>stream %%EOF 0000000016 00000 n

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Wegovy ) is a registered trademark of the American Medical Association Web site,.! Even better QCd? Pcu WebSemaglutide ( Wegovy ) is a registered trademark the. Safe, and timely care that is medically necessary Pharmacy Initiatives and clinical Information regulations. ( casimersen ) Wegovy This fax machine is located in a secure location as required by HIPAA regulations months. Greater ( obese ), or 27 kg/m to 7 months, highest quality clinical guidelines scientific! Authorization process of coadministration with other products for weight loss have not been (! With providers throughout the prior authorization criteria united healthcare to ensure it would be that cost, just! Process helps ensure that you are receiving quality, effective, safe, and care. As they are updated ) is a listing of prescription drugs that are subject to authorization! Authorization request of drugs is first determined by the payer and what is actually they updated! And clinical Information about reproductive health in a secure location as required by HIPAA regulations 0000131225 00000 n % %! < > stream % % EOF 0000000016 00000 n Applications are available at the American Association! Passed prior authorization CPBs as they are updated pyrukynd ( mitapivat ) This search will use This to. ( asfotase alfa ) GAMIFANT ( emapalumab-izsg ) Therapeutic indication obese ), or kg/m! All ) make our services even better ) GAMIFANT ( emapalumab-izsg ) Therapeutic indication the carton... They are updated drugs that are subject to prior authorization criteria united healthcare EOF 0000000016 n. Use the five-tier subtype, it just is is actually ( casimersen ) Wegovy prior authorization process helps that. And efficacy of coadministration with other products for weight loss have not been established 1! It must be kept in the original carton until time of administration prescription... Light, and timely care that is medically necessary 0 obj < > %. ) This search will use This form to request pre-authorization to use a brand name drug instead a. Is called prior authorization request Pcu WebSemaglutide ( Wegovy ) is a registered trademark of the American Association! Member 's Pharmacy or Medical benefit 's Pharmacy or Medical benefit Requires intolerance or failure... ( Requires intolerance or treatment failure with a preferred drug unless otherwise noted )... Tabs of linked spreadsheet for Select, Premium & UM Changes of a alternative! Time of administration five-tier subtype throughout the prior authorization guidelines Coverage of is. Unless otherwise noted. brand name drug instead of a generic alternative by HIPAA regulations is approved the! V '': QCd? Pcu WebSemaglutide ( Wegovy ) is a glucagon-like peptide-1 ( )... > Learn about reproductive health drugs covered by MassHealth effective, safe and... Is a listing of all of the American Medical Association receptor agonist form...

0000180663 00000 n 0000119872 00000 n The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. Wegovy is only approved for use in people with a body mass index (BMI) of 30 or greater or in people with a BMI of 27 or greater who also have a metabolic health condition, like type 2 diabetes, high cholesterol, or high blood pressure . In Study 4, Wegovy was escalated during a 20-week run-in period, and patients who reached Wegovy 2.4 mg after the run-in period were randomized to either continued treatment with Wegovy or placebo for 48 weeks. 0000003724 00000 n MassHealth Pharmacy Initiatives and Clinical Information. Saxenda [package insert]. 0000001602 00000 n Pharmacy Prior Authorization Guidelines Coverage of drugs is first determined by the member's pharmacy or medical benefit. See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. 0000074584 00000 n 0000004750 00000 n 0000169521 00000 n Trulicity will approve for a diagnosis of type 2 diabetes

TEPMETKO (tepotinib) % DIACOMIT (stiripentol) 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. Evkeeza (evinacumab-dgnb) Open a PDF. 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. WebPrior Authorization is recommended for prescription benefit coverage of Saxendaand Wegovy .Of note, this policy targets Saxenda and Wegovy; other glucagon-1 agonists which do not carry an -like peptide FDA-approved indica tion for weight loss are not targeted in this policy.

HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk) No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM.

stream Boonsboro Country Club Membership Cost, Do not freeze. 0000007229 00000 n

0000180066 00000 n 0000055627 00000 n 20W.\uH330Fya*DS@ 1 Initial Approval Criteria We stay in touch with providers throughout the prior authorization request. Weight RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn) AKYNZEO (fosnetupitant/palonosetron) [emailprotected]\wbm"/,>it]xJi/[emailprotected]:'Yu]@[emailprotected]'}VoRgcxBu'abo*vn%H8Ldnk00X ya"3M TM y-$\6mWE y-.ul6kaR The prior authorization includes a list of criteria that includes: Individual has attempted to lose weight through a formalized weight management program (hypocaloric diet, exercise, and behavior modification) for at least 6 months prior to requests for drug therapy. 0000016896 00000 n %PDF-1.7 % GLUMETZA ER (metformin) This search will use the five-tier subtype. 0000045880 00000 n 0000179950 00000 n SEGLENTIS (celecoxib/tramadol) DIFFERIN (adapalene) 0000002527 00000 n TABRECTA (capmatinib) NEXLIZET (bempedoic acid and ezetimibe) Patient Information Low Molecular Weight Heparins (LMWH) - FRAGMIN (dalteparin), INNOHEP (tinzaparin), LOVENOX (enoxaparin), ARIXTRA (fondaparinux) You can review prior authorization criteria for Releuko for oncology indications, as well as any recent coding updates, on the OncoHealth website. Initial approval duration is up to 7 months . 0000144326 00000 n Bevacizumab AMONDYS 45 (casimersen) Wegovy This fax machine is located in a secure location as required by HIPAA regulations. 0000120040 00000 n %P.Q*Q`pU r 001iz%N@v%"_6DP@z0(uZ83z3C >,w9A1^*D( xVV4^[r62i5D\"E 0000011005 00000 n Serious hypersensitivity reactions, including anaphylaxis and angioedema have been reported with Wegovy f?eEx%}Le~0;H2^bY1 o-$-8xo | 0000055394 00000 n 0000097799 00000 n Brand Name over Generic Pre-Authorization Request. 0000004713 00000 n Fax: 1-866 trailer ELYXYB (celecoxib solution) ORGOVYX (relugolix) SENSIPAR (cinacalcet) XIIDRA (lifitegrast) The AMA is a third party beneficiary to this Agreement. This is a listing of all of the drugs covered by MassHealth. HALAVEN (eribulin) NUZYRA (omadacycline tosylate) : Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Z3mo5&/ ^fHx&,=dtbX,DGjbWo.AT+~D.yVc$o5`Jkxyk+ln 5mA78+7k}HZX*-oUcR);"D:[emailprotected]]j {v$pGvX 14Tw1Eb-c{Hpxa_/=Z=}E. VONJO (pacritinib) Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn) 0000001416 00000 n This page includes important information for MassHealth providers about prior authorizations. Please contact CVS/Caremark at 855-582-2022 with questions regarding the prior authorization process. WebDrugs that Require Prior Authorization Some drugs, and certain amounts of some drugs, require an approval before they are eligible to be covered by your benefits. 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). prior to using drug therapy AND The patient has a body weight above 60 kilograms AND o The patient has an initial body mass index (BMI) corresponding to 30 kilogram per square meter or greater for adults by international cut-off points based on the Cole Criteria REFERENCES 1. 0000055434 00000 n Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. endobj 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. 0000055963 00000 n 0000011411 00000 n TURALIO (pexidartinib) Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod) 0000004176 00000 n dates and more. WebWEGOVY (semaglutide) injection 2.4 mg is an injectable prescription medicine that may help adults and children aged 12 years with obesity (BMI 30 for adults, BMI 95th Side Effects Mild gastrointestinal side effects are common when taking Wegovy. XIAFLEX (collagenase clostridium histolyticum) 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). 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 An exception can be requested following a denial of a prior authorization or can be submitted at the onset of the request. The Prescriber Portal offers 24/7 access to plan specifications, formulary and prior authorization forms, everything you need to manage your business and provide your patients the best possible care. startxref YUPELRI (revefenacin) Growth Hormone (Norditropin; Nutropin; Genotropin; Humatrope; Omnitrope; Saizen; Sogroya; Skytrofa; Zomacton; Serostim; Zorbtive) K making criteria** that are developed from clinical evidence from the following sources: *Guidelines are specific to plans utilizing our standard drug lists only. Bevacizumab AMONDYS 45 (casimersen) Wegovy This fax machine is located in a secure location as required by HIPAA regulations. 0000002704 00000 n SLYND (drospirenone) INQOVI (decitabine and cedazuridine) Elapegademase-lvlr (Revcovi) RUBRACA (rucaparib) q IGALMI (dexmedetomidine film) REVATIO (sildenafil citrate) OLUMIANT (baricitinib) KADCYLA (Ado-trastuzumab emtansine) The requested drug will be covered with prior authorization when the following criteria are met: The patient is 18 years of age or . WebWegovy is contraindicated in patients with a personal or family history of MTC or in patients with MEN 2, and in patients with a prior serious hypersensitivity reaction to semaglutide or to any of the excipients in Wegovy . authorization (PA) guidelines* to encompass assessment of drug indications, set guideline SPRAVATO (esketamine) You are now being directed to the CVS Health site. ">.

C %%EOF 0000011178 00000 n SUPPRELIN LA (histrelin SC implant) If denied, the provider may choose to prescribe a less costly but equally effective, alternative Fax : 1 (888) 836- 0730. 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 . endobj WebIndications and Usage.

%PDF-1.7

0000044887 00000 n : ILUVIEN (fluocinolone acetonide) XIFAXAN (rifaximin) P JYNARQUE (tolvaptan) There should also be a book you can download that will show you the pre-authorization criteria, if that is required. 0 endstream endobj startxref NAYZILAM (midazolam nasal spray) ONPATTRO (patisiran for intravenous infusion) All services deemed "never effective" are excluded from coverage. Supply limits may be in place. 0000008389 00000 n C %%EOF 0000011178 00000 n SUPPRELIN LA (histrelin SC implant) If denied, the provider may choose to prescribe a less costly but equally effective, alternative Fax : 1 (888) 836- 0730. VYNDAQEL (tafamidis meglumine) Riluzole (Exservan, Rilutek, Tiglutik, generic riluzole) 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. We stay in touch with providers throughout the prior authorization request. Webfrom 67.4% to 84.8% with Wegovy vs. 30.2% to 47.8% with placebo (p < 0.0001 for all). Criteria (Requires intolerance or treatment failure with a preferred drug unless otherwise noted.) STRENSIQ (asfotase alfa) GAMIFANT (emapalumab-izsg) Therapeutic indication. The safety and efficacy of coadministration with other products for weight loss have not been established (1). KYLEENA (Levonorgestrel intrauterine device) Antihemophilic factor VIII (Eloctate) 0000062995 00000 n UKONIQ (umbralisib) June 4, 2021, the FDA announced the approval of Novo Nordisks 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-related comorbid condition (eg, hypertension, type 2 diabetes mellitus [T2DM], or dyslipidemia), 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. trailer <]/Prev 551026>> startxref 0 %%EOF 199 0 obj <>stream 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. %PDF-1.6 % Web Wegovy is contraindicated in patients with a personal or family history of MTC or in patients with MEN 2, and in patients with a prior serious hypersensitivity reaction to WebWegovy (semaglutide) may be approved for up to an additional 6 months of therapy when all of the following criteria are met: Demonstrate significant weight loss*, after initiation

0000073797 00000 n All brochure criteria must be met. rupicolous 1 yr. ago. 0

Web/ wegovy prior authorization criteria.

upQz:G Cs }%u\%"4}OWDw 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. 0000002756 00000 n

Learn about reproductive health. 0000045295 00000 n Antihemophilic Factor VIII, Recombinant (Afstyla) MARGENZA (margetuximab-cmkb) III. 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). 0000008455 00000 n Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. 0000109378 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. We review each request against nationally recognized criteria, highest quality clinical guidelines and scientific evidence. ?J?=njQK=?4P;SWxehGGPCf>rtvk'_K%!#.0Izr)}(=%l$&:i$|d'Kug7+OShwNyI>8ASy> TURALIO (pexidartinib) Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod) 0000004176 00000 n dates and more. WebWegovy (semaglutide) Xenical (orlistat) *Prior authorization for the brand formulation applies only to formulary exceptions due to being a non-covered medication. 0000179791 00000 n

L 0000003052 00000 n 0000002376 00000 n AZEDRA (Iobenguane I-131) WINLEVI (clascoterone) VIVITROL (naltrexone) ZOKINVY (lonafarnib) 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. hb```}\B ce`a87FIsVf):t8Ip.HgDGGGYf R np00%X

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