ONPATTRO (patisiran for intravenous infusion) AMEVIVE (alefacept) SLYND (drospirenone) LETAIRIS (ambrisentan) TAZVERIK (tazematostat) encourage providers to submit PA requests using the ePA process as described 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. upQz:G Cs }%u\%"4}OWDw i GAMIFANT (emapalumab-izsg) NULIBRY (fosdenopterin) HAEGARDA (C1 Esterase Inhibitor SQ [human]) QELBREE (viloxazine extended-release) Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. 2'izZLW|zg UZFYqo M( YVuL%x=#mF"8<>Tt 9@%7z oeRa_W(T(y%*KC%KkM"J.\8,M 0000003755 00000 n RITUXAN (rituximab) RYPLAZIM (plasminogen, human-tvmh) If you wish to request a Medicare Part Determination (Prior Authorization or Exception request), please see your plan's website for the appropriate form and instructions on how to submit your request. CPT only Copyright 2022 American Medical Association. Visit the secure website, available through www.aetna.com, for more information. SOLIQUA (insulin glargine and lixisenatide) VIDAZA (azacitidine) Your benefits plan determines coverage. MINOCIN (minocycline tablets) The member's benefit plan determines coverage. x WAKIX (pitolisant) Xenical (orlistat) Capsule Obesity management including weight loss and weight maintenance when used in conjunction with a reduced-calorie diet and to reduce the risk for weight regain after prior weight loss. Wegovy has not been studied in patients with a history of pancreatitis ~ -The safety . the determination process. 2. or greater (obese), or 27 kg/m. RAVICTI (glycerol phenylbutyrate) Others have four tiers, three tiers or two tiers. If you do not intend to leave our site, close this message. all If patients do not tolerate the maintenance 2.4 mg once-weekly dosage, the dosage can be temporarily decreased to 1.7 mg once weekly, for a maximum of 4 weeks. dates and more. Step #3: At times, your request may not meet medical necessity criteria based on the review conducted by medical professionals. 0000010297 00000 n COPAXONE (glatiramer/glatopa) BCBSKS _ Commercial _ PS _ Weight Loss Agents Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ . ORGOVYX (relugolix) CPT only copyright 2015 American Medical Association. HALAVEN (eribulin) ZOLGENSMA (onasemnogene abeparvovec-xioi) OTEZLA (apremilast) GILENYA (fingolimod) Authorization will be issued for 12 months. 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. VONVENDI (von willebrand factor, recombinant) ALIQOPA (copanlisib) SOLODYN (minocycline 24 hour) X j 0000008635 00000 n PEPAXTO (melphalan flufenamide) INQOVI (decitabine and cedazuridine) RECLAST (zoledronic acid-mannitol-water) 0000004176 00000 n 0000002571 00000 n FORTEO (teriparatide) 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). TWIRLA (levonorgestrel and ethinyl estradiol) Coagulation Factor IX, recombinant, glycopegylated (Rebinyn) REBLOZYL (luspatercept) The AMA is a third party beneficiary to this Agreement. ILUVIEN (fluocinolone acetonide) LUCEMYRA (lofexidine) Were here with 24/7 support and resources to help you with work/life balance, caregiving, legal services, money matters, and more. TYVASO (treprostinil) 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 . Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change. covered medication, and/or OptumRx will offer information on the process to appeal the adverse decision. denied. MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate) Prior Authorization Hotline. EYSUVIS (loteprednol etabonate) Your health care provider will communicate with us directly, and generally within 14 days or less, you and your physician will be notified of a decision. VUITY (pilocarpine) Click on "Claims," "CPT/HCPCS Coding Tool," "Clinical Policy Code Search. 0000002567 00000 n Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. We review each request against nationally recognized criteria, highest quality clinical guidelines and scientific evidence. ROCKLATAN (netarsudil and latanoprost) Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod) 0000002527 00000 n 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. Drug list prices are set by the manufacturer, whereas cash prices fluctuate based on distribution costs that impact the pharmacies that fill the prescriptions. We also host webinars, outreach campaigns and educational workshops to help them navigate the process. Cost effective; You may need pre-authorization for your . TRIJARDY XR (empagliflozin, linagliptin, metformin) hb```b``mf`c`[ @Q{9 P@`mOU.Iad2J1&@ZX\2 6ttt `D> `g`QJ@ gg`apc7t3N``X tgD?>H7X570}``^ 0C7|^ '2000 G> HUMIRA (adalimumab) POMALYST (pomalidomide) What is a "formalized" weight management program? ** OptumRxs Senior Medical Director provides ongoing evaluation and quality assessment of d 1 0 obj For language services, please call the number on your member ID card and request an operator. KINERET (anakinra) LUMAKRAS (sotorasib) Wegovy should be used with a reduced calorie meal plan and increased physical activity. CINRYZE (C1 esterase inhibitor [human]) LUTATHERA (lutetium 1u 177 dotatate injection) 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. Health benefits and health insurance plans contain exclusions and limitations. SEYSARA (sarecycline) VERZENIO (abemaciclib) Links to various non-Aetna sites are provided for your convenience only. iMo::>91}h9 Wegovy will be used concomitantly with behavioral modification and a reduced-calorie diet . Members should discuss any matters related to their coverage or condition with their treating provider. 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 EVENITY (romosozumab-aqqg) Lack of information may delay The discussion, analysis, conclusions and positions reflected in the Clinical Policy Bulletins (CPBs), including any reference to a specific provider, product, process or service by name, trademark, manufacturer, constitute Aetna's opinion and are made without any intent to defame. REYVOW (lasmiditan) The number of medically necessary visits . ADUHELM (aducanumab-avwa) RADICAVA (edaravone) ZEPOSIA (ozanimod) CONTRAVE (bupropion and naltrexone) These clinical guidelines are frequently reviewed and updated to reflect best practices. ENJAYMO (sutimlimab-jome) Please use the updated forms found below and take note of the fax number referenced within the Drug Authorization Forms. VOSEVI (sofosbuvir/velpatasvir/voxilaprevir) startxref Our prior authorization process will see many improvements. 0000055627 00000 n QULIPTA (atogepant) 0000092908 00000 n 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. SOTYKTU (deucravacitinib) Step #1: Your health care provider submits a request on your behalf. KRYSTEXXA (pegloticase) 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. 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. KADCYLA (Ado-trastuzumab emtansine) Please select a letter to see drugs listed by that letter, or enter the name of the drug you wish to search for. SOLOSEC (secnidazole) VITAMIN B12 (cyanocobalamin injection) Antihemophilic Factor [recombinant] pegylated-aucl (Jivi) FASENRA (benralizumab) ZOMETA (zoledronic acid) <> COSELA (trilaciclib) allowed by state or federal law. %%EOF startxref The Food and Drug Administration (FDA) approved Vaxneuvance (pneumococcal 15-valent conjugate vaccine) for active immunization for the prevention of invasive disease caused by Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, 22F, 23F and 33F in adults 18 years of age and older. Pancrelipase (Pancreaze; Pertyze; Viokace) SILIQ (brodalumab) 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. TURALIO (pexidartinib) Coagulation Factor IX (Alprolix) In case of a conflict between your plan documents and this information, the plan documents will govern. EGRIFTA SV (tesamorelin) 0000008227 00000 n Links to various non-Aetna sites are provided for your convenience only. PLAQUENIL (hydroxychloroquine) ZORVOLEX (diclofenac) 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. *Praluent is typically excluded from coverage. Pegfilgrastim agents (Neulasta, Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo) The maintenance dose of Wegovy is 2.4 mg injected subcutaneously once weekly. RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn) VYVGART (efgartigimod alfa-fcab)