wegovy prior authorization criteria

Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations. 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. In doing so, CVS/Caremark will be able to decide whether or not the requested prescription is included in the patient's insurance plan. VOSEVI (sofosbuvir/velpatasvir/voxilaprevir) The member's benefit plan determines coverage. SUNOSI (solriamfetol) CYSTARAN (cysteamine ophthalmic) MYRBETRIQ (mirabegron granules) interferon peginterferon galtiramer (MS therapy) Wegovy has not been studied in patients with a history of pancreatitis ~ -The safety . : OFEV (nintedanib) RANEXA, ASPRUZYO (ranolazine) Pancrelipase (Pancreaze; Pertyze; Viokace) 0000001076 00000 n ACTIMMUNE (interferon gamma-1b injection) QELBREE (viloxazine extended-release) BALVERSA (erdafitinib) RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn) 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). 0000000016 00000 n Filgrastim agents (Nivestym, Zarxio, Neupogen, Granix, Releuko) Hyaluronic Acid derivatives (Synvisc, Hyalgan, Orthovisc, Euflexxa, Supartz) INVELTYS (loteprednol etabonate) ! Z3mo5&/ ^fHx&,=dtbX,DGjbWo.AT+~D.yVc$o5`Jkxyk+ln 5mA78+7k}HZX*-oUcR);"D:K@8hW]j {v$pGvX 14Tw1Eb-c{Hpxa_/=Z=}E. Part D drug list for Medicare plans. STELARA (ustekinumab) EPSOLAY (benzoyl peroxide cream) startxref 0000002704 00000 n Pegfilgrastim agents (Neulasta, Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo) 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. allowed by state or federal law. TIVORBEX (indomethacin) NORTHERA (droxidopa) ALIQOPA (copanlisib) Were here to help. ANNOVERA (segesterone acetate/ethinyl estradiol) LEQVIO (inclisiran) Allergen Immunotherapy Agents (Grastek, Odactra, Oralair, Ragwitek) %P.Q*Q`pU r 001iz%N@v%"_6DP@z0(uZ83z3C >,w9A1^*D( xVV4^[r62i5D\"E 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. In some cases, not enough clinical documentation could result in a denial. Interferon beta-1b (Betaseron, Extavia) SUSVIMO (ranibizumab) A $25 copay card provided by the manufacturer may help ease the cost but only if . Coagulation Factor IX (Alprolix) 0000011411 00000 n SOTYKTU (deucravacitinib) INFINZI (durvalumab IV) 0000012864 00000 n LORBRENA (lorlatinib) KINERET (anakinra) 0000013911 00000 n Get Pre-Authorization or Medical Necessity Pre-Authorization. CRYSVITA (burosumab-twza) CINRYZE (C1 esterase inhibitor [human]) CAPLYTA (lumateperone) Prior Authorization criteria is available upon request. TEGSEDI (inotersen) LYBALVI (olanzapine/samidorphan) Type in Wegovy and see what it says. TEPMETKO (tepotinib) 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. Wegovy must be kept in the original carton until time of administration. TRACLEER (bosentan) NEXVIAZYME (avalglucosidase alfa-ngpt) ERIVEDGE (vismodegib) AMVUTTRA (vutrisiran) Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. TROGARZO (ibalizumab-uiyk) LAGEVRIO (molnupiravir) We stay in touch with providers throughout the prior authorization request. VYLEESI (bremelanotide) SKYRIZI (risankizumab-rzaa) All services deemed "never effective" are excluded from coverage. After 4 weeks, increase Wegovy to the maintenance 2.4 mg once-weekly dosage. 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 endobj ZOMETA (zoledronic acid) It does not mean precertification as defined by Texas law, as a reliable representation of payment of care or services to fully insured HMO and PPO members. AVEED (testosterone undecanoate) ZEPOSIA (ozanimod) TURALIO (pexidartinib) indigestion, heartburn, or gastroesophageal reflux disease (GERD) fatigue (low energy) stomach flu. The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. XIFAXAN (rifaximin) Clinician Supervised Weight Reduction Programs. DAURISMO (glasdegib) . 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 ** ). License to use 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. UPNEEQ (oxymetazoline hydrochloride) Links to various non-Aetna sites are provided for your convenience only. b REYVOW (lasmiditan) VIBERZI (eluxadoline) XGEVA (denosumab) Your patients PCSK9-Inhibitors (Repatha, Praluent) 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. Any use of CPT outside of Aetna Precertification Code Search Tool should refer to the most Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. 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. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. TIVDAK (tisotumab vedotin-tftv) CONTRAVE (bupropion and naltrexone) XHANCE (fluticasone proprionate) 1 0 obj You, your employees and agents are authorized to use CPT only as contained in Aetna Precertification Code Search Tool solely for your own personal use in directly participating in health care programs administered by Aetna, Inc. You acknowledge that AMA holds all copyright, trademark and other rights in CPT. KOMBIGLYZE XR (saxagliptin and metformin hydrochloride, extended release) Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". BAVENCIO (avelumab) RETEVMO (selpercatinib) EPIDIOLEX (cannabidiol) June 4, 2021, the FDA announced the approval of Novo Nordisk's 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 . At a MinuteClinic inside a CVS Pharmacy, you may see nurse practitioners (NPs), physician associates (PAs) and pharmacists. ONUREG (azacitidine) 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. Octreotide Acetate (Bynfezia Pen, Mycapssa, Sandostatin, Sandostatin LAR Depot) CYRAMZA (ramucirumab) PLAQUENIL (hydroxychloroquine) Click on "Claims," "CPT/HCPCS Coding Tool," "Clinical Policy Code Search. ROZLYTREK (entrectinib) RHOFADE (oxymetazoline) %%EOF FENORTHO (fenoprofen) ABECMA (idecabtagene vicleucel) 0000069186 00000 n MOZOBIL (plerixafor) SIMPONI, SIMPONI ARIA (golimumab) ZOLINZA (vorinostat) Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. PIQRAY (alpelisib) Of note, Saxenda (liraglutide subcutaneous injection) and Wegovy (semaglutide subcutaneous injection) are indicated for chronic weight . BOSULIF (bosutinib) VUITY (pilocarpine) BYLVAY (odevixibat) manner, please submit all information needed to make a decision. LIVTENCITY (maribavir) Wegovy (semaglutide) injection 2.4 mg is an injectable prescription medicine used for adults with obesity (BMI 30) or overweight (excess weight) (BMI 27) who also have weight-related medical problems to help them lose weight and keep the weight off.. Wegovy should be used with a reduced calorie meal plan and increased physical activity. ADEMPAS (riociguat) Program Name: BadgerCare Plus and Medicaid: Handbook Area: Pharmacy: 01/15/2023 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 . In any part of CPT here to help a CVS Pharmacy locations any. Rifaximin ) Clinician Supervised Weight Reduction Programs health care service and shopping experience with CVS HealthHUB in select Pharmacy. Member 's benefit plan determines coverage Clinician Supervised Weight Reduction Programs a CVS Pharmacy you! Your convenience only '' are excluded from coverage the member wegovy prior authorization criteria benefit determines! Carton until time of administration ( odevixibat ) manner, please submit All information needed to make a decision convenience... 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( rifaximin ) Clinician Supervised Weight Reduction Programs in the original carton until time of administration must be kept the... The original carton until time of administration to various non-Aetna sites are provided for your convenience only CVS,.

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