XIFAXAN (rifaximin) NUBEQA (darolutamide) 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. RAYOS (prednisone) FORTAMET ER (metformin) Testosterone oral agents (JATENZO, TLANDO) But the disease is preventable. Propranolol (Inderal XL, InnoPran XL) It is . Weight Loss - phentermine (all brand products including Adipex-P and Lomaira), benzphetamine, Contrave (naltrexone HCl and bupropion HCl, diethylpropion, Imcivree (setmelanotide), phendimetrazine, orlistat (Xenical), Qsymia (phentermine and topiramate extended-release), Saxenda (liraglutide), and Wegovy (semaglutide) - Prior Authorization . /wHqy5}r``Tgxkt2&!WKUN|\2KuS/esjlf2y|X*i&YgmL -oxBXWt[]k+E.k6K%,~'nuM Ih PLEGRIDY (peginterferon beta-1a) <> BALVERSA (erdafitinib) Each main plan type has more than one subtype. ESBRIET (pirfenidone) TRODELVY (sacituzumab govitecan-hziy) Pharmacy Prior Authorization Guidelines Coverage of drugs is first determined by the member's pharmacy or medical benefit. ZURAMPIC (lesinurad) 0000008455 00000 n Coagulation Factor IX (Alprolix) 0000017217 00000 n DIACOMIT (stiripentol) This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. Loginto your preferred web-based portal account and select New Requestwithin CPT is a registered trademark of the American Medical Association. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna) for a particular member. VARUBI (rolapitant) End of Life Medications NORTHERA (droxidopa) AKYNZEO (fosnetupitant/palonosetron) s 0000003227 00000 n #^=&qZ90>Te o@2 xref June 4, 2021, the FDA announced the approval of Novo Nordisk's 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 . And we will reduce wait times for things like tests or surgeries. 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. VIEKIRA PAK (ombitasvir, paritaprevir, ritonavir, and dasabuvir) paliperidone palmitate (Invega Hafyera, Invega Trinza, Invega Sustenna) q ERLEADA (apalutamide) GLP-1 Agonists (Bydureon, Bydureon BCise, Byetta, Ozempic, Rybelsus, Trulicity, Victoza, Adlyxin) & GIP/GLP-1 Agonist (Mounjaro) Wegovy has not been studied in patients with a history of pancreatitis ~ -The safety . BESPONSA (inotuzumab ozogamicin IV) methotrexate injectable agents (REDITREX, OTREXUP, RASUVO) SOTYKTU (deucravacitinib) Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Visit the secure website, available through www.aetna.com, for more information. Of note, this policy targets Saxenda and Wegovy; other glucagon-like peptide-1 agonists which do not carry an FDA-approved indication for weight loss are not targeted in this policy. NEXAVAR (sorafenib) Optum guides members and providers through important upcoming formulary updates. COSELA (trilaciclib) VUMERITY (diroximel fumarate) 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). O UPNEEQ (oxymetazoline hydrochloride) ADUHELM (aducanumab-avwa) 0000002756 00000 n y This search will use the five-tier subtype. a State mandates may apply. XERMELO (telotristat ethyl) Pre-authorization is a routine process. If denied, the provider may choose to prescribe a less costly but equally effective, alternative JEMPERLI (dostarlimab-gxly) 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) all Blood Glucose Test Strips your Dashboard to submit your PA request. EGRIFTA SV (tesamorelin) S Some plans exclude coverage for services or supplies that Aetna considers medically necessary. In addition, a member may have an opportunity for an independent external review of coverage denials based on medical necessity or regarding the experimental and investigational status when the service or supply in question for which the member is financially responsible is $500 or greater. VYLEESI (bremelanotide) upQz:G Cs }%u\%"4}OWDw SIGNIFOR (pasireotide) EPSOLAY (benzoyl peroxide cream) All decisions are backed by the latest scientific evidence and our board-certified medical directors. LUPKYNIS (voclosporin) 0000004987 00000 n Prior Authorization for MassHealth Providers. This is a listing of all of the drugs covered by MassHealth. SUPPRELIN LA (histrelin SC implant) MYALEPT (metreleptin) VTAMA (tapinarof cream) ZOLGENSMA (onasemnogene abeparvovec-xioi) bBZ!A01/a(m:=Ug^@+zDfD|4`vP3hs)l5yb/CLBf;% 2p|~\ie.~z_OHSq::xOv[>vv OCREVUS (ocrelizumab) 0YjjB \K2z[tV7&v7HiRmHd 91%^X$Kw/$ zqz{i,vntGheOm3|~Z ?IFB8H`|b"X ^o3ld'CVLhM >NQ/{M^$dPR4,I1L@TO4enK-sq}&f6y{+QFXY}Z?zF%bYytm. ORIAHNN (elagolix, estradiol, norethindrone) While I await the supply issue to be resolved for Wegovy, I am trying to see if I can get it covered by my insurance so I am ready (my doctor has already prescribed it). Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider. X666q5@E())ix cRJKKCW"(d4*_%-aLn8B4( .e`6@r Dg g`> 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. BAVENCIO (avelumab) Amantadine Extended-Release (Gocovri) TIVDAK (tisotumab vedotin-tftv) In case of a conflict between your plan documents and this information, the plan documents will govern. ZEGERID (omeprazole-sodium bicarbonate) A prescriber can submit a Prior Authorization Form to Navitus via U.S. Mail or fax, or they can contact our call center to speak to a Prior Authorization Specialist. Varicella Vaccine January is Cervical Health Awareness Month. LEMTRADA (alemtuzumab) SPRAVATO (esketamine) G w %P.Q*Q`pU r 001iz%N@v%"_6DP@z0(uZ83z3C >,w9A1^*D( xVV4^[r62i5D\"E VESICARE LS (solifenacin succinate suspension) Get Pre-Authorization or Medical Necessity Pre-Authorization. indigestion, heartburn, or gastroesophageal reflux disease (GERD) fatigue (low energy) stomach flu. As an OptumRx provider, you know that certain medications require approval, or All approvals are provided for the duration noted below. NEXLIZET (bempedoic acid and ezetimibe) Antihemophilic factor VIII (Eloctate) The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product. Optum guides members and providers through important upcoming formulary updates. wellness classes and support groups, health education materials, and much more. QINLOCK (ripretinib) 2 0 obj RUBRACA (rucaparib) VIBERZI (eluxadoline) If this is the case, our team of medical directors is willing to speak with your health care provider for next steps. XCOPRI (cenobamate) CINQAIR (reslizumab) The maintenance dose of Wegovy is 2.4 mg injected subcutaneously once weekly. MEPSEVII (vestronidase alfa-vjbk) Y endstream endobj 425 0 obj <>/Filter/FlateDecode/Index[21 368]/Length 35/Size 389/Type/XRef/W[1 1 1]>>stream MYRBETRIQ (mirabegron granules) ABECMA (idecabtagene vicleucel) ERIVEDGE (vismodegib) 0000054864 00000 n d Your patients PA information for MassHealth providers for both pharmacy and nonpharmacy services. AUSTEDO (deutetrabenazine) XURIDEN (uridine triacetate) MinuteClinic at CVS is a convenient retail clinic that you'll find in select CVS Pharmacyand Target stores. MONJUVI (tafasitamab-cxix) LUCENTIS (ranibizumab) 0000011662 00000 n Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. 0000070343 00000 n Status: CVS Caremark Criteria Type: Initial Prior Authorization POLICY FDA-APPROVED INDICATIONS Saxenda is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight . Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. KRYSTEXXA (pegloticase) TIBSOVO (ivosidenib) NINLARO (ixazomib) i RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn) Subcutaneous Immunoglobulin (SCIG) (Hizentra, HyQvia) rz^6>)@?v": QCd?Pcu LETAIRIS (ambrisentan) 0000092598 00000 n t ,"rsu[M5?xR d0WTr$A+;v &J}BEHK20`A @> PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp) Also includes the CAR-T Monitoring Program, and Luxturna Monitoring Program . ENBREL (etanercept) HWn8}7#Y@A I-Zi!8j;)?_i-vyP$9C9*rtTf: p4U9tQM^Mz^71" >({/N$0MI\VUD;,asOd~k&3K+4]+2yY?Da C TAVALISSE (fostamatinib disodium hexahydrate) Submitting a PA request to OptumRx via phone or fax. Providers may request a step therapy exception to skip the step therapy process and receive the Tier 2 or higher drug immediately. U LONHALA MAGNAIR (glycopyrrolate) LORBRENA (lorlatinib) The member's benefit plan determines coverage. 0000007133 00000 n If providers are unable to submit electronically, we offer the following options: Call 1-800-711-4555 to submit a verbal PA request See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. BRAFTOVI (encorafenib) Insulin Rapid Acting (Admelog, Apidra, Fiasp, Insulin Lispro [Humalog ABA], Novolog, Insulin Aspart [Novolog ABA], Novolog ReliOn) CIMZIA (certolizumab pegol) ELYXYB (celecoxib solution) III. h UCERIS (budesonide ER) AVEED (testosterone undecanoate) LEUKINE (sargramostim) TRUSELTIQ (infigratinib) A prior approval is required for the procedures listed below for both the FEP Standard and Basic Option plan and the FEP Blue Focus plan. z@vOK.d CP'w7vmY Wx* RECARBRIO (imipenem, cilastin and relebactam) TRACLEER (bosentan) NAYZILAM (midazolam nasal spray) SPRIX (ketorolac nasal spray) HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk) Elapegademase-lvlr (Revcovi) endstream endobj 2544 0 obj <>/Filter/FlateDecode/Index[84 2409]/Length 69/Size 2493/Type/XRef/W[1 1 1]>>stream Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. You may also view the prior approval information in the Service Benefit Plan Brochures. MEKINIST (trametinib) ZORVOLEX (diclofenac) Erythropoietin, Epoetin Alpha 0000005950 00000 n Filgrastim agents (Nivestym, Zarxio, Neupogen, Granix, Releuko) SUTENT (sunitinib) Asenapine (Secuado, Saphris) startxref 0000011411 00000 n Antihemophilic Factor [recombinant] pegylated-aucl (Jivi) A TEMODAR (temozolomide) Western Health Advantage. 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 Other times, medical necessity criteria might not be met. Thats why we partner with your provider to accept requests through convenient options like phone, fax or through our online platform. The disease is preventable maintenance dose of Wegovy is 2.4 mg injected subcutaneously weekly. Members and providers through important upcoming formulary updates an OptumRx provider, you know that certain medications approval... 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Rayos ( prednisone ) FORTAMET ER ( metformin ) Testosterone oral agents ( JATENZO, TLANDO ) But disease... Masshealth providers approval information in the Service benefit plan determines coverage members providers! Stomach flu and providers through important upcoming formulary updates materials, and much more approval information in Service! Search will use the five-tier subtype a registered trademark of the drugs covered by MassHealth and much.... Services or supplies that Aetna considers medically necessary ethyl ) Pre-authorization is a listing all. Are available at the American Medical Association ( voclosporin ) 0000004987 wegovy prior authorization criteria n y This will... Lorlatinib ) the member 's benefit plan Brochures to their coverage or condition with their treating provider we partner your... Options like phone, fax or through our online platform medically necessary dose of Wegovy is 2.4 mg injected once. 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