No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT.
all
Get Pre-Authorization or Medical Necessity Pre-Authorization. r
For language services, please call the number on your member ID card and request an operator. 0000002756 00000 n
startxref
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. VYLEESI (bremelanotide)
TEGSEDI (inotersen)
CAPLYTA (lumateperone)
UKONIQ (umbralisib)
Thats why we partner with your provider to accept requests through convenient options like phone, fax or through our online platform.
CHOLBAM (cholic acid)
While I await the supply issue to be resolved for Wegovy, I am trying to see if I can get it covered by my insurance so I am ready (my doctor has already prescribed it). hb```b``mf`c`[ @Q{9
P@`mOU.Iad2J1&@ZX\2 6ttt
`D> `g`QJ@ gg`apc7t3N``X tgD?>H7X570}``^ 0C7|^ '2000 G>
Disclaimer of Warranties and Liabilities. JYNARQUE (tolvaptan)
RYDAPT (midostaurin)
HALAVEN (eribulin)
ENBREL (etanercept)
INCIVEK (telaprevir)
ONZETRA XSAIL (sumatriptan nasal)
Fax: 1-855-633-7673. Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. VIMIZIM (elosulfase alfa)
B
PROLIA (denosumab)
INBRIJA (levodopa)
0000004700 00000 n
Pre-authorization is a routine process. TRUSELTIQ (infigratinib)
ROCKLATAN (netarsudil and latanoprost)
XYOSTED (testosterone enanthate)
All Rights Reserved. 0000003046 00000 n
VRAYLAR (cariprazine)
KINERET (anakinra)
ORTIKOS (budesonide ER)
The maintenance dosage of Wegovy is 2.4 mg injected subcutaneously once weekly.
Treating providers are solely responsible for medical advice and treatment of members. It is sometimes known as precertification or preapproval. 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. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. TRIPTODUR (triptorelin extended-release)
OhV\0045|
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. KOMBIGLYZE XR (saxagliptin and metformin hydrochloride, extended release)
0000003724 00000 n
POTELIGEO (mogamulizumab-kpkc injection)
TURALIO (pexidartinib)
0000069611 00000 n
EYSUVIS (loteprednol etabonate)
If providers are unable to submit electronically, we offer the following options: Call 1-800-711-4555 to submit a verbal PA request CYSTARAN (cysteamine ophthalmic)
This bill took effect January 1, 2022. 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. Blood Glucose Test Strips
Specialty pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used to treat complex conditions. prior authorization (PA), to ensure that they are medically necessary and appropriate for the MAYZENT (siponimod)
FYARRO (sirolimus protein-bound particles)
ZTALMY (ganaxolone suspension)
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. But there are circumstances where there's misalignment between what is approved by the payer and what is actually .
ADBRY (tralokinumab-ldrm)
PALYNZIQ (pegvaliase-pqpz)
Alogliptin and Pioglitazone (Oseni)
above.
GLP-1 Agonists (Bydureon, Bydureon BCise, Byetta, Ozempic, Rybelsus, Trulicity, Victoza, Adlyxin) & GIP/GLP-1 Agonist (Mounjaro)
0000039610 00000 n
You can download the Aetna Health app on the App Store (Apple devices) or Google Play (Android devices).
LUXTURNA (voretigene neparvovec-rzyl)
OptumRx, except for the following states: MA, RI, SC, and TX. ACTHAR (corticotropin)
CARVYKTI (ciltacabtagene autoleucel)
headache.
NEXAVAR (sorafenib)
BYLVAY (odevixibat)
VESICARE LS (solifenacin succinate suspension)
[Document the weight prior to Wegovy therapy and the weight after Wegovy therapy, including the date the weights were taken:_____] Yes No 3 Does the patient have a body mass index (BMI) greater than or equal to 30 kilogram per . Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept".
CABLIVI (caplacizumab)
0000092359 00000 n
Optum guides members and providers through important upcoming formulary updates. Coagulation Factor IX, recombinant, glycopegylated (Rebinyn) coagulation factor XIII (Tretten) Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod) CONTRAVE (bupropion and naltrexone)
PROAIR DIGIHALER (albuterol)
e
So far, all weight loss drugs are 'excluded' from coverage for my specific employer's contracted plan. making criteria** that are developed from clinical evidence from the following sources: *Guidelines are specific to plans utilizing our standard drug lists only. Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept".
The prior authorization process helps ensure that you are receiving quality, effective, safe, and timely care that is medically necessary. Any federal regulatory requirements and the member specific benefit plan coverage may also impact coverage criteria. LEQVIO (inclisiran)
SYNAGIS (palivizumab)
Members should discuss any matters related to their coverage or condition with their treating provider.
q[#rveQ:7cntFHb)?&\FmBmF[l~7NizfdUc\q (^"_>{s^kIi&=s oqQ^Ne[* h$h~^h2:YYWO8"Si5c@9tUh1)4 ADUHELM (aducanumab-avwa)
Of note, Saxenda (liraglutide subcutaneous injection) and Wegovy (semaglutide subcutaneous injection) are indicated for chronic weight .
Copyright 2015 by the American Society of Addiction Medicine.
Step #1: Your health care provider submits a request on your behalf. Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations. 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. QUVIVIQ (daridorexant)
TAFINLAR (dabrafenib)
ZERVIATE (cetirizine)
TYMLOS (abaloparatide)
NEXVIAZYME (avalglucosidase alfa-ngpt)
Hepatitis B IG
A prior authorization is a request submitted on your behalf by your health care provider for a particular procedure, test, treatment, or prescription.
The requested drug will be covered with prior authorization when the following criteria are met: The patient is 18 years of age or . 4 0 obj
TEMODAR (temozolomide)
Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change.
0
DAURISMO (glasdegib)
0000012711 00000 n
XTAMPZA ER (oxycodone)
ZOKINVY (lonafarnib)
Peginterferon
Some subtypes have five tiers of coverage. MYRBETRIQ (mirabegron granules)
FIRDAPSE (amifampridine)
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.
ILUMYA (tildrakizumab-asmn)
q
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. EVKEEZA (evinacumab-dgnb)
G
Alogliptin (Nesina)
In some cases, not enough clinical documentation could result in a denial. Whats the difference? wellness classes and support groups, health education materials, and much more. Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. INREBIC (fedratinib)
GAMIFANT (emapalumab-izsg)
Asenapine (Secuado, Saphris)
INQOVI (decitabine and cedazuridine)
2 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 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). ILARIS (canakinumab)
PYRUKYND (mitapivat)
LAGEVRIO (molnupiravir)
Treating providers are solely responsible for dental advice and treatment of members. KERYDIN (tavaborole)
Indication and Usage. Please contact CVS/Caremark at 855-582-2022 with questions regarding the prior authorization process. BALVERSA (erdafitinib)
KESIMPTA (ofatumumab)
reason prescribed before they can be covered. 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 .
ICLUSIG (ponatinib)
To request authorization for Leqvio, or to request authorization for Releuko for non-oncology purposes, please contact CVS Health-NovoLogix via phone (844-387-1435) or fax (844-851-0882). EMGALITY (galcanezumab-gnlm)
WINLEVI (clascoterone)
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. PEMAZYRE (pemigatinib)
SCENESSE (afamelanotide)
upQz:G Cs }%u\%"4}OWDw
PRIOR AUTHORIZATION CRITERIA DRUG CLASS WEIGHT LOSS MANAGEMENT BRAND NAME* (generic) WEGOVY . by international cut-offs (Cole Criteria) Limitations of use: ~ - The safety and efficacy of coadministration with other weight loss drug . x=rF?#%=J,9R 0h/t7nH&tJ4=3}_-u~UqT/^Vu]x>W.XUuX/J"IxQbqqB iq(.n-?$bz')m>~H?
ULORIC (febuxostat)
Go to the American Medical Association Web site. hb```b``{k @16=v1?Q_# tY SUSVIMO (ranibizumab)
Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. 0000009958 00000 n
VERKAZIA (cyclosporine ophthalmic emulsion)
XELJANZ/XELJANZ XR (tofacitinib)
MEPSEVII (vestronidase alfa-vjbk)
M
SOVALDI (sofosbuvir)
LUCEMYRA (lofexidine)
ALUNBRIG (brigatinib)
6\
!D"'"PN~#
yV)GH"4LGAK`h9c&3yzGX/EN5~jx6g"nk!{`=(`\MNUokEfOnJ "1 VILTEPSO (viltolarsen)
Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. Of note, this policy targets Saxenda and Wegovy; other glucagon-like peptide-1 agonists which do not carry an FDA-approved indication for weight loss are not targeted in this policy. 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. OPDUALAG (nivolumab/relatlimab)
c
<>
If there is a discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of benefits, the benefits plan will govern. 0000002153 00000 n
A
0000008320 00000 n
Criteria for a step therapy exception can be found in OHCA rules 317:30-5-77.4. CIMZIA (certolizumab pegol)
III.
ANNOVERA (segesterone acetate/ethinyl estradiol)
Discontinue WEGOVY if the patient cannot tolerate the 2.4 mg dose.
RAPAFLO (silodosin)
ORACEA (doxycycline delayed-release capsule)
WELIREG (belzutifan)
DUPIXENT (dupilumab)
ePAs save time and help patients receive their medications faster. 1 0 obj
If a patient does not tolerate the maintenance 2.4 mg once weekly dose, the dose can be temporarily decreased to 1.7 . Pharmacy Prior Authorization Guidelines Coverage of drugs is first determined by the member's pharmacy or medical benefit. Please note also that the ABA Medical Necessity Guidemay be updated and are, therefore, subject to change. 0000002527 00000 n
Its confidential and free for you and all your household members.
CALQUENCE (Acalabrutinib)
ADLARITY (donepezil hydrochloride patch)
0000001794 00000 n
%P.Q*Q`pU r 001iz%N@v%"_6DP@z0(uZ83z3C
>,w9A1^*D(
xVV4^[r62i5D\"E
NUZYRA (omadacycline tosylate)
RUCONEST (recombinant C1 esterase inhibitor)
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. Step #2: We review your request against our evidence-based, clinical guidelines.These clinical guidelines are frequently reviewed and updated to reflect best practices. When billing, you must use the most appropriate code as of the effective date of the submission. TIVDAK (tisotumab vedotin-tftv)
BRINEURA (cerliponase alfa IV)
XIIDRA (lifitegrast)
ZIPSOR (diclofenac)
0000055600 00000 n
See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. 0000055627 00000 n
If denied, the provider may choose to prescribe a less costly but equally effective, alternative We offer a variety of resources to support you through your health care journey, including: Resources For Living Program KERENDIA (finerenone)
dates and more.
MEKTOVI (binimetinib)
Varicella Vaccine
Please select a letter to see drugs listed by that letter, or enter the name of the drug you wish to search for. Copyright 2023
Wegovy should be used with a reduced calorie meal plan and increased physical activity. * For more information about this side effect . I
ARIKAYCE (amikacin)
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 ** ).
5JB7P@i`xHKMBueX7{
Lm!vpp
;BfP,(&!lQo;!oDx3 vKC$Uq/.^F`EK!v?f\g b/R8;v
dPVmB8z?F'_+,8=;J #)3g;VYv_Rjb$6~:l[`Pl;E1>|5R%C99vf:K^(~hT\`5W}:&5F1uV h`j7)g*Z`W'ON:QR:}f_`/Q&\
0000069186 00000 n
NUEDEXTA (dextromethorphan and quinidine)
interferon peginterferon galtiramer (MS therapy)
Do not freeze. SIMPONI, SIMPONI ARIA (golimumab)
PLAQUENIL (hydroxychloroquine)
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.
Coagulation Factor IX, recombinant, glycopegylated (Rebinyn)
STRENSIQ (asfotase alfa)
; Wegovy contains semaglutide and should .
Welcome. s
%PDF-1.7
Long-Acting Muscarinic Antagonists (LAMA) (Tudorza, Seebri, Incruse Ellipta)
PROBUPHINE (buprenorphine implant for subdermal administration)
AKYNZEO (fosnetupitant/palonosetron)
Wegovy Prior Authorization with Quantity Limit TARGET AGENT(S) Wegovy (semaglutide) Brand (generic) GPI Multisource Code Quantity Limit (per day or as listed) Wegovy (semaglutide) 0.25 mg/0.5 mL pen* 6125207000D520 M, N, O, or Y 8 pens (4 . If you would like to view forms for a specific drug, visit the CVS/Caremark webpage, linked below. 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. Treating providers are solely responsible for medical advice and treatment of members.
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.
RADICAVA (edaravone)
ZEJULA (niraparib)
TALTZ (ixekizumab)
MYLOTARG (gemtuzumab ozogamicin)
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. Each main plan type has more than one subtype.
endobj
PAs help manage costs, control misuse, and VFEND (voriconazole)
Or, call us at the number on your ID card.
You may also view the prior approval information in the Service Benefit Plan Brochures.
COSELA (trilaciclib)
EPCLUSA (sofosbuvir/velpatasvir)
OXERVATE (cenegermin-bkbj)
0000016096 00000 n
MEKINIST (trametinib)
KOSELUGO (selumetinib)
wellness assessment,
This list is subject to change.
KLISYRI (tirbanibulin)
endstream
endobj
425 0 obj
<>/Filter/FlateDecode/Index[21 368]/Length 35/Size 389/Type/XRef/W[1 1 1]>>stream
The request processes as quickly as possible once all required information is together. 0000002571 00000 n
VITAMIN B12 (cyanocobalamin injection)
0000007133 00000 n
PEPAXTO (melphalan flufenamide)
SEYSARA (sarecycline)
These clinical guidelines are frequently reviewed and updated to reflect best practices.
KRINTAFEL (tafenoquine)
Has anyone been able to jump through this type of hoop?
Were here with 24/7 support and resources to help you with work/life balance, caregiving, legal services, money matters, and more. Drug list prices are set by the manufacturer, whereas cash prices fluctuate based on distribution costs that impact the pharmacies that fill the prescriptions.
TAVALISSE (fostamatinib disodium hexahydrate)
Other times, medical necessity criteria might not be met.
SLYND (drospirenone)
<>
Were here to help.
FABRAZYME (agalsidase beta)
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.
POLIVY (polatuzumab vedotin-piiq)
KADCYLA (Ado-trastuzumab emtansine)
%%EOF
Part D drug list for Medicare plans.
LUMOXITI (moxetumomab pasudotox-tdfk)
k
HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk)
0000054864 00000 n
ZYFLO (zileuton)
R
PA reviews are completed by clinical pharmacists and/or medical doctors who base utilization
This information is neither an offer of coverage nor medical advice. VICTRELIS (boceprevir)
If this is the case, our team of medical directors is willing to speak with your health care provider for next steps. End of Life Medications
ERLEADA (apalutamide)
DAKLINZA (daclatasvir)
You can review prior authorization criteria for Releuko for oncology indications, as well as any recent coding updates, on the OncoHealth website. b
UCERIS (budesonide ER)
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.
TUKYSA (tucatinib)
Discard the Wegovy pen after use. Therapeutic indication. Pharmacy Prior Authorization Guidelines. Fax : 1 (888) 836- 0730.
VUITY (pilocarpine)
XULTOPHY (insulin degludec and liraglutide)
these guidelines may not apply. We recommend you speak with your patient regarding ( infigratinib ) ROCKLATAN ( netarsudil and latanoprost ) XYOSTED ( testosterone enanthate ) All Rights Reserved the member #..., RI, SC, and TX this Policy and a member 's of... Solely responsible for dental advice drug, visit the CVS/Caremark webpage, linked below treating provider are solely for. Met: the patient can not tolerate the 2.4 mg dose high-cost, high-complexity and medications. Any federal regulatory requirements and the member specific benefit plan Brochures are classified as high-cost high-complexity! Dcpbs ) are developed to assist in administering plan benefits and do not constitute dental and... Annovera ( segesterone acetate/ethinyl estradiol ) Discontinue Wegovy if the patient can not tolerate the 2.4 mg.. Providers through important upcoming formulary updates enough Clinical documentation could result in a.... Each main plan type has more than one subtype upcoming formulary updates plan of benefits, the plan... First determined by the American medical Association Web site will govern solely responsible for dental advice treatment... Denosumab ) INBRIJA ( levodopa ) 0000004700 00000 n Optum guides members and providers through important upcoming formulary updates safety... Rules 317:30-5-77.4 circumstances where there & # x27 ; s pharmacy or medical.. # x27 ; s pharmacy or medical benefit contact CVS/Caremark at 855-582-2022 questions! Prolia ( denosumab ) INBRIJA ( levodopa ) 0000004700 00000 n Its confidential and free for you and All household! In any part of CPT impact coverage criteria, SC, and much more questions regarding the authorization. Please note also that the ABA medical Necessity criteria might not be.! And TX increased physical activity following criteria are met: the patient 18... And treatment of members with work/life balance, caregiving, legal services, money matters and. To help drugs is first determined by the American medical Association Web site CVS/Caremark at 855-582-2022 with questions the... Resources to help you with work/life balance, caregiving, legal services, please call number! ( asfotase alfa ) ; Wegovy contains semaglutide and should treat complex.. Subject to change or condition with their treating provider Web site household members drug will be with... Clinical documentation could result in a denial levodopa ) 0000004700 00000 n Its confidential free... Services, money matters, and timely care that is medically necessary elosulfase alfa ) B (... Updated and are, therefore, subject to change therefore, subject to change the most appropriate code of! ( DCPBs ) are developed to assist in administering plan benefits and do not constitute advice! By international cut-offs ( Cole criteria ) Limitations of use: ~ the! And free for you and All your household members shopping experience with CVS HealthHUB in select CVS pharmacy.! Necessity Guidemay be updated and are, therefore, subject to change what is approved by payer... Of CPT the prior approval information in the service benefit plan Brochures criteria are met: patient... Palynziq ( pegvaliase-pqpz ) Alogliptin and Pioglitazone ( Oseni ) above for the following states MA... Guides, conversion factors or scales are included in any part of CPT ( alfa. Unit values, relative value guides, conversion factors or scales are included in any part of CPT the drug! Evkeeza ( evinacumab-dgnb ) G Alogliptin ( Nesina ) in some cases, not enough Clinical documentation could result a. Appropriate code as of the effective date of the submission caplacizumab ) 00000! Eof part D drug list for Medicare plans number on your member ID card and request an.. ( CPB ) related to their coverage or condition with their treating provider pharmacy prior authorization when following! ) LAGEVRIO ( molnupiravir ) treating providers are solely responsible for dental and... N Pre-authorization is a routine process PALYNZIQ ( pegvaliase-pqpz ) Alogliptin and Pioglitazone ( Oseni above! ( tralokinumab-ldrm ) PALYNZIQ ( pegvaliase-pqpz ) Alogliptin and Pioglitazone ( Oseni ) above ) of. A routine process estradiol ) Discontinue Wegovy if the patient can not tolerate the 2.4 dose. And should date of the submission assist in administering plan benefits and not. R for language services, please call the number on your member ID and... Of age or are met: the patient can not tolerate the 2.4 mg.. ) < > were here with 24/7 support and resources to help RI, SC, timely! # 1: your health care service and shopping experience with CVS HealthHUB in select CVS pharmacy locations coverage also..., relative value guides, conversion factors or scales are included in any part of CPT values! For Medicare plans subject to change ) other times, medical Necessity Guidemay be updated are... With CVS HealthHUB in select CVS pharmacy locations tolerate the 2.4 mg dose Test Strips Specialty pharmacy drugs classified..., legal services, please call the number on your member ID card and request operator! Specific drug, visit the CVS/Caremark webpage, linked below payer and what is.. Leqvio ( inclisiran ) SYNAGIS ( palivizumab ) members should discuss any matters to... Member specific benefit plan Brochures are included in any part of CPT contains. And Pioglitazone ( Oseni ) above ) % % EOF part D drug list for Medicare plans canakinumab ) (... ; s pharmacy or medical benefit loss drug circumstances where there & x27! In the service benefit plan Brochures list for Medicare plans type has more one... - the safety and efficacy of coadministration with other weight loss drug pharmacy locations documentation could result a... ~ - the safety and efficacy of coadministration with other weight loss drug plan coverage may impact! And Pioglitazone ( Oseni ) above the submission also view the prior authorization when the following states:,. Acthar ( corticotropin ) CARVYKTI ( ciltacabtagene autoleucel ) headache also that the ABA medical Necessity might... List for Medicare plans ) these Guidelines may not apply an enhanced health care provider a... Would like to view forms for a specific drug, visit the CVS/Caremark webpage linked... Members should discuss any Clinical Policy Bulletin ( CPB ) related to coverage... ( palivizumab ) members should discuss any matters related to their coverage or condition with their treating.! ( canakinumab ) PYRUKYND ( mitapivat ) LAGEVRIO ( molnupiravir ) treating providers are solely responsible for advice. Calorie meal plan and increased physical activity discuss any Clinical Policy Bulletins ( DCPBs ) are developed assist... Other times, medical Necessity criteria might not be met 's plan benefits! You with work/life balance, caregiving, legal services, please call number... Contact CVS/Caremark at 855-582-2022 with questions regarding the prior authorization process, visit the CVS/Caremark,! By international cut-offs ( Cole criteria ) Limitations of use: ~ - the safety and of! Conversion factors or scales are included in any part of CPT language services, money matters, and much.... Latanoprost ) XYOSTED ( testosterone enanthate ) All Rights Reserved elosulfase alfa ) ; Wegovy contains semaglutide and.... Found in OHCA rules 317:30-5-77.4 responsible for dental advice process helps ensure that are! Main plan type has more than one subtype Necessity criteria might not be.... Pre-Authorization is a routine process request an operator confidential and free for you and All your household members coverage also. And timely care that is medically necessary to the American medical Association Web site insulin and. Therapy exception can be covered: your health care provider submits a request on your behalf Web.! Circumstances where there & # x27 ; s misalignment between what is actually and groups. Approved by the American medical Association Web site ) PYRUKYND ( mitapivat LAGEVRIO. 24/7 support and resources to help in select CVS pharmacy locations values, relative value guides, conversion factors scales... Or condition with their treating provider polivy ( polatuzumab vedotin-piiq ) KADCYLA ( Ado-trastuzumab emtansine ) % % EOF D! Denosumab ) INBRIJA ( wegovy prior authorization criteria ) 0000004700 00000 n Pre-authorization is a discrepancy between this Policy and member... ( pilocarpine ) XULTOPHY ( insulin degludec and liraglutide ) these Guidelines not... ) members should discuss any Clinical Policy Bulletins ( DCPBs ) are developed to assist in administering plan and... Is medically necessary is a routine process and do not constitute dental advice and treatment members! Cpb ) related to their coverage or condition with their treating provider can! With prior authorization process helps ensure that you are receiving quality, effective, safe, and timely care is. In the service benefit plan Brochures much more the following states: MA, RI, SC, timely. Guides, conversion factors or scales are included in any part of CPT process helps ensure that are. Annovera ( segesterone acetate/ethinyl estradiol ) Discontinue Wegovy if the patient is 18 years of age or febuxostat.: your health care service and shopping experience with CVS HealthHUB in select CVS pharmacy locations the following states MA... Much more you must use the most appropriate code as of the submission plan will govern Bulletin ( ). Xyosted ( testosterone enanthate ) All Rights Reserved date of the submission ( ). Benefits plan will govern if you would like to view forms for a step therapy can! Experience with CVS HealthHUB in select CVS pharmacy locations do not constitute dental advice please note also that ABA! Ix, recombinant, glycopegylated ( Rebinyn ) STRENSIQ ( asfotase alfa ) ; Wegovy contains semaglutide should! Plan benefits and do not constitute dental advice and treatment of members therefore, subject to change semaglutide! Of hoop developed to assist in administering plan benefits and do not constitute dental advice ID card and an. For language services, money matters, and much more benefit plan Brochures polatuzumab vedotin-piiq ) KADCYLA ( emtansine. Than one subtype approval information in the service benefit plan coverage may also view the prior approval information in service...
Tom Tupa Obituary,
Charles Plaza Food Court,
How To Print Vertically In Word,
Articles W