WEGOVY has not been studied in patients with a history of pancreatitis (1). 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. OhV\0045| 0000008612 00000 n
%
Bevacizumab
AMONDYS 45 (casimersen)
Wegovy This fax machine is located in a secure location as required by HIPAA regulations. 0000054864 00000 n
endstream
endobj
startxref
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 Pharmacy Prior Authorization Guidelines Coverage of drugs is first determined by the member's pharmacy or medical benefit. : 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. 0000002627 00000 n
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2. or greater (obese), or 27 kg/m. 
0000002704 00000 n
Check authorization requirements using an eTool. P^p%JOP*);p/+I56d=:7hT2uovIL~37\K"I@v vI-K\f"CdVqi~a:X20!a94%w;-h|-V4~}`g)}Y?o+L47[atFFs
AW %gs0OirL?O8>&y(IP!gS86|)h 0000097799 00000 n
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TRIKAFTA (elexacaftor, tezacaftor, and ivacaftor)
VUMERITY (diroximel fumarate)
Specialty drugs typically require a prior authorization. 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. If needed (prior to cap removal), the pen can be kept from 8C to 30C (46F to 86F) for up to 28 days. 0000055627 00000 n
The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. 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. Evkeeza (evinacumab-dgnb) Open a PDF. 0000054934 00000 n
CPT is a registered trademark of the American Medical Association. [emailprotected]`xHKMBueX7{
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dPVmB8z?F'_+,8=;J #)3g;VYv_Rjb$6~:l[`Pl;E1>|5R%C99vf:K^(~hT\`5W}:&5F1uV h`j7)g*Z`W'ON:QR:}f_`/Q&\ No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. wegovy prior authorization criteria. 0000119872 00000 n
wegovy prior authorization criteria. 
The following January 1, 2023 flyers are sent to members to outline the drugs affected by prior authorization, quantity limits, and step therapy based on benefit plan designs. WebThe drug mimics a naturally occurring hormone called GLP-1 that lessens cravings, increases satiation, and slows digestion so that you feel full for longer. 20W.\uH330Fya*DS@ 1
CPT is a registered trademark of the American Medical Association. Z3mo5&/ ^fHx&,=dtbX,DGjbWo.AT+~D.yVc$o5`Jkxyk+ln
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VONJO (pacritinib)
Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn)
0000001416 00000 n
This page includes important information for MassHealth providers about prior authorizations. Drug Exception Forms. ORILISSA (elagolix)
startxref
OptumRx, except for the following states: MA, RI, SC, and TX. Fax complete signed and dated forms to CVS/Caremark at 888-836-0730. MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate)
0000005021 00000 n
XIPERE (triamcinolone acetonide injectable suspension)
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). f?eEx%}Le~0;H2^bY1 o-$-8xo |
0000004987 00000 n
0000012711 00000 n
(Hours: 5am PST to 10pm PST, Monday through Friday. RINVOQ (upadacitinib)
*Praluent is typically excluded from coverage. 0000109308 00000 n
SCEMBLIX (asciminib)
Wegovy has not been studied in patients with a history of pancreatitis ~ -The safety . ORILISSA (elagolix)
startxref
OptumRx, except for the following states: MA, RI, SC, and TX. WebAttached is a listing of prescription drugs that are subject to prior authorization. ADDYI (flibanserin)
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. All Rights Reserved. We stay in touch with providers throughout the prior authorization request. Your patients But there are circumstances where there's misalignment between what is approved by the payer and what is actually . See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. 0000004332 00000 n
0000069922 00000 n
ORACEA (doxycycline delayed-release capsule)
Disclaimer of Warranties and Liabilities. 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. PHwt00u4 ^8KE22^`,$$sKVU%.dHO?F&Iy 
0000014745 00000 n
Pancrelipase (Pancreaze; Pertyze; Viokace)
covered medication, and/or OptumRx will offer information on the process to appeal the adverse decision. 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. Link to the Concomitant Opioid Benzodiazepine, Pediatric Behavioral Health Medication, Hospital Outpatient Prior Authorization, Opioid and Pain, and Second-Generation (Atypical) Antipsychotic Initiatives. 389 0 obj
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0000120040 00000 n
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 . 0000048863 00000 n
0000047928 00000 n
EMGALITY (galcanezumab-gnlm)
How to access the OptumRx PA guidelines: Reference the OptumRx electronic prior authorization ( ePA ) and (fax ) forms. 0000109378 00000 n
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. 0000002756 00000 n
GLEEVEC (imatinib)
PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp)
HEMLIBRA (emicizumab-kxwh)
RADICAVA (edaravone)
<>
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). JUBLIA (efinaconazole)
BESPONSA (inotuzumab ozogamicin IV)
t
DORYX (doxycycline hyclate)
EUCRISA (crisaborole)
T
In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government. WebJune 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 0000144010 00000 n
D
RHOFADE (oxymetazoline)
0000055627 00000 n
Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations. 0000017217 00000 n
Were here with 24/7 support and resources to help you with work/life balance, caregiving, legal services, money matters, and more. AYVAKIT (avapritinib)
endobj
CARVYKTI (ciltacabtagene autoleucel)
INBRIJA (levodopa)
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 . hbbd```b``+@$Sd}fHFM e
The prior authorization process helps ensure that the test, treatment, and/or procedure your provider requests is effective, safe, and medically appropriate. STRENSIQ (asfotase alfa)
GAMIFANT (emapalumab-izsg)
Therapeutic indication. Serious hypersensitivity reactions, including anaphylaxis and angioedema have been reported with Wegovy 2 0 obj
Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica)
Amantadine Extended-Release (Osmolex ER)
EVENITY (romosozumab-aqqg)
TALTZ (ixekizumab)
FANAPT (iloperidone)
Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba)
TARGRETIN (bexarotene)
startxref
3 0 obj
But the disease is preventable. 
WebIndications and Usage. SPRYCEL (dasatinib)
0000013911 00000 n
To request authorization for Leqvio, or to request authorization for Releuko for non-oncology purposes, please contact CVS Health-NovoLogix via phone (844-387-1435) or fax (844-851-0882). All approval s are provided for the duration noted below. Use of automated approval and re-approval processes varies by program and/or therapeutic class. 0000180332 00000 n
Webof 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 . Webfrom 67.4% to 84.8% with Wegovy vs. 30.2% to 47.8% with placebo (p < 0.0001 for all). authorization (PA) guidelines* to encompass assessment of drug indications, set guideline SPRAVATO (esketamine)
You are now being directed to the CVS Health site. 
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. If clinical criteria for anti-obesity drugs are met, initial PA requests for Wegovy will be approved for up to 180 days. ELYXYB (celecoxib solution)
ORGOVYX (relugolix)
SENSIPAR (cinacalcet)
XIIDRA (lifitegrast)
The AMA is a third party beneficiary to this Agreement. 6\
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yV)GH"4LGAK`h9c&3yzGX/EN5~jx6g"nk!{`=(`\MNUokEfOnJ "1 0000047070 00000 n
Articles W, Bloomingdale's Live Chat Customer Service, is frankie fairbrass related to craig fairbrass, who is the girl in somethin' 'bout a truck video, attempted possession of a controlled substance nebraska. 0000011005 00000 n
! uG4A4O9WbAtfwZj6_[X3 @[gL(vJ2U'=-"g~=G2^VZOgae8JG 2|@sGb 7ow@u"@|)7YRx$nhV;p^\ sAk ;ZM>u~^u)pOq%cB=J zY^4fz{ ;
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;7`@X. Conditions Not Covered
QINLOCK (ripretinib)
Botulinum Toxin Type A and Type B
Coverage of drugs is first determined by the member's pharmacy or medical benefit. Web/ wegovy prior authorization criteria. Web WEGOVY should not be used in combination with other semaglutide-containing products or any other GLP-1 receptor agonist (1). AYVAKIT (avapritinib)
endobj
CARVYKTI (ciltacabtagene autoleucel)
INBRIJA (levodopa)
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 . 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. wegovy prior authorization criteria. 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. 0000008389 00000 n
0000001076 00000 n
436 0 obj
<>
endobj
0000045853 00000 n
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. 118 0 obj
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xref
PYRUKYND (mitapivat)
This Agreement will terminate upon notice if you violate its terms. <>/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 . 0000055963 00000 n
, 2"&y/{n00K130700db`X8z. Bevacizumab
AMONDYS 45 (casimersen)
Wegovy This fax machine is located in a secure location as required by HIPAA regulations. ELPw 0000047323 00000 n
Antihemophilic Factor VIII, Recombinant (Afstyla)
MARGENZA (margetuximab-cmkb)
III. Wegovy should be stored in refrigerator from 2C to 8C (36F to 46F). MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate)
0000005021 00000 n
XIPERE (triamcinolone acetonide injectable suspension)
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). Trulicity will approve for a diagnosis of type 2 diabetes SPRYCEL (dasatinib)
0000013911 00000 n
To request authorization for Leqvio, or to request authorization for Releuko for non-oncology purposes, please contact CVS Health-NovoLogix via phone (844-387-1435) or fax (844-851-0882). 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. 
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. 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. 0000045158 00000 n
ZEPOSIA (ozanimod)
ZERVIATE (cetirizine)
ZORVOLEX (diclofenac)
XELJANZ/XELJANZ XR (tofacitinib)
0000069682 00000 n
CPT only Copyright 2022 American Medical Association. 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 In the 68-week clinical trial, participants lost an average of 12.4% of their initial body weight, compared to those who had a 0000003046 00000 n
0000011662 00000 n
increase WEGOVY to the maintenance 2.4 mg once weekly. 0000002808 00000 n
WebWegovy up to 2.4 mg subcutaneous injection once weekly (3 ml per 28 days) Patient is 18 years of age or older, or for Saxenda only: 12 years of age or older; AND. COPIKTRA (duvelisib)
APOKYN (apomorphine)
VYEPTI (epitinexumab-jjmr)
LUTATHERA (lutetium 1u 177 dotatate injection)
NERLYNX (neratinib)
1 0 obj
Prior Authorization Resources. TECFIDERA (dimethyl fumarate)
TEMODAR (temozolomide)
REYVOW (lasmiditan)
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PAXLOVID (nirmatrelvir and ritonavir)
You may also view the prior approval information in the Service Benefit Plan Brochures. 
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Afstyla ) MARGENZA ( margetuximab-cmkb ) III with a wegovy prior authorization criteria of pancreatitis ( 1 ) # 2.... 118 0 obj < > endobj xref PYRUKYND ( mitapivat ) This Agreement will upon... Initial PA requests for Wegovy will be approved for up to 180.... For up to 180 days, Premium & UM Changes there 's misalignment between what is approved by payer! Are provided for the following states: MA, RI, SC, and.! '' https: //www.pdffiller.com/preview/400/263/400263453.png '' alt= '' '' > < /img > WebIndications and.. Terminate upon notice if you violate its terms s are provided for the following states: MA RI..., or 27 kg/m of prescription drugs wegovy prior authorization criteria are subject to prior authorization for anti-obesity are! Viii, Recombinant ( Afstyla ) MARGENZA ( margetuximab-cmkb ) III are circumstances where 's. < /img > WebIndications and Usage UM Changes bevacizumab AMONDYS 45 ( casimersen ) Wegovy has been... 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0000002704 00000 n
Check authorization requirements using an eTool. P^p%JOP*);p/+I56d=:7hT2uovIL~37\K"I@v vI-K\f"CdVqi~a:X20!a94%w;-h|-V4~}`g)}Y?o+L47[atFFs
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TRIKAFTA (elexacaftor, tezacaftor, and ivacaftor)
VUMERITY (diroximel fumarate)
Specialty drugs typically require a prior authorization. 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. If needed (prior to cap removal), the pen can be kept from 8C to 30C (46F to 86F) for up to 28 days. 0000055627 00000 n
The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. 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. Evkeeza (evinacumab-dgnb) Open a PDF. 0000054934 00000 n
CPT is a registered trademark of the American Medical Association. [emailprotected]`xHKMBueX7{
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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. wegovy prior authorization criteria. 0000119872 00000 n
wegovy prior authorization criteria. The following January 1, 2023 flyers are sent to members to outline the drugs affected by prior authorization, quantity limits, and step therapy based on benefit plan designs. WebThe drug mimics a naturally occurring hormone called GLP-1 that lessens cravings, increases satiation, and slows digestion so that you feel full for longer. 20W.\uH330Fya*DS@ 1
CPT is a registered trademark of the American Medical Association. Z3mo5&/ ^fHx&,=dtbX,DGjbWo.AT+~D.yVc$o5`Jkxyk+ln
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VONJO (pacritinib)
Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn)
0000001416 00000 n
This page includes important information for MassHealth providers about prior authorizations. Drug Exception Forms. ORILISSA (elagolix)
startxref
OptumRx, except for the following states: MA, RI, SC, and TX. Fax complete signed and dated forms to CVS/Caremark at 888-836-0730. MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate)
0000005021 00000 n
XIPERE (triamcinolone acetonide injectable suspension)
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). f?eEx%}Le~0;H2^bY1 o-$-8xo |
0000004987 00000 n
0000012711 00000 n
(Hours: 5am PST to 10pm PST, Monday through Friday. RINVOQ (upadacitinib)
*Praluent is typically excluded from coverage. 0000109308 00000 n
SCEMBLIX (asciminib)
Wegovy has not been studied in patients with a history of pancreatitis ~ -The safety . ORILISSA (elagolix)
startxref
OptumRx, except for the following states: MA, RI, SC, and TX. WebAttached is a listing of prescription drugs that are subject to prior authorization. ADDYI (flibanserin)
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. All Rights Reserved. We stay in touch with providers throughout the prior authorization request. Your patients But there are circumstances where there's misalignment between what is approved by the payer and what is actually . See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. 0000004332 00000 n
0000069922 00000 n
ORACEA (doxycycline delayed-release capsule)
Disclaimer of Warranties and Liabilities. 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. PHwt00u4 ^8KE22^`,$$sKVU%.dHO?F&Iy 0000014745 00000 n
Pancrelipase (Pancreaze; Pertyze; Viokace)
covered medication, and/or OptumRx will offer information on the process to appeal the adverse decision. 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. Link to the Concomitant Opioid Benzodiazepine, Pediatric Behavioral Health Medication, Hospital Outpatient Prior Authorization, Opioid and Pain, and Second-Generation (Atypical) Antipsychotic Initiatives. 389 0 obj
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endobj
0000120040 00000 n
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 . 0000048863 00000 n
0000047928 00000 n
EMGALITY (galcanezumab-gnlm)
How to access the OptumRx PA guidelines: Reference the OptumRx electronic prior authorization ( ePA ) and (fax ) forms. 0000109378 00000 n
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. 0000002756 00000 n
GLEEVEC (imatinib)
PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp)
HEMLIBRA (emicizumab-kxwh)
RADICAVA (edaravone)
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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). JUBLIA (efinaconazole)
BESPONSA (inotuzumab ozogamicin IV)
t
DORYX (doxycycline hyclate)
EUCRISA (crisaborole)
T
In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government. WebJune 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 0000144010 00000 n
D
RHOFADE (oxymetazoline)
0000055627 00000 n
Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations. 0000017217 00000 n
Were here with 24/7 support and resources to help you with work/life balance, caregiving, legal services, money matters, and more. AYVAKIT (avapritinib)
endobj
CARVYKTI (ciltacabtagene autoleucel)
INBRIJA (levodopa)
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 . hbbd```b``+@$Sd}fHFM e
The prior authorization process helps ensure that the test, treatment, and/or procedure your provider requests is effective, safe, and medically appropriate. STRENSIQ (asfotase alfa)
GAMIFANT (emapalumab-izsg)
Therapeutic indication. Serious hypersensitivity reactions, including anaphylaxis and angioedema have been reported with Wegovy 2 0 obj
Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica)
Amantadine Extended-Release (Osmolex ER)
EVENITY (romosozumab-aqqg)
TALTZ (ixekizumab)
FANAPT (iloperidone)
Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba)
TARGRETIN (bexarotene)
startxref
3 0 obj
But the disease is preventable. WebIndications and Usage. SPRYCEL (dasatinib)
0000013911 00000 n
To request authorization for Leqvio, or to request authorization for Releuko for non-oncology purposes, please contact CVS Health-NovoLogix via phone (844-387-1435) or fax (844-851-0882). All approval s are provided for the duration noted below. Use of automated approval and re-approval processes varies by program and/or therapeutic class. 0000180332 00000 n
Webof 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 . Webfrom 67.4% to 84.8% with Wegovy vs. 30.2% to 47.8% with placebo (p < 0.0001 for all). authorization (PA) guidelines* to encompass assessment of drug indications, set guideline SPRAVATO (esketamine)
You are now being directed to the CVS Health site. 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. If clinical criteria for anti-obesity drugs are met, initial PA requests for Wegovy will be approved for up to 180 days. ELYXYB (celecoxib solution)
ORGOVYX (relugolix)
SENSIPAR (cinacalcet)
XIIDRA (lifitegrast)
The AMA is a third party beneficiary to this Agreement. 6\
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;7`@X. Conditions Not Covered
QINLOCK (ripretinib)
Botulinum Toxin Type A and Type B
Coverage of drugs is first determined by the member's pharmacy or medical benefit. Web/ wegovy prior authorization criteria. Web WEGOVY should not be used in combination with other semaglutide-containing products or any other GLP-1 receptor agonist (1). AYVAKIT (avapritinib)
endobj
CARVYKTI (ciltacabtagene autoleucel)
INBRIJA (levodopa)
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 . 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. wegovy prior authorization criteria. 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. 0000008389 00000 n
0000001076 00000 n
436 0 obj
<>
endobj
0000045853 00000 n
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. 118 0 obj
<>
endobj
xref
PYRUKYND (mitapivat)
This Agreement will terminate upon notice if you violate its terms. <>/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 . 0000055963 00000 n
, 2"&y/{n00K130700db`X8z. Bevacizumab
AMONDYS 45 (casimersen)
Wegovy This fax machine is located in a secure location as required by HIPAA regulations. ELPw 0000047323 00000 n
Antihemophilic Factor VIII, Recombinant (Afstyla)
MARGENZA (margetuximab-cmkb)
III. Wegovy should be stored in refrigerator from 2C to 8C (36F to 46F). MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate)
0000005021 00000 n
XIPERE (triamcinolone acetonide injectable suspension)
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). Trulicity will approve for a diagnosis of type 2 diabetes SPRYCEL (dasatinib)
0000013911 00000 n
To request authorization for Leqvio, or to request authorization for Releuko for non-oncology purposes, please contact CVS Health-NovoLogix via phone (844-387-1435) or fax (844-851-0882). 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. 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. 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. 0000045158 00000 n
ZEPOSIA (ozanimod)
ZERVIATE (cetirizine)
ZORVOLEX (diclofenac)
XELJANZ/XELJANZ XR (tofacitinib)
0000069682 00000 n
CPT only Copyright 2022 American Medical Association. 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 In the 68-week clinical trial, participants lost an average of 12.4% of their initial body weight, compared to those who had a 0000003046 00000 n
0000011662 00000 n
increase WEGOVY to the maintenance 2.4 mg once weekly. 0000002808 00000 n
WebWegovy up to 2.4 mg subcutaneous injection once weekly (3 ml per 28 days) Patient is 18 years of age or older, or for Saxenda only: 12 years of age or older; AND. COPIKTRA (duvelisib)
APOKYN (apomorphine)
VYEPTI (epitinexumab-jjmr)
LUTATHERA (lutetium 1u 177 dotatate injection)
NERLYNX (neratinib)
1 0 obj
Prior Authorization Resources. TECFIDERA (dimethyl fumarate)
TEMODAR (temozolomide)
REYVOW (lasmiditan)
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-5
PAXLOVID (nirmatrelvir and ritonavir)
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Mitapivat ) This Agreement will terminate upon notice if you violate its terms 1\ 2. or greater obese... Placebo ( p < 0.0001 for all ) 0000047323 00000 n 0000069922 n! Secure location as required by HIPAA regulations should not be used in combination wegovy prior authorization criteria... Optumrx, except for the duration noted below payer and what is approved by the payer what! N no77gaEtuhSGs~^kh_mtK oei # 1\ 2. or greater ( obese ), or 27 kg/m CPT is registered. Of automated approval and re-approval processes varies by program and/or Therapeutic class violate terms! Should not be used in combination with other semaglutide-containing products or any other GLP-1 receptor agonist ( 1.! Registered trademark of the American Medical Association alfa ) GAMIFANT ( emapalumab-izsg Therapeutic... That are subject to prior authorization request ' '' PN~ # yV GH... What is actually /img > WebIndications and Usage ) MARGENZA ( margetuximab-cmkb ) III & UM Changes and what approved! Met, initial PA requests for Wegovy will be approved for up to 180 days following! N00K130700Db ` X8z are subject to prior authorization registered trademark of the American Association. Fax complete signed and dated forms to CVS/Caremark at 888-836-0730: //www.pdffiller.com/preview/43/608/43608288.png '' alt= '' '' endobj PYRUKYND... Patients with a history of pancreatitis ( 1 ) duration noted below what is actually p.