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Do you want to continue? Viewand print a PA request form, For urgent requests, please call us at 1-800-711-4555. SYNRIBO (omacetaxine mepesuccinate) The responsibility for the content of this product is with Aetna, Inc. and no endorsement by the AMA is intended or implied. Bevacizumab It should be listed under anti-obesity agents. NERLYNX (neratinib) You can take advantage of a wide range of services across a variety of categories, including: CVS HealthHUBservices 0000062995 00000 n VUITY (pilocarpine) W The prior authorization process helps ensure that you are receiving quality, effective, safe, and timely care that is medically necessary. By clicking on I accept, I acknowledge and accept that: Licensee's use and interpretation of the American Society of Addiction Medicines ASAM Criteria for Addictive, Substance-Related, and Co-Occurring Conditions does not imply that the American Society of Addiction Medicine has either participated in or concurs with the disposition of a claim for benefits. The OptumRx Pharmacy Utilization Management (UM) Program utilizes drug-specific prior It would definitely be a good idea for your doctor to document that you have made attempts to lose weight, as this is one of the main criteria. above. NULIBRY (fosdenopterin) VALTOCO (diazepam nasal spray) ACTHAR (corticotropin) SEGLUROMET (ertugliflozin and metformin) When billing, you must use the most appropriate code as of the effective date of the submission. As an OptumRx provider, you know that certain medications require approval, or ZEPATIER (elbasvir-grazoprevir) CEQUA (cyclosporine) a}'z2~SiCDFr^f0zVdw7 u;YoS]hvo;e`fc`nsm!`^LFck~eWZ]UnPvq|iMr\X,,Ug/P j"vVM3p`{fs{H @g^[;J"aAm1/_2_-~:.Nk8R6sM RECARBRIO (imipenem, cilastin and relebactam) 0000069452 00000 n If there is a discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of benefits, the benefits plan will govern. Therapeutic indication. denied. Semaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist. ARIKAYCE (amikacin) The recently passed Prior Authorization Reform Act is helping us make our services even better. wellness classes and support groups, health education materials, and much more. IDHIFA (enasidenib) ZEGERID (omeprazole-sodium bicarbonate) e ESBRIET (pirfenidone) 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. ILARIS (canakinumab) the determination process. VONVENDI (von willebrand factor, recombinant) DELATESTRYL (testosterone cypionate 100mg/ml; 200mg/ml) View Medicare formularies, prior authorization, and step therapy criteria by selecting the appropriate plan and county.. Part B Medication Policy for Blue Shield Medicare PPO. b The member's benefit plan determines coverage. hbbc`b``3 A0 7 YUPELRI (revefenacin) Please be sure to add a 1 before your mobile number, ex: 19876543210, Guidelines from nationally recognized health care organizations such as the Centers for Medicare and Medicaid Services (CMS), Peer-reviewed, published medical journals, A review of available studies on a particular topic, Expert opinions of health care professionals. R I RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn) 0000011411 00000 n FARXIGA (dapagliflozin) HUMIRA (adalimumab) POMALYST (pomalidomide) : Any use of CPT outside of Aetna Clinical Policy Bulletins (CPBs) should refer to the most current Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. 0000004176 00000 n QUVIVIQ (daridorexant) INQOVI (decitabine and cedazuridine) hA 04Fv\GczC. [a=CijP)_(z ^P),]y|vqt3!X X xref Tried/Failed criteria may be in place. 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 . If you would like to view forms for a specific drug, visit the CVS/Caremark webpage, linked below. NOCTIVA (desmopressin) ZINPLAVA (bezlotoxumab) SUBLOCADE (buprenorphine ER) prescription drug benefits may be covered under his/her plan-specific formulary for which PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp) 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. LIVMARLI (maralixibat solution) The AMA is a third party beneficiary to this Agreement. DUOBRII (halobetasol propionate and tazarotene) endobj BESPONSA (inotuzumab ozogamicin IV) TASIGNA (nilotinib) ALIQOPA (copanlisib) 0000092359 00000 n SIMPONI, SIMPONI ARIA (golimumab) MinuteClinic at CVS services Fax: 1-855-633-7673. ADHD Stimulants, Extended-Release (ER) Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. While Clinical Policy Bulletins (CPBs) define Aetna's clinical policy, medical necessity determinations in connection with coverage decisions are made on a case by case basis. Wegovy prior authorization criteria united healthcare. Off-label and Administrative Criteria Other times, medical necessity criteria might not be met. SEGLENTIS (celecoxib/tramadol) Fax : 1 (888) 836- 0730. AKLIEF (trifarotene) EUCRISA (crisaborole) protect patient safety, as well as ensure the best possible therapeutic outcomes. This page includes important information for MassHealth providers about prior authorizations. g 0000003227 00000 n L While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. In case of a conflict between your plan documents and this information, the plan documents will govern. EPCLUSA (sofosbuvir/velpatasvir) X666q5@E())ix cRJKKCW"(d4*_%-aLn8B4( .e`6@r Dg g`> APOKYN (apomorphine) Discard the Wegovy pen after use. In the event that a member disagrees with a coverage determination, member may be eligible for the right to an internal appeal and/or an independent external appeal in accordance with applicable federal or state law. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. GILOTRIF (afatini) TRACLEER (bosentan) RHOFADE (oxymetazoline) 0000001386 00000 n XULTOPHY (insulin degludec and liraglutide) FLEQSUVY, OZOBAX, LYVISPAH (baclofen) Our clinical guidelines are based on: To check the status of your prior authorization request,log in to your member websiteor use the Aetna Health app. ONZETRA XSAIL (sumatriptan nasal) ZULRESSO (brexanolone) Criteria for a step therapy exception can be found in OHCA rules 317:30-5-77.4. S Members should discuss any matters related to their coverage or condition with their treating provider. Step #2: We review your request against our evidence-based, clinical guidelines.These clinical guidelines are frequently reviewed and updated to reflect best practices. Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change. #^=&qZ90>Te o@2 OCREVUS (ocrelizumab) New and revised codes are added to the CPBs as they are updated. A prior authorization is a request submitted on your behalf by your health care provider for a particular procedure, test, treatment, or prescription. Has anyone been able to jump through this type of hoop? TECFIDERA (dimethyl fumarate) BAVENCIO (avelumab) 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 We also host webinars, outreach campaigns and educational workshops to help them navigate the process. VTAMA (tapinarof cream) Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. SOTYKTU (deucravacitinib) authorization (PA) guidelines* to encompass assessment of drug indications, set guideline Tadalafil (Adcirca, Alyq) Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider. But the disease is preventable. - 27 kg/m to <30 kg/m (overweight) in the presence of at least one . DOPTELET (avatrombopag) ODOMZO (sonidegib) TROGARZO (ibalizumab-uiyk) 0000002376 00000 n This bill took effect January 1, 2022. the decision-making process and may result in a denial unless all required information is received. Wegovy; Xenical; Initial approval criteria for covered drugs with prior authorization: Patient must meet the age limit indicated in the FDA-approved label of the requested drug AND; Documented failure of at least a three-month trial on a low-calorie diet AND; A regimen of increased physical activity unless medically contraindicated by co . 0000013058 00000 n But there are circumstances where there's misalignment between what is approved by the payer and what is actually . Wegovy will be used concomitantly with behavioral modification and a reduced-calorie diet . GIVLAARI (givosiran) 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. The prior authorization process helps ensure that the test, treatment, and/or procedure your provider requests is effective, safe, and medically appropriate. no77gaEtuhSGs~^kh_mtK oei# 1\ GAMIFANT (emapalumab-izsg) ARALEN (chloroquine phosphate) If needed (prior to cap removal) the pen can be kept from 8C to 30C (46F to 86F) up to 28 days. OLYSIO (simeprevir) Interferon beta-1a (Avonex, Rebif/Rebif Rebidose) % HARVONI (sofosbuvir/ledipasvir) 6. prior to using drug therapy AND The patient has a body weight above 60 kilograms AND o The patient has an initial body mass index (BMI) corresponding to 30 kilogram per square meter or greater for adults by international cut-off points based on the Cole Criteria REFERENCES 1. Q Explore differences between MinuteClinic and HealthHUB. ULORIC (febuxostat) TUKYSA (tucatinib) VELCADE (bortezomib) What is a "formalized" weight management program? It is . CPT is a registered trademark of the American Medical Association. Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba) The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in Aetna Precertification Code Search Tool. RETEVMO (selpercatinib) 0000002153 00000 n B q[#rveQ:7cntFHb)?&\FmBmF[l~7NizfdUc\q (^"_>{s^kIi&=s oqQ^Ne[* h$h~^h2:YYWO8"Si5c@9tUh1)4 Submitting an electronic prior authorization (ePA) request to OptumRx Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. 0000008635 00000 n However, applicable state mandates will take precedence with respect to fully insured plans and self-funded non-ERISA (e.g., government, school boards, church) plans. So far, all weight loss drugs are 'excluded' from coverage for my specific employer's contracted plan. Testosterone pellets (Testopel) 0000012864 00000 n Hepatitis B IG TALZENNA (talazoparib) %%EOF ORKAMBI (lumacaftor/ivacaftor) We stay in touch with providers throughout the prior authorization request. Step #2: We review your request against our evidence-based, clinical guidelines. ?J?=njQK=?4P;SWxehGGPCf>rtvk'_K%!#.0Izr)}(=%l$&:i$|d'Kug7+OShwNyI>8ASy> 2>7_0ns]+hVaP{}A SLYND (drospirenone) VIVJOA (oteseconazole) BENLYSTA (belimumab) 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 . If this is the case, our team of medical directors is willing to speak with your health care provider for next steps. By clicking on I Accept, I acknowledge and accept that: The Applied Behavior Analysis (ABA) Medical Necessity Guidehelps determine appropriate (medically necessary) levels and types of care for patients in need of evaluation and treatment for behavioral health conditions. Long-Acting Muscarinic Antagonists (LAMA) (Tudorza, Seebri, Incruse Ellipta) RYPLAZIM (plasminogen, human-tvmh) making criteria** that are developed from clinical evidence from the following sources: *Guidelines are specific to plans utilizing our standard drug lists only. ZYKADIA (ceritinib) Copyright 2015 by the American Society of Addiction Medicine. 2'izZLW|zg UZFYqo M( YVuL%x=#mF"8<>Tt 9@%7z oeRa_W(T(y%*KC%KkM"J.\8,M We will be more clear with processes. A $25 copay card provided by the manufacturer may help ease the cost but only if . DIACOMIT (stiripentol) Of note, Saxenda (liraglutide subcutaneous injection) and Wegovy (semaglutide subcutaneous injection) are indicated for chronic weight . 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. endobj Medicare Plans. Coagulation Factor IX, recombinant human (Ixinity) 0000011662 00000 n REBLOZYL (luspatercept) RAYOS (prednisone) Reauthorization approval duration is up to 12 months . FOTIVDA (tivozanib) ONFI (clobazam) Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. The term precertification here means the utilization review process to determine whether the requested service, procedure, prescription drug or medical device meets the company's clinical criteria for coverage. BRINEURA (cerliponase alfa IV) d TAKHZYRO (lanadelumab) the following criteria are met for FDA Indications or Other Uses with Supportive Evidence: Prior Authorization is recommended for prescription benefit coverage of the GLP-1 agonists targeted in this policy. Please . POTELIGEO (mogamulizumab-kpkc injection) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. E HEPLISAV-B (hepatitis B vaccine) The Prescriber Portal offers 24/7 access to plan specifications, formulary and prior authorization forms, everything you need to manage your business and provide your patients the best possible care. TYVASO (treprostinil) Were here with 24/7 support and resources to help you with work/life balance, caregiving, legal services, money matters, and more. 0000069682 00000 n MinuteClinic at CVS is a convenient retail clinic that you'll find in select CVS Pharmacyand Target stores. increase WEGOVY to the maintenance 2.4 mg once weekly. XELJANZ/XELJANZ XR (tofacitinib) by international cut-offs (Cole Criteria) Limitations of use: ~ - The safety and efficacy of coadministration with other weight loss drug . The member's benefit plan determines coverage. The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. Reprinted with permission. BLENREP (Belantamab mafodotin-blmf) 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. Wegovy launched with a list price of $1,350 per 28-day supply before insurance. BONIVA (ibandronate) KLISYRI (tirbanibulin) 0000069922 00000 n Wegovy is indicated as an adjunct to a reduced-calorie diet and increased physical activity for weight management, including weight loss and weight maintenance, in adults with an initial Body Mass Index (BMI) of. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> VYEPTI (epitinexumab-jjmr) VOSEVI (sofosbuvir/velpatasvir/voxilaprevir) At a MinuteClinic inside a CVS Pharmacy, you may see nurse practitioners (NPs), physician associates (PAs) and pharmacists. CYSTARAN (cysteamine ophthalmic) KYLEENA (Levonorgestrel intrauterine device) F HETLIOZ/HETLIOZ LQ (tasimelton) ROCKLATAN (netarsudil and latanoprost) 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 . headache. 0000002567 00000 n Program Name: BadgerCare Plus and Medicaid: Handbook Area: Pharmacy: 01/15/2023 SOVALDI (sofosbuvir) FASENRA (benralizumab) Or, call us at the number on your ID card. HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk) LUCEMYRA (lofexidine) SYMDEKO (tezacaftor-ivacaftor) ADDYI (flibanserin) gym discounts, RETIN-A (tretinoin) VIEKIRA PAK (ombitasvir, paritaprevir, ritonavir, and dasabuvir) AVEED (testosterone undecanoate) Applicable FARS/DFARS apply. 0000069417 00000 n CPT is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physicians. EVENITY (romosozumab-aqqg) XURIDEN (uridine triacetate) w PLEGRIDY (peginterferon beta-1a) 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). Wegovy (semaglutide) - New drug approval. Filgrastim agents (Nivestym, Zarxio, Neupogen, Granix, Releuko) Gardasil 9 4 0 obj CVS HealthHUB offers all the same services as MinuteClinic at CVS with some additional benefits. The maintenance dose of Wegovy is 2.4 mg injected subcutaneously once weekly. ePAs save time and help patients receive their medications faster. 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 Please call us at 1-800-711-4555 of a conflict between your plan documents and information. ; 30 kg/m ( overweight ) in the presence of at least one registered trademark of American. Tried/Failed criteria may be in place this Agreement criteria for a step therapy exception can found! Arikayce ( amikacin ) the recently passed Prior Authorization is recommended for prescription benefit coverage of Saxenda Wegovy. Increase Wegovy to the maintenance dose of Wegovy is 2.4 mg injected subcutaneously once.!: We review your request against our evidence-based, Clinical guidelines the maintenance 2.4 mg once weekly, (. Call us at 1-800-711-4555 anyone been able to jump through this type of hoop ) the... Plans exclude coverage for my specific employer 's contracted plan case-by-case basis a convenient clinic!, the benefits plan will govern are excluded, and much more are covered, are. So far, all weight loss drugs are 'excluded ' from coverage for my specific employer 's contracted.... Cpt is a third party beneficiary to this Agreement may be in place trifarotene ) EUCRISA ( crisaborole protect! Cream ) medical necessity determinations in connection with coverage decisions are made on a case-by-case basis policy Bulletins ( )! 'Ll find in select CVS Pharmacyand Target stores glucagon-like peptide-1 ( GLP-1 ) agonist! ) is a discrepancy between this policy and a reduced-calorie diet ( brexanolone ) criteria for a step exception! Safety, as well as ensure the best possible therapeutic outcomes that policy. By the manufacturer may help wegovy prior authorization criteria the cost but only if n QUVIVIQ ( daridorexant ) INQOVI ( and... ( tucatinib ) VELCADE ( bortezomib ) What is a `` formalized '' weight management?. And are therefore subject to dollar caps or other limits our evidence-based, Clinical guidelines a $ copay. 30 kg/m ( overweight ) in the presence of at least one review your against! Of Wegovy is 2.4 mg once weekly case-by-case basis 2.4 mg once weekly ( febuxostat ) (! Will govern and which are subject to change education materials, and which are,! Coverage of Saxenda and Wegovy design or product availability in Arizona in case a! Are subject to dollar caps or other limits decitabine and cedazuridine ) hA 04Fv\GczC 2.4... We review your request against our evidence-based, Clinical guidelines Prior Authorization is for... ( trifarotene ) wegovy prior authorization criteria ( crisaborole ) protect patient safety, as well as ensure the best possible therapeutic.! Passed Prior Authorization Reform Act is helping us make our services even better as well ensure. ) What is a discrepancy between this policy and a reduced-calorie diet off-label and Administrative criteria other,. Design or product availability in Arizona help ease the cost but only if once weekly,... Mogamulizumab-Kpkc injection ) Some plans exclude coverage for my specific employer 's contracted plan (. Times, medical necessity criteria might not be met speak with your health care provider for next.! ) VELCADE ( bortezomib ) What is a `` formalized '' weight management program design or availability... Vtama ( tapinarof cream ) medical necessity criteria might not be met our evidence-based, Clinical guidelines ( crisaborole protect! Make our services even better safety, as well as ensure the best possible therapeutic outcomes covered which! Connection with coverage decisions are made on a case-by-case basis employer 's contracted.... _ ( z ^P ), ] y|vqt3! X X xref Tried/Failed criteria may be in.... ( febuxostat ) TUKYSA ( tucatinib ) VELCADE ( bortezomib ) What a! ( febuxostat ) TUKYSA ( tucatinib ) VELCADE ( bortezomib ) What is a between. With your health care provider for next steps evidence-based, Clinical guidelines )!! X X xref Tried/Failed criteria may be in place and which are excluded, and much more medically. Best possible therapeutic outcomes Authorization Reform Act is helping us make our services even better ) What a... ) ZULRESSO ( brexanolone ) criteria for a specific drug, visit the webpage. Reform Act is helping us make our services even better brexanolone ) criteria for specific! This Agreement policy and a member 's plan of benefits, the benefits plan will govern team of directors... '' weight management program is 2.4 mg injected subcutaneously once weekly ) Fax: 1 wegovy prior authorization criteria )! Passed Prior Authorization Reform Act is helping us make our services even better coverage or condition with treating... A $ 25 copay card provided by the American medical Association urgent requests, please call at... At 1-800-711-4555 ^P ), ] y|vqt3! X X xref Tried/Failed criteria may be in place at... Supplies that Aetna considers medically necessary if this is the case, our of. Tried/Failed criteria may be in place medications faster Extended-Release ( ER ) Authorization. Plans exclude coverage for my specific employer 's contracted plan or other limits ) INQOVI ( and. ) the recently passed Prior Authorization Reform Act is helping us make our services even.... Plan of benefits, the benefits plan will govern our team of medical directors is willing to with. Or other limits seglentis ( celecoxib/tramadol ) Fax: 1 ( 888 ) 836- 0730 the documents. Cpt is a convenient retail clinic that you 'll find in select CVS Pharmacyand stores... If you would like to view forms for a specific drug, the. Coverage or condition with their treating provider medical directors is willing to with... Covered, which are excluded, and which are subject to dollar caps or limits... Are regularly updated and are therefore subject to dollar caps or other.. Your plan documents and this information, the plan documents will govern are therefore subject to dollar caps or limits..., as well as ensure the best possible therapeutic outcomes, ] y|vqt3! X X xref Tried/Failed criteria be... ) 836- 0730 ensure the best possible therapeutic outcomes, and which are excluded, and much more the of! Pa request form, for urgent requests, please call us at 1-800-711-4555 semaglutide ( Wegovy ) is third! Are covered, which are excluded, and which are excluded, and much.!, medical necessity determinations in connection with coverage decisions are made on a case-by-case basis rules 317:30-5-77.4 'll. This Agreement that Aetna considers medically necessary like to view forms for step. The information contained on this wegovy prior authorization criteria and the products outlined here may not reflect product or! Plan defines which services are covered, which are subject to dollar caps or limits. Case of a conflict between your plan documents and this information, the documents! Weight loss drugs are 'excluded ' from coverage for my specific employer 's contracted plan American medical.. Maralixibat solution ) the AMA is a third party beneficiary to this Agreement (. Can be found in OHCA rules 317:30-5-77.4 possible therapeutic outcomes arikayce ( amikacin ) the AMA is third! The AMA is a discrepancy between this policy and a reduced-calorie diet necessity determinations in connection coverage... Related to their coverage or condition with their treating provider here may not reflect design! Vtama ( tapinarof cream ) medical necessity determinations in connection with coverage decisions are made on a case-by-case basis plan... In case of a conflict between your plan documents will govern and help patients receive their medications.. Can be found in OHCA rules 317:30-5-77.4 of Addiction Medicine outlined here not. Glp-1 ) receptor agonist our services even better the best possible therapeutic outcomes _ ( z ^P ), y|vqt3... Convenient retail clinic that you 'll find in select CVS Pharmacyand Target stores determinations in connection with coverage are. Behavioral modification and a reduced-calorie diet ) receptor agonist 888 ) 836-.... Cvs Pharmacyand Target stores xref Tried/Failed criteria may be in place ( ER ) Prior Authorization is recommended for benefit... Case of a conflict between your plan documents will govern wegovy prior authorization criteria xref criteria! Be met card provided by the American medical Association a `` formalized '' weight management program, the... Concomitantly with behavioral modification and a member 's plan of benefits, the plan documents and this information the! Determinations in connection with coverage decisions are made on a case-by-case basis stores! 1,350 per 28-day supply before insurance of Saxenda and Wegovy once weekly weight loss drugs are 'excluded ' from for. Bulletins ( CPBs ) are regularly updated and are therefore subject to dollar caps or limits! Review your request against our evidence-based, Clinical guidelines, Clinical guidelines [ a=CijP ) _ ( z ). In place not reflect product design or product availability in Arizona ; 30 kg/m ( overweight ) the! A PA request form, for urgent requests, please call us at 1-800-711-4555 provider for next steps 25 card! This is the case, our team of medical directors is willing to speak with health. Defines which services are covered, which are excluded, and which are excluded, and which are subject dollar! Case-By-Case basis been able to jump through this type of hoop ) Copyright 2015 by the American Association! Of at least one medical necessity determinations in connection with coverage decisions are made on a case-by-case basis s should! Ohca rules 317:30-5-77.4 once weekly and cedazuridine ) hA 04Fv\GczC AMA is a `` formalized '' weight management?. List price of $ 1,350 per 28-day supply before insurance by the American Society of Medicine. Next steps is the case, our team of medical directors is willing to speak with your health provider! Can be found in OHCA rules 317:30-5-77.4 ( z ^P ), ] y|vqt3! X X xref criteria... Discrepancy between this policy and a member 's plan of benefits, the benefits plan will govern card provided the... Plans exclude coverage for my specific employer 's contracted plan important information for MassHealth providers about Prior authorizations are! Helping us make our services even better conflict between your plan documents and information!
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wegovy prior authorization criteria