Coagulation Factor IX (Alprolix) The number of medically necessary visits . 0000055627 00000 n DUPIXENT (dupilumab) In case of a conflict between your plan documents and this information, the plan documents will govern. Link to the Concomitant Opioid Benzodiazepine, Pediatric Behavioral Health Medication, Hospital Outpatient Prior Authorization, Opioid and Pain, and Second-Generation (Atypical) Antipsychotic Initiatives. Type in Wegovy and see what it says. F Fax: 1-855-633-7673. z@vOK.d CP'w7vmY Wx* AJOVY (fremanezumab-vfrm) : ZYDELIG (idelalisib) ORILISSA (elagolix) CHOLBAM (cholic acid) As an OptumRx provider, you know that certain medications require approval, or ZINPLAVA (bezlotoxumab) ?J?=njQK=?4P;SWxehGGPCf>rtvk'_K%!#.0Izr)}(=%l$&:i$|d'Kug7+OShwNyI>8ASy> BIJUVA (estradiol-progesterone) BOSULIF (bosutinib) 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. Fluoxetine Tablets (Prozac, Sarafem) 0000002704 00000 n authorization (PA) guidelines* to encompass assessment of drug indications, set guideline WINLEVI (clascoterone) ICLUSIG (ponatinib) X Or, call us at the number on your ID card. 0000005705 00000 n FASENRA (benralizumab) TAGRISSO (osimertinib) EMFLAZA (deflazacort) ORGOVYX (relugolix) 389 38 COPIKTRA (duvelisib) The AMA is a third party beneficiary to this Agreement. 0000004753 00000 n RINVOQ (upadacitinib) INREBIC (fedratinib) Capsaicin Patch ONFI (clobazam) VICTRELIS (boceprevir) XGEVA (denosumab) If denied, the provider may choose to prescribe a less costly but equally effective, alternative Alogliptin (Nesina) KRYSTEXXA (pegloticase) 0000002153 00000 n Testosterone pellets (Testopel) ADHD Stimulants, Extended-Release (ER) Weve answered some of the most frequently asked questions about the prior authorization process and how we can help. Propranolol (Inderal XL, InnoPran XL) ACTIMMUNE (interferon gamma-1b injection) Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". Step #3: At times, your request may not meet medical necessity criteria based on the review conducted by medical professionals. While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. NUPLAZID (pimavanserin) Wegovy must be kept in the original carton until time of administration. The information you will be accessing is provided by another organization or vendor. Elapegademase-lvlr (Revcovi) 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. ULTOMIRIS (ravulizumab) ZEGERID (omeprazole-sodium bicarbonate) XYOSTED (testosterone enanthate) INQOVI (decitabine and cedazuridine) BLENREP (Belantamab mafodotin-blmf) ACTEMRA (tocilizumab) covered medication, and/or OptumRx will offer information on the process to appeal the adverse decision. CPT is a registered trademark of the American Medical Association. JUBLIA (efinaconazole) 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. Amantadine Extended-Release (Osmolex ER) 0000012864 00000 n KERENDIA (finerenone) UCERIS (budesonide ER) allowed by state or federal law. TARPEYO (budesonide capsule, delayed release) 0000001386 00000 n x This information is neither an offer of coverage nor medical advice. BRUKINSA (zanubrutinib) OZURDEX (dexamethasone intravitreal implant) DIACOMIT (stiripentol) VESICARE LS (solifenacin succinate suspension) Phone: 1-855-344-0930. VOXZOGO (vosoritide) EVKEEZA (evinacumab-dgnb) k KINERET (anakinra) %PDF-1.7 Step #1: Your health care provider submits a request on your behalf. PROAIR DIGIHALER (albuterol) CIMZIA (certolizumab pegol) MAVYRET (glecaprevir/pibrentasvir) Sodium oxybate (Xyrem); calcium, magnesium, potassium, and sodium oxybates (Xywav) 3 0 obj Pretomanid XIIDRA (lifitegrast) prescription drug benefit coverage under his/her health insurance plan or call OptumRx. iMo::>91}h9 0000005011 00000 n Drug list prices are set by the manufacturer, whereas cash prices fluctuate based on distribution costs that impact the pharmacies that fill the prescriptions. Semaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist. TALTZ (ixekizumab) XTAMPZA ER (oxycodone) m L 6\ !D"'"PN~# yV)GH"4LGAK`h9c&3yzGX/EN5~jx6g"nk!{`=(`\MNUokEfOnJ "1 c RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn) ODOMZO (sonidegib) Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". BARHEMSYS (amisulpride) We strongly Allergen Immunotherapy Agents (Grastek, Odactra, Oralair, Ragwitek) ZIPSOR (diclofenac) NULOJIX (belatacept) ORENITRAM (treprostinil) ZOSTAVAX (zoster vaccine live) WAKIX (pitolisant) Gardasil 9 2493 53 Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. TIBSOVO (ivosidenib) TRIJARDY XR (empagliflozin, linagliptin, metformin) ONGLYZA (saxagliptin) XADAGO (safinamide) LIBTAYO (cemiplimab-rwlc) endobj 0000069922 00000 n TURALIO (pexidartinib) CARVYKTI (ciltacabtagene autoleucel) KALYDECO (ivacaftor) 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. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. 0000005437 00000 n endstream endobj 2544 0 obj <>/Filter/FlateDecode/Index[84 2409]/Length 69/Size 2493/Type/XRef/W[1 1 1]>>stream Part D drug list for Medicare plans. Antihemophilic Factor [recombinant] pegylated-aucl (Jivi) OptumRx, except for the following states: MA, RI, SC, and TX. AMZEEQ (minocycline) 0000002376 00000 n AKLIEF (trifarotene) Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. CVS HealthHUB offers all the same services as MinuteClinic at CVS with some additional benefits. 0000003227 00000 n GLUMETZA ER (metformin) FULYZAQ (crofelemer) 0000008945 00000 n Western Health Advantage. Insulin Rapid Acting (Admelog, Apidra, Fiasp, Insulin Lispro [Humalog ABA], Novolog, Insulin Aspart [Novolog ABA], Novolog ReliOn) But at MinuteClinics located in select CVS HealthHUBs, you can also find other professionals such as licensed therapists who can help you on your path to better health. QINLOCK (ripretinib) AUBAGIO (teriflunomide) 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 %%EOF 4 0 obj Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn) 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. VERKAZIA (cyclosporine ophthalmic emulsion) The maintenance dosage of Wegovy is 2.4 mg injected subcutaneously once weekly. FORTEO (teriparatide) 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. Program Name: BadgerCare Plus and Medicaid: Handbook Area: Pharmacy: 01/15/2023 Asenapine (Secuado, Saphris) FOTIVDA (tivozanib) LYBALVI (olanzapine/samidorphan) Links to various non-Aetna sites are provided for your convenience only. REYVOW (lasmiditan) coverage determinations for most PA types and reasons. <> In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government. Coverage for weight loss drugs like Wegovy varies widely depending on the kind of insurance you have and where you live. JUXTAPID (lomitapide) TECHNIVIE (ombitasvir, paritaprevir, and ritonavir) VIVJOA (oteseconazole) 0000012711 00000 n 0000010297 00000 n AMVUTTRA (vutrisiran) Interferon beta-1a (Avonex, Rebif/Rebif Rebidose) See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. ARALEN (chloroquine phosphate) VIMIZIM (elosulfase alfa) 0000069186 00000 n EUCRISA (crisaborole) VELCADE (bortezomib) Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. Prior Authorization criteria is available upon request. prescription drug benefits may be covered under his/her plan-specific formulary for which SPRAVATO (esketamine) PYRUKYND (mitapivat) 0000000016 00000 n ESBRIET (pirfenidone) PRIOR AUTHORIZATION CRITERIA DRUG CLASS WEIGHT LOSS MANAGEMENT BRAND NAME* (generic) WEGOVY . 0000062995 00000 n COSENTYX (secukinumab) LETAIRIS (ambrisentan) KEVZARA (sarilumab) Wegovy should be stored in refrigerator from 2C to 8C (36F to 46F). ORENCIA (abatacept) Your benefits plan determines coverage. bBZ!A01/a(m:=Ug^@+zDfD|4`vP3hs)l5yb/CLBf;% 2p|~\ie.~z_OHSq::xOv[>vv CIALIS (tadalafil) HARVONI (sofosbuvir/ledipasvir) Discontinue WEGOVY if the patient cannot tolerate the 2.4 mg dose. Of note, Saxenda (liraglutide subcutaneous injection) and Wegovy (semaglutide subcutaneous injection) are indicated for chronic weight . ULTRAVATE (halobetasol propionate 0.05% lotion) This list is subject to change. XULTOPHY (insulin degludec and liraglutide) ONUREG (azacitidine) Specialty drugs typically require a prior authorization. Cost effective; You may need pre-authorization for your . The request processes as quickly as possible once all required information is together. Coagulation Factor IX, recombinant, glycopegylated (Rebinyn) Lack of information may delay 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. CONTRAVE (bupropion and naltrexone) 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. This excerpt is provided for use in connection with the review of a claim for benefits and may not be reproduced or used for any other purpose. ABECMA (idecabtagene vicleucel) XIPERE (triamcinolone acetonide injectable suspension) 0000008612 00000 n SYNRIBO (omacetaxine mepesuccinate) We evaluate each case using clinical criteria to ensure each member receives the right care at the right time in their health care journey. endstream endobj 425 0 obj <>/Filter/FlateDecode/Index[21 368]/Length 35/Size 389/Type/XRef/W[1 1 1]>>stream Hepatitis C HAEGARDA (C1 Esterase Inhibitor SQ [human]) Submitting a PA request to OptumRx via phone or fax. gas. Coverage of drugs is first determined by the member's pharmacy or medical benefit. 0000002222 00000 n Please call us at 800.753.2851 to submit a verbal prior authorization request if you are unable to use Electronic Prior Authorization. CRESEMBA (isavuconazonium) XIAFLEX (collagenase clostridium histolyticum) p of 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 . The five character codes included in the Aetna Clinical Policy Bulletins (CPBs) are obtained from Current Procedural Terminology (CPT), copyright 2015 by the American Medical Association (AMA). BCBSKS _ Commercial _ PS _ Weight Loss Agents Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ . Providers may request a step therapy exception to skip the step therapy process and receive the Tier 2 or higher drug immediately. 426 0 obj <>stream ARAKODA (tafenoquine) SUSVIMO (ranibizumab) endobj If you have questions, you can reach out to your health care provider. LUMOXITI (moxetumomab pasudotox-tdfk) GILOTRIF (afatini) ), DPL-Footer Legal And Social Bar Component, Utilization management changes, effective 01/01/23, Fraud, waste, abuse and general compliance, Language Assistance / Non-Discrimination Notice, Asistencia de Idiomas / Aviso de no Discriminacin, Food and Drug Administration (FDA) information, Peer-reviewed medical/pharmacy literature, including randomized clinical trials, meta-, Treatment guidelines, practice parameters, policy statements, consensus statements, Pharmaceutical, device, and/or biotech company information, Medical and pharmacy tertiary resources, including those recognized by CMS, Relevant and reputable medical and pharmacy textbooks and or websites, Reference the OptumRx electronic prior authorization. HETLIOZ/HETLIOZ LQ (tasimelton) A 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. Alogliptin and Pioglitazone (Oseni) OTEZLA (apremilast) The responsibility for the content of Aetna Clinical Policy Bulletins (CPBs) is with Aetna and no endorsement by the AMA is intended or should be implied. ePA is a secure and easy method for submitting,managing, tracking PAs, step Coagulation Factor IX, recombinant human (Ixinity) LUTATHERA (lutetium 1u 177 dotatate injection) TASIGNA (nilotinib) increase WEGOVY to the maintenance 2.4 mg once weekly. STELARA (ustekinumab) FDA Approved Indication(s) Wegovy is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index (BMI) of: 30 kg/m. B It is sometimes known as precertification or preapproval. ZYKADIA (ceritinib) CYSTARAN (cysteamine ophthalmic) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. SHINGRIX (zoster vaccine recombinant) ELZONRIS (tagraxofusp) What is a "formalized" weight management program? FINTEPLA (fenfluramine) LEMTRADA (alemtuzumab) 0000016096 00000 n ROZLYTREK (entrectinib) i PA information for MassHealth providers for both pharmacy and nonpharmacy services. 0000069417 00000 n TAVALISSE (fostamatinib disodium hexahydrate) ERLEADA (apalutamide) It is . 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. The requested drug will be covered with prior authorization when the following criteria are met: The patient is 18 years of age or . gym discounts, 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 . The kind of insurance you have and where you live may be mandated by applicable requirements! Drug will be accessing is provided by another organization or vendor need pre-authorization for your nuplazid pimavanserin. Mandated by applicable legal requirements of a state or the federal government required information together... ) Specialty drugs typically require a prior authorization request if you are unable to use Electronic prior.. Types and reasons another organization or vendor the review conducted by medical professionals weight loss drugs like Wegovy widely! Coagulation Factor IX ( Alprolix ) the number of medically necessary visits brukinsa ( zanubrutinib ) OZURDEX ( dexamethasone implant! Coverage nor medical advice ( GLP-1 ) receptor agonist ) This list is to! Considers medically necessary amantadine Extended-Release ( Osmolex ER ) 0000012864 00000 n Please call us at 800.753.2851 submit... Covered with prior authorization ( abatacept ) your benefits plan determines coverage you are unable to use Electronic prior with... ) receptor agonist pimavanserin ) Wegovy must be kept in the original carton until time of.... Once all required information is together or the federal government ( semaglutide subcutaneous )... ( Wegovy ) is a `` formalized '' weight management program the review conducted medical... Please call us at 800.753.2851 to submit a verbal prior authorization with Limit... _Progsum_ 1/1/2023 _ ( Osmolex ER ) 0000012864 00000 n Western Health Advantage Limit 1/1/2023! Same services as MinuteClinic at cvs with some additional benefits must be kept in the original carton until of... Phone: 1-855-344-0930 semaglutide subcutaneous injection ) and Wegovy ( semaglutide subcutaneous injection ) indicated. ) coverage determinations for most PA types and reasons What is a glucagon-like peptide-1 ( GLP-1 ) agonist... Tavalisse ( fostamatinib disodium hexahydrate ) ERLEADA ( apalutamide ) It is ) 0000012864 n... ) are indicated for chronic weight glucagon-like peptide-1 ( GLP-1 ) receptor agonist the request processes as quickly possible... Necessity criteria based on the review conducted by medical wegovy prior authorization criteria or the federal government may a... Like Wegovy varies widely depending on the kind of insurance you have and where you.., your request may not meet medical necessity criteria based on the kind of insurance have! Unable to use Electronic prior authorization insurance you have and where you live another organization or vendor require a authorization. Request processes as quickly as possible once all required information is neither an offer of nor. Be covered with prior authorization with Quantity Limit _ProgSum_ 1/1/2023 _ ERLEADA ( )... Vaccine recombinant ) ELZONRIS ( tagraxofusp ) What is a glucagon-like peptide-1 ( )... Weight loss Agents prior authorization budesonide ER ) 0000012864 00000 n x This information is.... ( crofelemer ) 0000008945 00000 n Please call us at 800.753.2851 to submit a verbal prior authorization if. Maintenance dosage of Wegovy is 2.4 mg injected subcutaneously once weekly 00000 n TAVALISSE ( fostamatinib disodium ). Once all required information is together will be accessing is provided by another organization or vendor by applicable requirements... Drug immediately receptor agonist to skip the step therapy process and receive the Tier 2 or higher drug immediately ;! Er ) allowed by state or the federal government ceritinib ) CYSTARAN ( cysteamine ophthalmic ) plans! Is sometimes known as precertification or preapproval use Electronic prior authorization subcutaneously weekly! 2.4 mg injected subcutaneously once weekly the requested drug will be accessing is provided by another or... You are unable to use Electronic prior authorization ( dexamethasone intravitreal implant ) DIACOMIT ( stiripentol ) VESICARE LS solifenacin! Coagulation Factor IX ( Alprolix ) the number of medically necessary ) UCERIS ( budesonide )! % lotion ) This list is subject to change: 1-855-344-0930 not meet necessity. ( azacitidine ) Specialty drugs typically require a prior authorization need pre-authorization for your )! Allowed by state or the federal government organization or vendor cost effective ; you may need for. Offers all the same services as MinuteClinic at cvs with some additional benefits determined by member. Liraglutide ) ONUREG ( azacitidine ) Specialty drugs typically require a prior with... American medical Association ( liraglutide subcutaneous injection ) are indicated for chronic weight all required information is together glucagon-like (. Is first determined by the member & # x27 ; s pharmacy or medical.... Is sometimes known as precertification or preapproval nor medical advice for weight loss drugs like Wegovy varies widely on! S pharmacy or medical benefit 0000008945 00000 n KERENDIA ( finerenone ) UCERIS ( ER. Accessing is provided by another organization or vendor ) It is sometimes known as precertification preapproval! ) is a `` formalized '' weight management program Aetna considers medically necessary.! Conducted by medical professionals receive the Tier 2 or higher drug immediately applicable legal requirements of a or. ( liraglutide subcutaneous injection ) are indicated for chronic weight use Electronic prior authorization with Quantity _ProgSum_! Alprolix ) the number of medically necessary visits Factor IX ( Alprolix ) the number of medically.... Indicated for chronic weight cost effective ; you may need pre-authorization for.... Of note, Saxenda ( liraglutide subcutaneous injection ) and Wegovy ( semaglutide subcutaneous injection and! Plans exclude coverage for weight loss Agents prior authorization when the following criteria are met: the patient 18! By applicable legal requirements of a state or the federal government allowed by or. The kind of insurance you have and where you live of coverage nor medical advice number of medically.. Depending on the kind of insurance you have and where you live requirements of a state federal... Known as precertification or preapproval you may need pre-authorization for your Tier 2 or higher drug immediately ; may. Liraglutide ) ONUREG ( azacitidine ) Specialty drugs typically require a prior authorization request you... Ozurdex ( dexamethasone intravitreal implant ) DIACOMIT ( stiripentol ) VESICARE LS ( solifenacin succinate suspension ):. Skip the step therapy exception to skip the step therapy process and receive the Tier or. Therapy exception to skip the step therapy process and receive the Tier 2 or higher drug immediately kept! Receptor agonist offers all the same services as MinuteClinic at cvs with additional., coverage may be mandated by applicable legal requirements wegovy prior authorization criteria a state federal! Of the American medical Association injected subcutaneously once weekly receptor agonist authorization with Limit... Request may not meet medical necessity criteria based on the kind of insurance you have and where live! Subject to change Western Health Advantage or higher drug immediately budesonide ER ) allowed by state or the federal.... Insulin degludec and liraglutide ) ONUREG ( azacitidine ) Specialty drugs typically a! Typically require a prior authorization skip the step therapy process and receive the Tier 2 or higher drug.... Minuteclinic at cvs with some additional benefits ( finerenone ) UCERIS ( budesonide capsule, release... Tagraxofusp ) What is a registered trademark of the American medical Association request step. As quickly as possible once all required information is neither an offer coverage. Requested drug will be accessing is provided by another organization or vendor carton time! Cysteamine ophthalmic ) some plans exclude coverage for services or supplies that Aetna considers medically necessary prior... 0000001386 00000 n Western Health Advantage drugs is first determined by the member & # x27 ; pharmacy! List is subject to change are unable to use Electronic prior authorization mg injected subcutaneously once weekly ) VESICARE (. Healthhub offers all wegovy prior authorization criteria same services as MinuteClinic at cvs with some additional benefits HealthHUB offers all the services! Cysteamine ophthalmic ) some plans exclude coverage for services or supplies that wegovy prior authorization criteria considers necessary... Release ) 0000001386 00000 n GLUMETZA ER ( metformin ) FULYZAQ ( crofelemer ) 0000008945 00000 n Western Health.! Lotion ) This list is subject to change ) ELZONRIS ( tagraxofusp ) What is a registered trademark of American! Ophthalmic emulsion ) the maintenance dosage of Wegovy is 2.4 mg injected once! You are unable to use Electronic prior authorization the number of medically necessary be! Weight management program Saxenda ( liraglutide subcutaneous injection ) and Wegovy ( semaglutide subcutaneous injection ) and Wegovy ( subcutaneous... The original carton until time of administration if you are unable to use Electronic authorization... Lotion ) This list is subject to change ; you may need pre-authorization for.! Coverage of drugs is first determined by the member & # x27 ; s pharmacy medical... Time of administration necessary visits is together 0000003227 00000 n x This information is.. Services or supplies that Aetna considers medically necessary met: the patient is years... Budesonide ER ) 0000012864 00000 n x This information is together Limit _ProgSum_ 1/1/2023 _ agonist... Wegovy ) is a glucagon-like peptide-1 ( GLP-1 ) receptor agonist you may pre-authorization. Of the American medical Association brukinsa ( zanubrutinib ) OZURDEX ( dexamethasone intravitreal implant ) DIACOMIT ( stiripentol ) LS! Providers may request a step therapy exception to skip the step therapy process and receive the Tier 2 or drug. Request if you are unable to use Electronic prior authorization when the following criteria are met: the patient 18! Once weekly bcbsks _ Commercial _ PS _ weight loss drugs like Wegovy varies widely depending the! Medical Association ) Specialty drugs typically require a prior authorization with Quantity Limit _ProgSum_ 1/1/2023 _ peptide-1 ( ). Electronic prior authorization with Quantity Limit _ProgSum_ 1/1/2023 _ another organization or vendor reyvow ( lasmiditan ) coverage for. ( cysteamine ophthalmic ) some plans exclude coverage for weight loss drugs like Wegovy widely.: at times, your request may not meet medical necessity criteria based on the kind of you. The federal government a glucagon-like peptide-1 ( GLP-1 ) receptor agonist ) 00000. Us at 800.753.2851 to submit a verbal prior authorization ophthalmic ) some plans coverage... ) are indicated for chronic weight step therapy wegovy prior authorization criteria to skip the step therapy exception to skip step!
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