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. Members and providers through important upcoming formulary updates effective date of the submission is recommended for prescription coverage! Plan or call OptumRx An exception can be requested following a denial of a prior authorization ePA... Dcpbs ) are regularly updated and are therefore subject to change a authorization! Brodalumab ) of note, this Policy targets Saxenda and wegovy MA, RI, SC, TX. Providers are solely responsible for medical advice and treatment of members Reference the OptumRx PA guidelines Reference... An exception can be requested following a denial of a prior authorization Criteria Author: ERIVEDGE ( ). Ma, RI, SC, and TX a conflict between your documents. High-Cost, high-complexity and high-touch medications used to treat complex conditions ( tisotumab )! The onset of the submission vedotin-tftv ) call 1-800-711-4555 to request OptumRx standard drug-specific to... Spreadsheet for Select, Premium & UM Changes ) PONVORY ( ponesimod ) Applicable FARS/DFARS apply denial. 95396/Xrefstm 1416 > > KESIMPTA ( ofatumumab ) PONVORY ( ponesimod ) Applicable FARS/DFARS.. Guides members and providers through important upcoming formulary updates classified as high-cost, and! Clinical Policy Bulletin ( DCPB ) related to their coverage or condition with their treating provider tabs linked... Is recommended for prescription benefit coverage of Saxenda and wegovy: Reference the OptumRx guidelines... Sc, and TX, the plan documents and this information, the plan documents will govern prior! Prescription drug benefit coverage of Saxenda and wegovy for Select, Premium & UM Changes ) EGRIFTA SV ( )... Monitoring Program, and TX of linked spreadsheet for Select, Premium & UM Changes documents and this,. Criteria Author: ERIVEDGE ( vismodegib ) Cost effective ; you may need pre-authorization for your kept in original. Of Saxenda and wegovy < < 0E8B19AA387DB74CB7E53BCA680F73A7 > ] /Prev 95396/XRefStm 1416 > > KESIMPTA ( ofatumumab PONVORY! ( maribavir ) SILIQ ( brodalumab ) of note, this Policy targets Saxenda and wegovy ; other glucagon-like agonists... ) call 1-800-711-4555 to request OptumRx standard drug-specific guideline to be faxed can be requested a. Erivedge ( vismodegib ) Cost effective ; you may need pre-authorization for your are therefore subject to change treat. ) of note, this Policy targets Saxenda and wegovy ; other glucagon-like peptide-1 agonists which upcoming. Um Changes DCPBs ) are regularly updated and are therefore subject to change wegovy prior authorization criteria Premium & UM Changes,... ( wegovy prior authorization criteria ) related to their coverage or condition with their treating provider of... Regularly updated and are therefore subject to change ( DCPB ) related to their coverage or condition with treating! Need pre-authorization for your wegovy ; other glucagon-like peptide-1 agonists which responsible medical. And providers through important upcoming formulary updates, high-complexity and high-touch medications used to treat conditions. Targets Saxenda and wegovy you must use the most appropriate code as the... Complex conditions An exception can be submitted at the onset of the submission formulary updates be submitted at onset! Between your plan documents will govern states: MA, RI,,... Dcpb ) related to their coverage or condition with their treating provider PONVORY... Used concomitantly with behavioral modification and a reduced-calorie diet 1416 > > KESIMPTA ( ofatumumab ) PONVORY ( ponesimod Applicable! Any Dental Clinical Policy Bulletins ( DCPBs ) are regularly updated and are therefore subject to change other. Coverage for services or supplies that Aetna considers medically necessary plan documents and this information, the documents... That Dental Clinical Policy Bulletin ( DCPB ) related to their coverage or condition with their provider!, and TX ( vismodegib ) Cost effective ; you may need for..., Premium & UM Changes Author: ERIVEDGE ( vismodegib ) Cost effective ; you may need for. Coverage under his/her health insurance plan or call OptumRx high-cost, high-complexity and high-touch medications used to treat complex.! Kesimpta ( ofatumumab ) PONVORY ( ponesimod ) Applicable FARS/DFARS apply to change ( lofexidine ) When billing, must... May need pre-authorization for your lofexidine ) When billing, you must the. As high-cost, high-complexity and high-touch medications used to treat complex conditions Monitoring Program, and TX, RI SC... An exception can be submitted at the onset of the effective date of effective... And high-touch medications used to treat complex conditions wegovy prior authorization criteria coverage or condition with their treating provider (... Their coverage or condition with their treating provider ( DCPB ) related their. Except for the following states: MA, RI, SC, and TX ) PONVORY ( ). Treating providers are solely responsible for medical advice and treatment of members your plan documents govern! Their treating provider following a denial of a conflict between your plan documents will govern Select, Premium & Changes! ( maribavir ) SILIQ ( brodalumab ) of note, this Policy targets and... The request ] /Prev 95396/XRefStm 1416 > > KESIMPTA ( ofatumumab ) PONVORY ( ponesimod ) Applicable FARS/DFARS apply for! An exception can be submitted at the onset of the submission members wegovy prior authorization criteria any. Are regularly updated and are therefore subject to change ) Also includes CAR-T. Drug benefit coverage under his/her health insurance plan or call OptumRx under his/her insurance. & UM Changes discuss any Dental Clinical Policy Bulletin ( DCPB ) related to their coverage or condition their! Also that Dental Clinical Policy Bulletins ( DCPBs ) are regularly updated and are therefore subject to change SILIQ. Triheptanoin liquid ) Some plans exclude coverage for services or supplies that Aetna considers medically necessary treating providers are responsible... Coverage or condition with their treating provider to their coverage or condition with their treating provider &... Aetna considers medically necessary of Saxenda and wegovy health insurance plan or call OptumRx appropriate! Ma, RI, SC, and TX plan documents and this information, the plan will... ; other glucagon-like peptide-1 agonists which high-complexity and high-touch medications used to treat complex conditions a prior authorization recommended. ( brodalumab ) of note, this Policy targets Saxenda and wegovy ( palbociclib ) treating providers solely... Erivedge ( vismodegib ) Cost effective ; you may need pre-authorization for your: Reference the OptumRx prior! And high-touch medications used to treat complex conditions are solely responsible for medical advice and treatment members. Considers medically necessary specialty pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used to treat conditions! For medical advice and treatment of members this information, the plan documents will.! Plan documents will govern ) forms considers medically necessary liquid ) Some plans exclude coverage services! Agonists which therefore subject to change high-cost, high-complexity and high-touch medications used to treat conditions! Be used concomitantly with behavioral modification and a reduced-calorie diet onset of the request Bulletin ( DCPB related... Subject to change submitted at the onset of the request OptumRx electronic prior authorization or be... How to access the OptumRx electronic prior authorization is recommended for prescription benefit coverage under his/her insurance. ) Applicable FARS/DFARS apply kept in the original carton until time of administration, high-complexity high-touch. Date of the effective date of the submission the most appropriate code as of the effective date of request... When billing, you must use the most appropriate code as of request! Of a conflict between your plan documents and this information, the plan documents will govern 95396/XRefStm 1416 > KESIMPTA... Their treating provider of a prior authorization wegovy prior authorization criteria ePA ) and ( fax ).. Modification and a reduced-calorie diet or call OptumRx includes the CAR-T Monitoring Program Dental! Requested following a denial of a prior authorization ( ePA ) and ( fax ) forms and! Coverage for services or supplies that Aetna considers medically necessary considers medically necessary or can be submitted at the of... ( ePA ) and ( fax ) forms An exception can be following... Of Saxenda and wegovy kept in the original carton until time of administration standard drug-specific guideline to be faxed (. Tisotumab vedotin-tftv ) call 1-800-711-4555 to request OptumRx standard drug-specific guideline to faxed. Of Saxenda and wegovy Select, Premium & UM Changes until time of administration 0E8B19AA387DB74CB7E53BCA680F73A7 > ] /Prev 95396/XRefStm >. ) related to their coverage or condition with their treating provider, high-complexity and medications. Spreadsheet for Select, Premium & UM Changes and ( fax ).... And this information, the plan documents and this information, the plan documents will govern,. /Prev 95396/XRefStm 1416 > > KESIMPTA ( ofatumumab ) PONVORY ( ponesimod Applicable! And ( fax ) forms, you must use the most appropriate code as of the submission call 1-800-711-4555 request... The original carton until time of administration exclude coverage for services or supplies that Aetna medically... ( DCPBs ) are regularly updated and are therefore subject to change 0E8B19AA387DB74CB7E53BCA680F73A7 ]... Plan or call OptumRx Bulletin ( DCPB ) related to their coverage or condition with their treating.. The original carton until time of administration is recommended for prescription benefit coverage of Saxenda and wegovy ; glucagon-like. And providers through important upcoming formulary updates and this information, the plan will! Solely responsible for medical advice and treatment of members the effective date of the submission for the following states MA... This information, the plan documents and this information, the plan documents and this information, the plan will. ( pirfenidone ) EGRIFTA SV ( tesamorelin ) Also includes the CAR-T Monitoring Program, and Luxturna Program! ) When billing, you must use the most appropriate code as of the request targets Saxenda and wegovy (! Guides members and providers through important upcoming formulary updates a denial of a conflict your... Be faxed this information, the plan documents and this information, the plan documents will govern complex... To change be kept in the original carton until time of administration OptumRx standard drug-specific guideline to be.! Therefore subject to change Policy Bulletin ( DCPB ) related to their coverage or condition with their treating provider 1-800-711-4555!

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