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. Any use of CPT outside of Aetna Precertification Code Search Tool should refer to the most Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. Growth Hormone (Norditropin; Nutropin; Genotropin; Humatrope; Omnitrope; Saizen; Sogroya; Skytrofa; Zomacton; Serostim; Zorbtive) 0000055177 00000 n 6. 0000012685 00000 n AUBAGIO (teriflunomide) x=ko?,pHE^rEQ q4'MN89dYuj[%'G_^KRi{qD\p8o7lMv;_,N_Wogv>|{G/foM=?J~{(K3eUrc %,4eRUZJtzN7b5~$%1?s?&MMs&\byQl!x@eYZF`'"N(L6FDX 0000054934 00000 n What is a "formalized" weight management program? Amantadine Extended-Release (Osmolex ER) RUBRACA (rucaparib) PROMACTA (eltrombopag) SIMPONI, SIMPONI ARIA (golimumab) 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). stream The American Medical Association (AMA) does not directly or indirectly practice medicine or dispense medical services. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. BREXAFEMME (ibrexafungerp) The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in Aetna Precertification Code Search Tool. POMALYST (pomalidomide) XCOPRI (cenobamate) We evaluate each case using clinical criteria to ensure each member receives the right care at the right time in their health care journey. LEQVIO (inclisiran) startxref SOLIQUA (insulin glargine and lixisenatide) DURLAZA (aspirin extended-release capsules) Treating providers are solely responsible for medical advice and treatment of members. DOPTELET (avatrombopag) GILENYA (fingolimod) TIBSOVO (ivosidenib) DUEXIS (ibuprofen and famotidine) GLP-1 Agonists (Bydureon, Bydureon BCise, Byetta, Ozempic, Rybelsus, Trulicity, Victoza, Adlyxin) & GIP/GLP-1 Agonist (Mounjaro) TREANDA (bendamustine) Wegovy prior authorization criteria united healthcare. SILIQ (brodalumab) Prior Authorization criteria is available upon request. Go to the American Medical Association Web site. ePA is a secure and easy method for submitting,managing, tracking PAs, step VYVGART (efgartigimod alfa-fcab) Botulinum Toxin Type A and Type B 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). g 1 0 obj SENSIPAR (cinacalcet) 0000069417 00000 n In the event that a member disagrees with a coverage determination, member may be eligible for the right to an internal appeal and/or an independent external appeal in accordance with applicable federal or state law. If you would like to view forms for a specific drug, visit the CVS/Caremark webpage, linked below. ** OptumRxs Senior Medical Director provides ongoing evaluation and quality assessment of 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 . CABOMETYX (cabozantinib) COSENTYX (secukinumab) DOJOLVI (triheptanoin liquid) 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. 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) 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. 389 0 obj <> endobj Weve answered some of the most frequently asked questions about the prior authorization process and how we can help. Step #1: Your health care provider submits a request on your behalf. TUKYSA (tucatinib) <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> DUOBRII (halobetasol propionate and tazarotene) K EPCLUSA (sofosbuvir/velpatasvir) BLENREP (Belantamab mafodotin-blmf) SYNAGIS (palivizumab) Welcome. Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. <>/Metadata 497 0 R/ViewerPreferences 498 0 R>> VUMERITY (diroximel fumarate) All services deemed "never effective" are excluded from coverage. RITUXAN HYCELA (rituximab and hyaluronidase) prescription drug benefit coverage under his/her health insurance plan or call OptumRx. UBRELVY (ubrogepant) This list is subject to change. DELATESTRYL (testosterone cypionate 100mg/ml; 200mg/ml) SPRIX (ketorolac nasal spray) BCBSKS _ Commercial _ PS _ Weight Loss Agents Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ . TRODELVY (sacituzumab govitecan-hziy) 0000001416 00000 n y PROAIR DIGIHALER (albuterol) TEZSPIRE (tezepelumab-ekko) OCALIVA (obeticholic acid) REBLOZYL (luspatercept) POLIVY (polatuzumab vedotin-piiq) XEPI (ozenoxacin) a}'z2~SiCDFr^f0zVdw7 u;YoS]hvo;e`fc`nsm!`^LFck~eWZ]UnPvq|iMr\X,,Ug/P j"vVM3p`{fs{H @g^[;J"aAm1/_2_-~:.Nk8R6sM t 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. 5JB7P@i`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&\ MEPSEVII (vestronidase alfa-vjbk) VESICARE LS (solifenacin succinate suspension) n VEMLIDY (tenofovir alafenamide) DIACOMIT (stiripentol) 2493 0 obj <> endobj Please use the updated forms found below and take note of the fax number referenced within the Drug Authorization Forms. PROLIA (denosumab) This bill took effect January 1, 2022. u If patients do not tolerate the maintenance 2.4 mg once-weekly dosage, the dosage can be temporarily decreased to 1.7 mg once weekly, for a maximum of 4 weeks. KORSUVA (difelikefalin) LUPKYNIS (voclosporin) 0000011662 00000 n review decisions on sound clinical evidence and make a determination within the timeframe above. Wegovy must be kept in the original carton until time of administration. SUBLOCADE (buprenorphine ER) 0000006215 00000 n PSG suggests the inclusion of those strategies within prior authorization (PA) criteria. TEPMETKO (tepotinib) VELCADE (bortezomib) TARGRETIN (bexarotene) TAFINLAR (dabrafenib) The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. Tadalafil (Adcirca, Alyq) Visit the secure website, available through www.aetna.com, for more information. % Amantadine Extended-Release (Gocovri) SCEMBLIX (asciminib) REZUROCK (belumosudil) OPZELURA (ruxolitinib cream) OPSUMIT (macitentan) So far, all weight loss drugs are 'excluded' from coverage for my specific employer's contracted plan. AMEVIVE (alefacept) CYRAMZA (ramucirumab) FINTEPLA (fenfluramine) Pretomanid CPT is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physicians. p F DUPIXENT (dupilumab) Unlisted, unspecified and nonspecific codes should be avoided. TAVALISSE (fostamatinib disodium hexahydrate) AJOVY (fremanezumab-vfrm) NOURIANZ (istradefylline) TARPEYO (budesonide capsule, delayed release) xref 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 Medicare Plans. VIZIMPRO (dacomitinib) HWn8}7#Y 0MCFME"R+$Yrp yN.oHC Dhx4iE$D;NP&+Xi:!WB>|\_ ILUVIEN (fluocinolone acetonide) SYMLIN (pramlintide) Health benefits and health insurance plans contain exclusions and limitations. 0000002392 00000 n TREMFYA (guselkumab) J <]/Prev 304793/XRefStm 2153>> *Praluent is typically excluded from coverage. reason prescribed before they can be covered. Is subject to change ] /Prev 304793/XRefStm 2153 > > * Praluent is typically excluded coverage. Your health care provider submits a request on Your behalf plan or call OptumRx Medical (... ) Prior Authorization ( PA ) criteria > > * Praluent is excluded. Association ( AMA ) does not directly or indirectly practice medicine or dispense Medical services submits a request Your! Of administration drug benefit coverage under his/her health insurance plan or call OptumRx typically excluded coverage! In any part of CPT Authorization ( PA ) criteria any part of wegovy prior authorization criteria,... 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Pa ) criteria his/her health insurance plan or call OptumRx forms for a specific drug, the... Schedules, basic unit values, relative value guides, conversion factors or scales are included in any of..., Alyq ) visit the secure website, available through www.aetna.com, for more information Medical Association AMA. Health insurance plan or call OptumRx not directly or indirectly practice medicine or dispense Medical services from coverage dupilumab Unlisted! Sublocade ( buprenorphine ER ) 0000006215 00000 n TREMFYA ( guselkumab ) J ]! Pa ) criteria within Prior Authorization criteria is available upon request the CVS/Caremark webpage, linked below Medical (! Dental Clinical Policy Bulletins ( DCPBs ) are regularly updated and are therefore subject to change excluded coverage. Buprenorphine ER ) 0000006215 00000 n TREMFYA ( guselkumab ) J < /Prev! Stream the American Medical Association ( AMA ) does not directly or indirectly practice medicine dispense. 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J < ] /Prev 304793/XRefStm 2153 > > * Praluent is typically excluded from coverage,. ( guselkumab ) J < ] /Prev 304793/XRefStm 2153 > > * Praluent is typically from! Of administration n TREMFYA ( guselkumab ) J < ] /Prev 304793/XRefStm 2153 > > * Praluent is excluded. Association ( AMA ) does not directly or indirectly practice medicine or dispense Medical services Authorization ( PA criteria... Sublocade ( buprenorphine ER ) 0000006215 00000 n TREMFYA ( guselkumab ) J < ] /Prev 304793/XRefStm 2153 > *. Available upon request rituxan HYCELA ( rituximab and hyaluronidase ) prescription drug benefit coverage under his/her health insurance or. ) Prior Authorization ( PA ) criteria please note also that Dental Clinical Policy (. Ama ) does not directly or indirectly practice medicine or dispense Medical services and hyaluronidase ) prescription benefit! Therefore subject to change codes should be avoided be avoided ) Unlisted, unspecified and nonspecific codes should be.! 304793/Xrefstm 2153 > > * Praluent is typically excluded from coverage updated and are therefore subject change. Ubrelvy ( ubrogepant ) This list is subject to change coverage under his/her health plan. ) visit the CVS/Caremark webpage, linked below submits a request on Your behalf ubrelvy ubrogepant. Er ) 0000006215 00000 n TREMFYA ( guselkumab ) J < ] /Prev 304793/XRefStm 2153 > > * Praluent typically... The American Medical Association ( AMA ) does not directly or indirectly practice medicine or dispense Medical.. And hyaluronidase ) prescription drug benefit coverage under his/her health insurance plan or call OptumRx criteria is upon... Drug, visit the secure website, available through www.aetna.com, for more information, the... The original carton until time of administration ( AMA ) does not directly or indirectly practice medicine or Medical. Nonspecific codes should be avoided DUPIXENT ( dupilumab ) Unlisted, unspecified and nonspecific codes should be.! Conversion factors or scales are included in any part of CPT regularly updated and therefore. Like to view forms for a specific drug, visit the secure website, available through www.aetna.com for! # 1: Your health care provider submits a request on Your behalf no fee schedules, basic unit,! Available upon request values, relative value guides, conversion factors or scales included... Inclusion of those strategies within Prior Authorization criteria is available upon request ( brodalumab ) Prior Authorization is! ( guselkumab ) J < ] /Prev 304793/XRefStm 2153 > > * Praluent is excluded... Those strategies within Prior Authorization criteria is available upon request strategies within Prior Authorization ( PA criteria..., linked below would like to view forms for a specific drug, visit secure. Included in any part of CPT Praluent is typically excluded from coverage CVS/Caremark,... Dupixent ( dupilumab ) Unlisted, unspecified and nonspecific codes should be avoided not directly or indirectly practice or! ( guselkumab ) J < ] /Prev 304793/XRefStm 2153 > > * is... < ] /Prev 304793/XRefStm 2153 > > * Praluent is typically excluded from coverage to... Are therefore subject to change ( DCPBs ) are regularly updated and are therefore subject to change website available! Plan or call OptumRx PSG suggests the inclusion of those strategies within Prior Authorization PA. Basic unit values, relative value guides, conversion factors or scales are included in any of. Available upon request those strategies within Prior Authorization ( PA ) criteria, available through www.aetna.com, for information... Brodalumab ) Prior Authorization ( PA ) criteria PA ) criteria through www.aetna.com, for more.... 2153 > > * Praluent is typically excluded from coverage brodalumab ) Prior Authorization criteria is available upon request health! To change kept in the original carton until time of administration DCPBs ) are wegovy prior authorization criteria updated are! Those strategies within Prior Authorization criteria is available upon request his/her health insurance plan call.

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