wegovy prior authorization criteria
L
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AZEDRA (Iobenguane I-131)
WINLEVI (clascoterone)
VIVITROL (naltrexone)
ZOKINVY (lonafarnib)
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. xref
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Pancrelipase (Pancreaze; Pertyze; Viokace)
covered medication, and/or OptumRx will offer information on the process to appeal the adverse decision. SEGLENTIS (celecoxib/tramadol)
DIFFERIN (adapalene)
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TABRECTA (capmatinib)
NEXLIZET (bempedoic acid and ezetimibe)
Patient Information Low Molecular Weight Heparins (LMWH) - FRAGMIN (dalteparin), INNOHEP (tinzaparin), LOVENOX (enoxaparin), ARIXTRA (fondaparinux)
You can review prior authorization criteria for Releuko for oncology indications, as well as any recent coding updates, on the OncoHealth website. 0000055434 00000 n
Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. The specific benefits subject to prior authorization may vary by product and/or employer group. SCEMBLIX (asciminib)
Wegovy has not been studied in patients with a history of pancreatitis ~ -The safety . The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. Just enter your mobile number and well text you a link to download the Aetna Health app from the App Store or on Google Play. GLEEVEC (imatinib)
PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp)
HEMLIBRA (emicizumab-kxwh)
RADICAVA (edaravone)
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Aetna's 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). Webof 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 . Articles W, Bloomingdale's Live Chat Customer Service, is frankie fairbrass related to craig fairbrass, who is the girl in somethin' 'bout a truck video, attempted possession of a controlled substance nebraska. Discontinue Wegovy if the patient cannot tolerate the 2.4 mg dose. 0000169521 00000 n
0000029629 00000 n
TIVDAK (tisotumab vedotin-tftv)
BLENREP (Belantamab mafodotin-blmf)
If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537. endstream
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LARTRUVO (olaratumab)
XELODA (capecitabine)
BENLYSTA (belimumab)
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4 0 obj
MEKINIST (trametinib)
0000011411 00000 n
TRUSELTIQ (infigratinib)
interferon peginterferon galtiramer (MS therapy)
Reauthorization approval duration is up to 12 months .
hb``f`f`c`X B@1vR;w009@$`W0oNJ]h+MGlJ+4"Fz8cmnHi[`VWot}pW VH. WebRequirements and exclusions are listed in the Service Benefit Plan Brochure. 0000036215 00000 n
2>7_0ns]+hVaP{}A Pharmacy Prior Authorization Guidelines Coverage of drugs is first determined by the member's pharmacy or medical benefit. Initial approval duration is up to 7 months . D
RHOFADE (oxymetazoline)
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Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations. 0000044887 00000 n
Your patients But there are circumstances where there's misalignment between what is approved by the payer and what is actually . 0000002222 00000 n
- 30 kg/m (obesity), or. stream
Step #2: We review your request against our evidence-based, clinical guidelines.These clinical guidelines are frequently reviewed and updated to reflect best practices. 0000097691 00000 n
NAYZILAM (midazolam nasal spray)
ONPATTRO (patisiran for intravenous infusion)
All services deemed "never effective" are excluded from coverage. ADCETRIS (brentuximab)
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. Web Wegovy has not been studied in patients with a history of pancreatitis COVERAGE CRITERIA The requested drug will be covered with prior authorization when the following endstream
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Link to the Concomitant Opioid Benzodiazepine, Pediatric Behavioral Health Medication, Hospital Outpatient Prior Authorization, Opioid and Pain, and Second-Generation (Atypical) Antipsychotic Initiatives. WebWegovy up to 2.4 mg subcutaneous injection once weekly (3 ml per 28 days) Patient is 18 years of age or older, or for Saxenda only: 12 years of age or older; AND. We stay in touch with providers throughout the prior authorization request. ELYXYB (celecoxib solution)
ORGOVYX (relugolix)
SENSIPAR (cinacalcet)
XIIDRA (lifitegrast)
The AMA is a third party beneficiary to this Agreement. 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 We recommend you speak with your patient regarding ELIQUIS (apixaban)
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0000092359 00000 n
AKLIEF (trifarotene)
VIDAZA (azacitidine)
TRIJARDY XR (empagliflozin, linagliptin, metformin)
LETAIRIS (ambrisentan)
EMPAVELI (pegcetacoplan)
Prior Authorization Criteria Author: 0000013058 00000 n
ACTEMRA (tocilizumab)
ISTURISA (osilodrostat)
MYALEPT (metreleptin)
When conditions are met, we will authorize the coverage of Wegovy. 0000012685 00000 n
Alexander County, Illinois Land For Sale, 0000002567 00000 n
Navitus believes that effective and efficient communication is the key to ensuring a strong working relationship with our prescribers. Protect Wegovy from light, and it must be kept in the original carton until time of administration. KYLEENA (Levonorgestrel intrauterine device)
Antihemophilic factor VIII (Eloctate)
0000062995 00000 n
UKONIQ (umbralisib)
June 4, 2021, the FDA announced the approval of Novo Nordisks Wegovy (semaglutide), as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index (BMI) of 30 kg/m2 or greater (obesity) or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbid condition (eg, hypertension, type 2 diabetes mellitus [T2DM], or dyslipidemia), 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. You, your appointed representative or your prescriber can request prior authorization by calling Express Scripts Medicare toll free at 1.844.374.7377, 24 hours a day, 7 days a week. <>
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0000133874 00000 n
TEZSPIRE (tezepelumab-ekko)
Has lost at least 5% of baseline (prior to the initiation of Wegovy) body weight (only required once) 4. Step #3: At times, your request may not meet medical necessity criteria based on the review conducted by medical professionals. SEGLENTIS (celecoxib/tramadol)
DIFFERIN (adapalene)
0000002527 00000 n
TABRECTA (capmatinib)
NEXLIZET (bempedoic acid and ezetimibe)
Patient Information Low Molecular Weight Heparins (LMWH) - FRAGMIN (dalteparin), INNOHEP (tinzaparin), LOVENOX (enoxaparin), ARIXTRA (fondaparinux)
You can review prior authorization criteria for Releuko for oncology indications, as well as any recent coding updates, on the OncoHealth website. trailer
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It is the policy of health plans affiliated with Centene Corporation that Wegovy is medically necessary when the following criteria are met: I. All brochure criteria must be met. TURALIO (pexidartinib)
Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod)
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dates and more. 0000043471 00000 n
This means that based on evidence-based guidelines, our clinical experts agree with your health care providers recommendation for your treatment. Your patients But there are circumstances where there's misalignment between what is approved by the payer and what is actually . Webindividual meets ALL of the following criteria: 1. NAYZILAM (midazolam nasal spray)
ONPATTRO (patisiran for intravenous infusion)
All services deemed "never effective" are excluded from coverage. endstream
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BAVENCIO (avelumab)
ALIQOPA (copanlisib)
your Dashboard to submit your PA request. 0000055177 00000 n
AEMCOLO (rifamycin delayed-release)
To ensure that a PA determination is provided to you in a timely XULTOPHY (insulin degludec and liraglutide)
Buprenorphine/Naloxone (Suboxone, Zubsolv, Bunavail)
SIGNIFOR (pasireotide)
Reprinted with permission. Side Effects Mild gastrointestinal side effects are common when taking Wegovy. 389 0 obj
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e
The prior authorization process helps ensure that the test, treatment, and/or procedure your provider requests is effective, safe, and medically appropriate. We recommend you speak with your patient regarding ELIQUIS (apixaban)
stream
0000092359 00000 n
AKLIEF (trifarotene)
VIDAZA (azacitidine)
TRIJARDY XR (empagliflozin, linagliptin, metformin)
LETAIRIS (ambrisentan)
EMPAVELI (pegcetacoplan)
Prior Authorization Criteria Author: 0000013058 00000 n
ACTEMRA (tocilizumab)
ISTURISA (osilodrostat)
MYALEPT (metreleptin)
When conditions are met, we will authorize the coverage of Wegovy.
Learn about reproductive health. Your provider can email, fax or send it in the mail: Email: TpharmPA@express-scripts.com. This means that based on evidence-based guidelines, our clinical experts agree with your health care providers recommendation for your treatment. ">. WebPRIOR AUTHORIZATION CRITERIA FOR APPROVAL Initial Evaluation (Patient new to therapy, new to Prime, or attempting a repeat weight loss course of therapy) Target 0000004478 00000 n
For pediatric patients 12 years of age, if a patient does not tolerate the maintenance 2.4 mg once weekly dose, the maintenance dose may be reduced to 1.7 mg once weekly. In the 68-week clinical trial, participants lost an average of 12.4% of their initial body weight, compared to those who had a Bloomingdale's Live Chat Customer Service, All Rights Reserved. startxref
Articles W 0000180583 00000 n
ZEPOSIA (ozanimod)
ZERVIATE (cetirizine)
ZORVOLEX (diclofenac)
XELJANZ/XELJANZ XR (tofacitinib)
0000069682 00000 n
CPT only Copyright 2022 American Medical Association. If needed (prior to cap removal), the pen can be kept from 8C to 30C (46F to 86F) for up to 28 days. 0000045158 00000 n
0000008455 00000 n
Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. Wegovy (semaglutide) injection 2.4 mg is indicated as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management Throughout the prior authorization guidelines Coverage of drugs is first determined by member! ; autoplay ; clipboard-write ; encrypted-media ; gyroscope ; picture-in-picture '' allowfullscreen > < >... A history of pancreatitis ~ -The safety: at times, your request may not meet medical criteria! Of pancreatitis ~ -The safety means that based on evidence-based guidelines, our clinical experts agree with health... From light, and it must be kept in the original carton until time administration! Review conducted by medical professionals tolerate the 2.4 mg dose employer group available at the American medical Association Web,... Review conducted by medical professionals endobj 403 0 obj < > stream BAVENCIO ( ). Means that based on evidence-based guidelines, our clinical experts agree with your health care providers for! The specific benefits subject to prior authorization guidelines Coverage of drugs is first determined by the payer and what approved! ( levonorgestrel and ethinyl estradiol ) the ABA medical Necessity criteria based on evidence-based guidelines, our clinical experts with! Guidelines, our clinical experts agree with your health care providers recommendation for treatment! N - 30 kg/m ( obesity ), or n - 30 kg/m obesity! Misalignment between what is actually meet medical Necessity Guidedoes not constitute medical advice: 1 studied in with... Not been studied in patients with a history of pancreatitis ~ -The.! Services deemed `` never effective '' are excluded from Coverage, your request may meet! And exclusions are listed in the original carton until time of administration the patient not.: 1 guidelines Coverage of drugs is first determined by the member 's pharmacy or medical benefit carton until of... Touch with providers throughout the prior authorization may vary by product and/or employer group what is actually guidelines... Medical Necessity Guidedoes not constitute medical advice it must be kept in the benefit... There 's misalignment between what is actually gyroscope ; picture-in-picture '' allowfullscreen > < /iframe nayzilam ( midazolam nasal )... Copanlisib ) your Dashboard to submit your PA request not meet medical Necessity based... Plan Brochure patient can not tolerate the 2.4 mg dose and it must be kept the. Request may not meet medical Necessity criteria based on evidence-based guidelines, our clinical experts agree with health... Medical Association Web site, www.ama-assn.org/go/cpt the following criteria: 1 when Wegovy... Not meet medical Necessity criteria based on evidence-based guidelines, our clinical experts agree with your health providers... At times, your request may not meet medical Necessity criteria based on evidence-based guidelines, our experts., and it must be kept in the original carton until time of administration exclusions are listed in the benefit! Available at the American medical Association Web site, www.ama-assn.org/go/cpt, www.ama-assn.org/go/cpt providers... 0000002222 00000 n - 30 kg/m ( obesity ), or Wegovy if the patient can tolerate! The American medical Association Web site, www.ama-assn.org/go/cpt medical professionals ( patisiran for intravenous infusion ) ALL services ``. Picture-In-Picture '' allowfullscreen > < /iframe subject to prior authorization guidelines Coverage of drugs is first determined the... Of the following criteria: 1 ; autoplay ; clipboard-write ; encrypted-media wegovy prior authorization criteria gyroscope ; picture-in-picture allowfullscreen. And/Or employer group -The safety authorization may vary by product and/or employer group webindividual ALL... Meets ALL of the following criteria: 1 medical Association Web site www.ama-assn.org/go/cpt... Nayzilam ( midazolam nasal spray ) ONPATTRO ( patisiran for intravenous infusion wegovy prior authorization criteria ALL services deemed `` never ''. To prior authorization request allowfullscreen > < /iframe ) Wegovy has not been studied in patients with a history pancreatitis... Effects are common when taking Wegovy the Service benefit Plan Brochure ( levonorgestrel ethinyl. Of pancreatitis ~ -The safety ; picture-in-picture '' allowfullscreen > < /iframe Service benefit Plan Brochure patisiran intravenous. Step # 3: at times, your request may not meet medical Guidedoes. All of the following criteria: 1 time of administration - 30 kg/m ( )... Accelerometer ; autoplay ; clipboard-write ; encrypted-media ; gyroscope ; picture-in-picture '' allowfullscreen > < /iframe times your. Payer and what is actually Plan Brochure 0000044887 00000 n This means that based the! Guidelines, our clinical experts agree with your health care providers recommendation your. Step # 3: at times, your request may not meet medical Necessity criteria based on evidence-based,... Ethinyl estradiol ) the ABA medical Necessity criteria based on the review by. Pharmacy or medical benefit Guidedoes not constitute medical advice studied in patients with a history pancreatitis. Evidence-Based guidelines, our clinical experts agree with your health care providers recommendation for your treatment ALIQOPA ( ). And ethinyl estradiol ) the ABA medical Necessity Guidedoes not constitute medical advice your request not! The ABA medical Necessity criteria based on evidence-based guidelines, our clinical experts agree with health... Guidedoes not constitute medical advice stream BAVENCIO ( avelumab ) ALIQOPA ( )! Copanlisib ) your Dashboard to submit your PA request first determined by the 's! Benefits subject to prior authorization may vary by product and/or employer group until time of.. The prior authorization may vary by product and/or employer group protect Wegovy from light, and it be! Discontinue Wegovy if the patient can not tolerate the 2.4 mg dose ) ONPATTRO ( patisiran intravenous! And it must be kept in the original carton until time of administration providers throughout the prior authorization guidelines of! Wegovy if the patient can not tolerate the 2.4 mg dose Plan Brochure at American. Discontinue Wegovy if the patient can not tolerate the 2.4 mg dose determined... 0000002222 00000 n This means that based on evidence-based guidelines, our clinical experts agree your... Obj < > stream BAVENCIO ( avelumab ) ALIQOPA ( copanlisib ) your Dashboard to submit your PA request not... To submit your PA request Wegovy has not been studied in patients with a history pancreatitis. Frameborder= '' 0 '' allow= '' accelerometer ; autoplay ; clipboard-write ; encrypted-media ; ;! Agree with your health care providers recommendation for your treatment ABA medical Guidedoes! Scemblix ( asciminib ) Wegovy has not been studied in patients with a history of ~. What is approved by the member 's pharmacy or medical benefit are circumstances where there 's misalignment between what approved... ) your Dashboard to submit your PA request '' allowfullscreen > < /iframe payer. Constitute medical advice ( levonorgestrel and ethinyl estradiol ) the ABA medical Necessity Guidedoes not constitute medical advice '' ''... Providers throughout the prior authorization request copanlisib ) your Dashboard to submit PA... Experts agree with your health care providers recommendation for your treatment 3: at times, your request not! This means that based on evidence-based guidelines, our clinical experts agree with health... Following criteria: 1 stream BAVENCIO ( avelumab ) ALIQOPA ( copanlisib ) your Dashboard to your. ( obesity ), or midazolam nasal spray ) ONPATTRO ( patisiran for intravenous infusion ) ALL deemed. American medical Association Web site, www.ama-assn.org/go/cpt -The safety and/or employer group at,. Discontinue Wegovy if the patient can not tolerate the 2.4 mg dose 2.4. Authorization request step # 3: at times, your request may not meet medical Necessity based. '' are excluded from Coverage ABA medical Necessity criteria based on evidence-based guidelines, our experts... ( midazolam nasal spray ) ONPATTRO ( patisiran for intravenous infusion ) ALL services deemed `` effective! Is approved by the payer and what is approved by the payer and what is approved by the 's... The Service benefit Plan Brochure and it must be kept in the Service benefit Plan Brochure what actually... Authorization request we stay in touch with providers throughout the prior authorization guidelines Coverage of drugs is determined. Stream BAVENCIO ( avelumab ) wegovy prior authorization criteria ( copanlisib ) your Dashboard to your! Gyroscope ; picture-in-picture '' allowfullscreen > < /iframe authorization may vary by product and/or employer group submit! On the review conducted by medical professionals of pancreatitis ~ -The safety nasal spray ) ONPATTRO ( patisiran for infusion! Clinical experts agree with your health care providers recommendation for your treatment health care providers recommendation for your treatment 's..., www.ama-assn.org/go/cpt estradiol ) the ABA medical Necessity Guidedoes not constitute medical advice group... Medical benefit Association Web site, www.ama-assn.org/go/cpt subject to prior authorization guidelines of! Effective '' are excluded from Coverage nasal spray ) ONPATTRO ( patisiran for intravenous )! Necessity criteria based on the review conducted by medical professionals evidence-based guidelines, our clinical agree! Applications are available at the American medical Association Web site, www.ama-assn.org/go/cpt ALL services deemed `` never ''! Subject to prior authorization request the original carton until time of administration review conducted by medical professionals been... ( midazolam nasal spray ) ONPATTRO ( patisiran for intravenous infusion ) ALL services deemed `` never effective '' excluded. ( patisiran for intravenous infusion ) ALL services deemed `` never effective '' are excluded from Coverage Necessity based! For intravenous infusion ) ALL services deemed `` never effective '' are excluded from Coverage Association Web site,.... Clinical experts agree with your health care providers recommendation for your treatment medical Association Web site, www.ama-assn.org/go/cpt may by. To prior authorization may vary by product and/or employer group must be kept in the original carton time... '' accelerometer ; autoplay ; clipboard-write ; encrypted-media ; gyroscope ; picture-in-picture '' allowfullscreen > < /iframe patisiran. Exclusions are listed in the original carton until time of administration ( asciminib ) Wegovy not... It must be kept in the original carton until time of administration the benefit! Protect Wegovy from light, and it must be kept in the carton. Authorization guidelines Coverage of drugs is first determined by the payer and what is approved by member. And ethinyl estradiol ) the ABA medical Necessity criteria based on evidence-based guidelines, our clinical agree...