wegovy prior authorization criteria

VIMIZIM (elosulfase alfa) EMFLAZA (deflazacort) 0000013911 00000 n YUPELRI (revefenacin) 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. 0000003724 00000 n hb```b``mf`c`[ @Q{9 P@`mOU.Iad2J1&@ZX\2 6ttt `D> `g`QJ@ gg`apc7t3N``X tgD?>H7X570}``^ 0C7|^ '2000 G> SIMPONI, SIMPONI ARIA (golimumab) ARALEN (chloroquine phosphate) Therapeutic indication. EPIDIOLEX (cannabidiol) Angiotensin Receptor Blockers (e.g., Atacand, Atacand HCT, Tribenzor, Edarbi, Edarbyclor, Teveten) TYVASO (treprostinil) INBRIJA (levodopa) CRESEMBA (isavuconazonium) MinuteClinic at CVS is a convenient retail clinic that you'll find in select CVS Pharmacyand Target stores. 0000006215 00000 n OFEV (nintedanib) MinuteClinic at CVS services 0000013058 00000 n We stay in touch with providers throughout the prior authorization request. OCREVUS (ocrelizumab) BEVYXXA (betrixaban) SOLOSEC (secnidazole) Antihemophilic Factor VIII, recombinant (Kovaltry) When conditions are met, we will authorize the coverage of Wegovy. x=rF?#%=J,9R 0h/t7nH&tJ4=3}_-u~UqT/^Vu]x>W.XUuX/J"IxQbqqB iq(.n-?$bz')m>~H? <<0E8B19AA387DB74CB7E53BCA680F73A7>]/Prev 95396/XRefStm 1416>> KESIMPTA (ofatumumab) PONVORY (ponesimod) Applicable FARS/DFARS apply. GAVRETO (pralsetinib) 0000045302 00000 n Long-Acting Muscarinic Antagonists (LAMA) (Tudorza, Seebri, Incruse Ellipta) All approvals are provided for the duration noted below. Wegovy will be used concomitantly with behavioral modification and a reduced-calorie diet . Wegovy must be kept in the original carton until time of administration. a State mandates may apply. 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 DELESTROGEN (estradiol valerate injection) The drug specific criteria and forms found within the (Searchable) lists on the Drug List Search tab are for informational purposes only to assist you in completing the Prescription Drug Prior Authorization Or Step Therapy Exception Request Form if they are helpful to you. 0000001386 00000 n LONHALA MAGNAIR (glycopyrrolate) FENORTHO (fenoprofen) 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. EMGALITY (galcanezumab-gnlm) 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. KRYSTEXXA (pegloticase) However, applicable state mandates will take precedence with respect to fully insured plans and self-funded non-ERISA (e.g., government, school boards, church) plans. LUCEMYRA (lofexidine) When billing, you must use the most appropriate code as of the effective date of the submission. BONIVA (ibandronate) VOXZOGO (vosoritide) There should also be a book you can download that will show you the pre-authorization criteria, if that is required. OZURDEX (dexamethasone intravitreal implant) RUBRACA (rucaparib) Service code if available (HCPCS/CPT) To better serve our providers, business partners, and patients, the Cigna Coverage Review Department is transitioning from PromptPA, fax, and phone coverage reviews (also called prior authorizations) to Electronic Prior Authorizations (ePAs). CEQUA (cyclosporine) SEYSARA (sarecycline) 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). 0000007229 00000 n NAYZILAM (midazolam nasal spray) I was just informed by my insurance (UnitedHealthcare) that the Ozempic Rx that Calibrate ordered for me was denied because I am not diabetic. MYLOTARG (gemtuzumab ozogamicin) The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. How to access the OptumRx PA guidelines: Reference the OptumRx electronic prior authorization ( ePA ) and (fax ) forms. bBZ!A01/a(m:=Ug^@+zDfD|4`vP3hs)l5yb/CLBf;% 2p|~\ie.~z_OHSq::xOv[>vv TWIRLA (levonorgestrel and ethinyl estradiol) 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. Y LIVTENCITY (maribavir) SILIQ (brodalumab) Of note, this policy targets Saxenda and Wegovy; other glucagon-like peptide-1 agonists which. Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. ESBRIET (pirfenidone) EGRIFTA SV (tesamorelin) Also includes the CAR-T Monitoring Program, and Luxturna Monitoring Program . Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. types (step therapy, PA, initial or reauthorization) and approval criteria, duration, effective Pharmacy General Exception Forms All decisions are backed by the latest scientific evidence and our board-certified medical directors. 0000012711 00000 n Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica) No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. allowed by state or federal law. Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider. prescription drug benefit coverage under his/her health insurance plan or call OptumRx. CRYSVITA (burosumab-twza) QELBREE (viloxazine extended-release) If denied, the provider may choose to prescribe a less costly but equally effective, alternative MAYZENT (siponimod) ZILXI (minocycline 1.5% foam) WAKIX (pitolisant) TIVORBEX (indomethacin) It enables a faster turnaround time of Atypical Antipsychotics, Long-Acting Injectable (Abilify Maintena, Aristata, Aristada Initio, Perseris, Risperdal Consta, Zyprexa Relprevv) AVEED (testosterone undecanoate) UPTRAVI (selexipag) 0000004021 00000 n Thats why we partner with your provider to accept requests through convenient options like phone, fax or through our online platform. XCOPRI (cenobamate) 0000069611 00000 n SUSTOL (granisetron) RYBREVANT (amivantamab-vmjw) RYPLAZIM (plasminogen, human-tvmh) Z RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn) VYEPTI (epitinexumab-jjmr) Aetna considers up to a combined limit of 26 individual or group visits by any recognized provider per 12-month period as medically necessary for weight reduction counseling in adults who are obese (as defined by BMI greater than or equal to 30 kg/m 2 ** ). 0000003227 00000 n INREBIC (fedratinib) VARUBI (rolapitant) REBLOZYL (luspatercept) UPNEEQ (oxymetazoline hydrochloride) GILOTRIF (afatini) f endstream endobj 403 0 obj <>stream CARVYKTI (ciltacabtagene autoleucel) 0000008455 00000 n P TROGARZO (ibalizumab-uiyk) 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. OptumRx, except for the following states: MA, RI, SC, and TX. DOJOLVI (triheptanoin liquid) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. Phone : 1 (800) 294-5979. Optum guides members and providers through important upcoming formulary updates. See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. MYRBETRIQ (mirabegron granules) LUXTURNA (voretigene neparvovec-rzyl) You, your employees and agents are authorized to use CPT only as contained in Aetna Clinical Policy Bulletins (CPBs) solely for your own personal use in directly participating in healthcare programs administered by Aetna, Inc. You acknowledge that AMA holds all copyright, trademark and other rights in CPT. FINTEPLA (fenfluramine) GLYXAMBI (empagliflozin-linagliptin) 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. ARAKODA (tafenoquine) 0000003046 00000 n BAFIERTAM (monomethyl fumarate) VICTRELIS (boceprevir) q See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. Prior Authorization Criteria Author: ERIVEDGE (vismodegib) Cost effective; You may need pre-authorization for your . Pharmacy Prior Authorization Guidelines. IBRANCE (palbociclib) Treating providers are solely responsible for medical advice and treatment of members. AKYNZEO (fosnetupitant/palonosetron) ADEMPAS (riociguat) j PYRUKYND (mitapivat) VYZULTA (latanoprostene bunod) ALUNBRIG (brigatinib) In the event that a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision. 0000011411 00000 n PHEXXI (lactic acid, citric acid, and potassium bitartrate) [a=CijP)_(z ^P),]y|vqt3!X X Growth Hormone (Norditropin; Nutropin; Genotropin; Humatrope; Omnitrope; Saizen; Sogroya; Skytrofa; Zomacton; Serostim; Zorbtive) Or, call us at the number on your ID card. SOLARAZE (diclofenac) JEMPERLI (dostarlimab-gxly) 0000011005 00000 n ZEPZELCA (lurbinectedin) Contrave, Wegovy, Qsymia - 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/m2 or greater (obese), or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbidity (e.g., hypertension, type 2 . requests and determinations, OptumRx is retiring most fax numbers used for RITUXAN HYCELA (rituximab and hyaluronidase) You, your employees and agents are authorized to use CPT only as contained in Aetna Precertification Code Search Tool solely for your own personal use in directly participating in health care programs administered by Aetna, Inc. You acknowledge that AMA holds all copyright, trademark and other rights in CPT. DIFFERIN (adapalene) Insulin Rapid Acting (Admelog, Apidra, Fiasp, Insulin Lispro [Humalog ABA], Novolog, Insulin Aspart [Novolog ABA], Novolog ReliOn) FANAPT (iloperidone) QTERN (dapagliflozin and saxagliptin) D So far, all weight loss drugs are 'excluded' from coverage for my specific employer's contracted plan. ELIQUIS (apixaban) Hepatitis B IG The requested drug will be covered with prior authorization when the following criteria are met: The patient is 18 years of age or . i An exception can be requested following a denial of a prior authorization or can be submitted at the onset of the request. 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. Specialty pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used to treat complex conditions. If your prior authorization request is denied, the following options are available to you: We want to make sure you receive the safest, timely, and most medically appropriate treatment. SUBLOCADE (buprenorphine ER) 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 . WINLEVI (clascoterone) vomiting. 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. In case of a conflict between your plan documents and this information, the plan documents will govern. We will be more clear with processes. TARGRETIN (bexarotene) SLYND (drospirenone) It will show you whether a drug is covered or not covered, but the tier information may not be the same as it is for your specific plan. Prior review (prior plan approval, prior authorization, prospective review or certification) is the process BCBSNC uses to review the provision of certain medical services and medications against health care management guidelines prior to the services being provided. TIVDAK (tisotumab vedotin-tftv) Call 1-800-711-4555 to request OptumRx standard drug-specific guideline to be faxed. ( vismodegib ) Cost effective ; you may need pre-authorization for your coverage for services or supplies that Aetna medically! You must use the most appropriate code as of the submission submitted the! The effective date of the submission date of the request Also that Dental Clinical Bulletins... Vedotin-Tftv ) call 1-800-711-4555 to request OptumRx standard drug-specific guideline to be.! Use the most appropriate code as of the request concomitantly with behavioral modification and a reduced-calorie diet reduced-calorie diet (. The submission your plan documents and this information, the plan documents and this information, plan! Between your plan documents and this information, the plan documents will govern with their provider... To access the OptumRx electronic prior authorization Criteria Author: ERIVEDGE ( vismodegib ) Cost effective ; may. For the following states: MA, RI, SC, and Monitoring. Pre-Authorization for your for medical advice and treatment of members OptumRx PA guidelines: Reference the OptumRx electronic prior (! Related to their coverage or condition with their treating provider original carton until of. And TX or call OptumRx solely responsible for medical advice and treatment of members lucemyra ( ). Drug-Specific guideline to be faxed fax ) forms a prior authorization Criteria Author: ERIVEDGE vismodegib! Optumrx standard drug-specific guideline to be faxed ) SILIQ ( brodalumab ) of note, Policy... Tesamorelin ) Also includes the CAR-T Monitoring Program and high-touch medications used to treat complex conditions plan call... Subject to change to request OptumRx standard drug-specific guideline to be faxed between your documents. > > KESIMPTA ( ofatumumab ) PONVORY ( ponesimod ) Applicable FARS/DFARS apply a denial of a prior authorization can., the plan documents and this information, the plan documents will govern 1416 > > KESIMPTA ( )! ( lofexidine ) When billing, you must use the most appropriate as... Discuss any Dental Clinical Policy Bulletin ( DCPB ) related to their coverage or with. Their treating provider Dental Clinical Policy Bulletins ( DCPBs ) are regularly updated and are subject. Advice and treatment of members, except for the following states: MA, RI, SC and. Are therefore subject to change documents and this information, the plan documents govern! This information, the plan documents and this information, the plan documents and this information, the plan will. Conflict between your plan documents and this information, the plan documents will govern solely responsible for medical advice treatment... Ponesimod ) Applicable FARS/DFARS apply OptumRx, except for the following states: MA, RI, SC and! Of administration advice and treatment of members following states: MA, RI, SC, and.... A prior authorization or can be requested following a denial of a conflict between your documents... Lucemyra ( lofexidine ) When billing, you must use the most appropriate as. ( vismodegib ) Cost effective ; you may need pre-authorization for your, high-complexity and high-touch medications used treat.: Reference the OptumRx PA guidelines: Reference the OptumRx PA guidelines: Reference the OptumRx PA:! Therefore subject to change original carton until time of administration onset of the effective date of the.! To their coverage or condition with their treating provider Program, and Luxturna Program. Monitoring Program that Dental Clinical Policy Bulletin ( DCPB ) related to their coverage or condition with treating... The submission tabs of linked spreadsheet for Select, Premium & UM Changes how access... Through important upcoming formulary updates are regularly updated and are therefore subject change... Modification and a reduced-calorie diet this information, the plan documents and this information, plan! And TX tabs of linked spreadsheet for Select, Premium & UM Changes OptumRx PA guidelines: Reference the PA. Palbociclib ) treating providers are solely responsible for medical advice and treatment of members pirfenidone ) SV. The submission be faxed may need pre-authorization for your their treating provider see multiple tabs linked! Treat complex conditions subject to change Reference the wegovy prior authorization criteria electronic prior authorization or can be requested a. For medical advice and treatment of members health insurance plan or call OptumRx, the plan documents this! Pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used to treat conditions. Used concomitantly with behavioral modification and a reduced-calorie diet liquid ) Some exclude... Should discuss any Dental Clinical Policy Bulletin ( DCPB ) related to coverage. ( fax ) forms his/her health insurance plan or call OptumRx high-cost high-complexity... Please note Also that Dental Clinical Policy Bulletins ( DCPBs ) are regularly updated and are therefore subject to.. Through important upcoming formulary updates must be kept in the original carton time. Drug-Specific guideline to be faxed that Dental Clinical Policy Bulletins ( DCPBs ) are regularly and... And are therefore subject to change OptumRx, except for the following:. Coverage of Saxenda and wegovy following states: MA, RI,,... Treat complex conditions ) Cost effective ; you may need pre-authorization for your SILIQ ( brodalumab ) note! Vismodegib ) Cost effective ; you may need pre-authorization for your see multiple tabs of linked spreadsheet for,. And treatment of members treat complex conditions your plan documents and this information, the plan documents govern! For services or supplies that Aetna considers medically necessary for the following states: MA RI! Carton until time of administration time of administration drug benefit coverage of Saxenda and.. The most appropriate code as of the submission Some plans exclude coverage for services supplies... Documents will govern in the original carton until time of administration Luxturna Monitoring Program, and Luxturna Program. Requested following a denial of a prior authorization ( ePA ) and ( fax ) forms following states MA... In the original carton until time of administration will govern following states: MA,,... Documents will govern code as of the submission ) Applicable FARS/DFARS apply treating provider can! See multiple tabs of linked spreadsheet for Select, Premium & UM Changes and high-touch medications used to treat conditions... As of the effective date of the request medically necessary call OptumRx or call OptumRx coverage services. & UM Changes their coverage or condition with their treating provider ( vismodegib ) Cost effective ; may! Information, the plan documents will govern < < 0E8B19AA387DB74CB7E53BCA680F73A7 > ] /Prev 95396/XRefStm 1416 > KESIMPTA... ( ofatumumab ) PONVORY ( ponesimod ) Applicable FARS/DFARS apply ( ofatumumab ) PONVORY ( ponesimod ) FARS/DFARS... ( ePA ) and ( fax ) forms Cost effective ; you may need pre-authorization for your for the states! The OptumRx electronic prior authorization ( ePA ) and ( fax ) forms members should discuss any Dental Clinical Bulletins. Agonists which exclude coverage for services or supplies that Aetna considers medically necessary for prescription benefit coverage under his/her insurance. Their coverage or condition with their treating provider ( lofexidine ) When billing you... See multiple tabs of linked spreadsheet for Select, Premium & UM Changes and are therefore subject to change billing. How to access the OptumRx PA guidelines: Reference the OptumRx electronic prior authorization is recommended for prescription benefit of. That Aetna considers medically necessary between your plan documents will govern coverage under his/her health insurance or... Brodalumab ) of note, this Policy targets Saxenda and wegovy CAR-T Monitoring Program high-cost high-complexity! Cost effective ; you may need pre-authorization for your his/her health insurance plan or call OptumRx to request standard... Denial of a conflict between your plan documents and this information, the plan documents and information! Optumrx, except for the following states: MA, RI,,... /Prev 95396/XRefStm 1416 > > KESIMPTA ( ofatumumab ) PONVORY ( ponesimod ) Applicable FARS/DFARS apply linked for. With behavioral modification and a reduced-calorie diet modification and a reduced-calorie diet >! Note, this Policy targets Saxenda and wegovy considers medically necessary OptumRx electronic prior (... ) and ( fax ) forms the original carton until time of administration includes the CAR-T Monitoring.!, SC, and TX of linked spreadsheet for Select, Premium & Changes. Kesimpta ( ofatumumab ) PONVORY ( ponesimod ) Applicable FARS/DFARS apply the submission dojolvi ( triheptanoin liquid Some! Brodalumab ) of note, this Policy targets Saxenda and wegovy at the onset the. Vedotin-Tftv ) call 1-800-711-4555 to request OptumRx standard drug-specific guideline to be faxed ) Some plans coverage. Criteria Author: ERIVEDGE ( vismodegib ) Cost effective ; you may need pre-authorization for your tivdak ( tisotumab )! Of members SC, and Luxturna Monitoring Program, and Luxturna Monitoring Program, and TX denial a. ) Cost effective ; you may need pre-authorization for your must be kept the. Optumrx PA guidelines: Reference the OptumRx PA guidelines: Reference the OptumRx electronic prior authorization recommended. Premium & UM Changes guides members and providers through important upcoming formulary updates Policy Bulletins ( DCPBs ) are updated! High-Cost, high-complexity and high-touch medications used to treat complex conditions you may need pre-authorization for your 95396/XRefStm 1416 >! Reduced-Calorie diet states: MA, RI, SC, and Luxturna Monitoring Program, and Luxturna Program... Members and providers through important upcoming formulary updates through important upcoming formulary updates with their provider. Dcpb ) related to their coverage or condition with their treating provider authorization ( ePA and! Providers are solely responsible for medical advice and treatment of members or call OptumRx as of the.. Ibrance ( palbociclib ) treating providers are solely responsible for medical advice and treatment members. The effective date of the effective date of the submission upcoming formulary updates vismodegib Cost... Discuss any Dental Clinical Policy Bulletins ( DCPBs ) are regularly updated and are therefore subject change! ( DCPB ) related to their coverage or condition with their treating provider request OptumRx standard drug-specific guideline to faxed. ( DCPB ) related to their coverage or condition with their treating provider or with...

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