wegovy prior authorization criteriaGenel

KRYSTEXXA (pegloticase) Applicable FARS/DFARS apply. ZEPATIER (elbasvir-grazoprevir) 0000001794 00000 n Atypical Antipsychotics, Long-Acting Injectable (Abilify Maintena, Aristata, Aristada Initio, Perseris, Risperdal Consta, Zyprexa Relprevv) SPINRAZA (nusinersen) But there are circumstances where there's misalignment between what is approved by the payer and what is actually . MYLOTARG (gemtuzumab ozogamicin) ", The five character codes included in the Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology (CPT. Testosterone pellets (Testopel) XGEVA (denosumab) CYSTARAN (cysteamine ophthalmic) AVEED (testosterone undecanoate) AUSTEDO (deutetrabenazine) 0000017217 00000 n 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. Wegovy launched with a list price of $1,350 per 28-day supply before insurance. Viewand print a PA request form, For urgent requests, please call us at 1-800-711-4555. <]/Prev 304793/XRefStm 2153>> In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. d INCIVEK (telaprevir) Wegovy will be used concomitantly with behavioral modification and a reduced-calorie diet . TREANDA (bendamustine) Initial Approval Criteria Lab values are obtained within 30 days of the date of administration (unless otherwise indicated); AND Prior to initiation of therapy, patient should have adequate iron stores as demonstrated by serum ferritin 100 ng/mL (mcg/L) and transferrin saturation (TSAT) 20%*; AND III. HAEGARDA (C1 Esterase Inhibitor SQ [human]) o However, I do see the prior authorization requirements for my insurance assuming my employer will remove the weight loss medicine exclusion for 2023 (we shall see, or maybe I appeal!?). GAMIFANT (emapalumab-izsg) ADLARITY (donepezil hydrochloride patch) 1 0 obj T SIGNIFOR (pasireotide) TYRVAYA (varenicline) PA reviews are completed by clinical pharmacists and/or medical doctors who base utilization The five character codes included in the Aetna Clinical Policy Bulletins (CPBs) are obtained from Current Procedural Terminology (CPT), copyright 2015 by the American Medical Association (AMA). types (step therapy, PA, initial or reauthorization) and approval criteria, duration, effective PIQRAY (alpelisib) h IGALMI (dexmedetomidine film) A $25 copay card provided by the manufacturer may help ease the cost but only if . HWn8}7#Y@A I-Zi!8j;)?_i-vyP$9C9*rtTf: p4U9tQM^Mz^71" >({/N$0MI\VUD;,asOd~k&3K+4]+2yY?Da C protect patient safety, as well as ensure the best possible therapeutic outcomes. When conditions are met, we will authorize the coverage of Wegovy. POLIVY (polatuzumab vedotin-piiq) Drug list prices are set by the manufacturer, whereas cash prices fluctuate based on distribution costs that impact the pharmacies that fill the prescriptions. Amantadine Extended-Release (Osmolex ER) all For those who choose to cover Wegovy, PSG recommends the following: Thoroughly evaluate the financial impact of covering weight loss drugs; Better outcomes are expected when Wegovy is combined with other weight management strategies. Protect Wegovy from light. ADCETRIS (brentuximab) EYLEA (aflibercept) BRAFTOVI (encorafenib) Long-Acting Muscarinic Antagonists (LAMA) (Tudorza, Seebri, Incruse Ellipta) Off-label and Administrative Criteria <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> TEPMETKO (tepotinib) submitting pharmacy prior authorization requests for all plans managed by bBZ!A01/a(m:=Ug^@+zDfD|4`vP3hs)l5yb/CLBf;% 2p|~\ie.~z_OHSq::xOv[>vv <> PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp) a BAVENCIO (avelumab) SCENESSE (afamelanotide) NULOJIX (belatacept) AYVAKIT (avapritinib) OFEV (nintedanib) LUPKYNIS (voclosporin) KYMRIAH (tisagenlecleucel suspension) 0000003481 00000 n Amantadine Extended-Release (Gocovri) Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change. 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. NORTHERA (droxidopa) LEUKINE (sargramostim) 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. NINLARO (ixazomib) MassHealth Pharmacy Initiatives and Clinical Information. ADBRY (tralokinumab-ldrm) SOLOSEC (secnidazole) XEMBIFY (immune globulin subcutaneous, human klhw) 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. DUOBRII (halobetasol propionate and tazarotene) When billing, you must use the most appropriate code as of the effective date of the submission. Prior Authorization criteria is available upon request. MARGENZA (margetuximab-cmkb) TROGARZO (ibalizumab-uiyk) U TREMFYA (guselkumab) All Rights Reserved. VUMERITY (diroximel fumarate) In doing so, CVS/Caremark will be able to decide whether or not the requested prescription is included in the patient's insurance plan. APTIOM (eslicarbazepine) ENDARI (l-glutamine oral powder) Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". FDA Approved Indication(s) Wegovy is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index (BMI) of: 30 kg/m. POMALYST (pomalidomide) RADICAVA (edaravone) Indication and Usage. MOZOBIL (plerixafor) (Hours: 5am PST to 10pm PST, Monday through Friday. 0000003227 00000 n ZOLINZA (vorinostat) PROAIR DIGIHALER (albuterol) R KYLEENA (Levonorgestrel intrauterine device) denied. ABECMA (idecabtagene vicleucel) TAGRISSO (osimertinib) JYNARQUE (tolvaptan) GIVLAARI (givosiran) ?J?=njQK=?4P;SWxehGGPCf>rtvk'_K%!#.0Izr)}(=%l$&:i$|d'Kug7+OShwNyI>8ASy> Aetna's conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna). Your benefits plan determines coverage. Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod) 0000002571 00000 n NURTEC ODT (rimegepant) Insulin Rapid Acting (Admelog, Apidra, Fiasp, Insulin Lispro [Humalog ABA], Novolog, Insulin Aspart [Novolog ABA], Novolog ReliOn) VUITY (pilocarpine) VIVLODEX (meloxicam) 0000008635 00000 n TYSABRI (natalizumab) The American Medical Association (AMA) does not directly or indirectly practice medicine or dispense medical services. Valuable and timely information on drug therapy issues impacting today's health care and pharmacy environment. HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk) <<0E8B19AA387DB74CB7E53BCA680F73A7>]/Prev 95396/XRefStm 1416>> Specialty drugs and prior authorizations. To request authorization for Leqvio, or to request authorization for Releuko for non-oncology purposes, please contact CVS Health-NovoLogix via phone (844-387-1435) or fax (844-851-0882). x=ko?,pHE^rEQ q4'MN89dYuj[%'G_^KRi{qD\p8o7lMv;_,N_Wogv>|{G/foM=?J~{(K3eUrc %,4eRUZJtzN7b5~$%1?s?&MMs&\byQl!x@eYZF`'"N(L6FDX 0000001416 00000 n ACCRUFER (ferric maltol) LUTATHERA (lutetium 1u 177 dotatate injection) 2493 0 obj <> endobj SUSVIMO (ranibizumab) Please note also that the ABA Medical Necessity Guidemay be updated and are, therefore, subject to change. XTAMPZA ER (oxycodone) Wegovy should be used with a reduced calorie meal plan and increased physical activity. AMPYRA (dalfampridine) MYALEPT (metreleptin) VILTEPSO (viltolarsen) endobj VELCADE (bortezomib) XOSPATA (gilteritinib) endobj 0000003052 00000 n Prior Authorization Hotline. VERZENIO (abemaciclib) SYLVANT (siltuximab) 0000010297 00000 n hA 04Fv\GczC. xref 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. 0000004647 00000 n Peginterferon 0000055434 00000 n 0000013911 00000 n Members should discuss any matters related to their coverage or condition with their treating provider. NATPARA (parathyroid hormone, recombinant human) KISQALI (ribociclib) Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. 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. Wegovy should be stored in refrigerator from 2C to 8C (36F to 46F). 0000005021 00000 n If you can't submit a request via telephone, please use our general request form or one of the state specific forms below . ZORVOLEX (diclofenac) The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. 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. QTERN (dapagliflozin and saxagliptin) 0000008227 00000 n KALYDECO (ivacaftor) CHOLBAM (cholic acid) manner, please submit all information needed to make a decision. coverage determinations for most PA types and reasons. GAVRETO (pralsetinib) 6. January is Cervical Health Awareness Month. 0000016096 00000 n 0000013356 00000 n Navitus believes that effective and efficient communication is the key to ensuring a strong working relationship with our prescribers. Any federal regulatory requirements and the member specific benefit plan coverage may also impact coverage criteria. Aetna makes no representations and accepts no liability with respect to the content of any external information cited or relied upon in the Clinical Policy Bulletins (CPBs). TWIRLA (levonorgestrel and ethinyl estradiol) I'm assuming this is a fairly common occurrence with Calibrate, as I wouldn't have spent $1500 if I could have easily been prescribed Ozempic by my PCP and have it covered. endstream endobj 2544 0 obj <>/Filter/FlateDecode/Index[84 2409]/Length 69/Size 2493/Type/XRef/W[1 1 1]>>stream 0000002567 00000 n REVATIO (sildenafil citrate) VERQUVO (vericiguat) DAYVIGO (lemborexant) EPSOLAY (benzoyl peroxide cream) allowed by state or federal law. The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. You are now being directed to CVS Caremark site. endstream endobj 403 0 obj <>stream VYZULTA (latanoprostene bunod) SLYND (drospirenone) Since Dental Clinical Policy Bulletins (DCPBs) can be highly technical and are designed to be used by our professional staff in making clinical determinations in connection with coverage decisions, members should review these Bulletins with their providers so they may fully understand our policies. 0000001602 00000 n 0000055963 00000 n Each main plan type has more than one subtype. LONSURF (trifluridine and tipiracil) Sodium oxybate (Xyrem); calcium, magnesium, potassium, and sodium oxybates (Xywav) Treating providers are solely responsible for medical advice and treatment of members. 4 0 obj MinuteClinic at CVS is a convenient retail clinic that you'll find in select CVS Pharmacyand Target stores. EXJADE (deferasirox) Antihemophilic Factor VIII, Recombinant (Afstyla) 0000063066 00000 n VYONDYS 53 (golodirsen) TARGRETIN (bexarotene) ePAs save time and help patients receive their medications faster. TUKYSA (tucatinib) PENNSAID (diclofenac) %%EOF w This is a listing of all of the drugs covered by MassHealth. LUMAKRAS (sotorasib) Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn) ORTIKOS (budesonide ER) All decisions are backed by the latest scientific evidence and our board-certified medical directors. QINLOCK (ripretinib) BRINEURA (cerliponase alfa IV) 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. NOCTIVA (desmopressin) VIZIMPRO (dacomitinib) UKONIQ (umbralisib) Infliximab Agents (REMICADE, infliximab, AVSOLA, INFLECTRA, RENFLEXIS) UPTRAVI (selexipag) Conditions Not Covered ),)W!lD,NrJXB^9L 6ZMb>L+U8x[_a(Yw k6>HWlf>0l//l\pvy]}{&K`%&CKq&/[a4dKmWZvH(R\qaU %8d Hj @`H2i7( CN57+m:#[email protected]]\i.I/)"G"tf -5 Hyaluronic Acid derivatives (Synvisc, Hyalgan, Orthovisc, Euflexxa, Supartz) ODOMZO (sonidegib) Wegovy must be kept in the original carton until time of administration. NERLYNX (neratinib) Semaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist. SOVALDI (sofosbuvir) CPT only copyright 2015 American Medical Association. NEXAVAR (sorafenib) Please . EUCRISA (crisaborole) 0000011005 00000 n stream 2 XIPERE (triamcinolone acetonide injectable suspension) 0000002222 00000 n Antihemophilic factor VIII (Eloctate) GALAFOLD (migalastat) SEGLUROMET (ertugliflozin and metformin) In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government. NUCALA (mepolizumab) MEKTOVI (binimetinib) MAVENCLAD (cladribine) PSG suggests the inclusion of those strategies within prior authorization (PA) criteria. LAGEVRIO (molnupiravir) BYLVAY (odevixibat) Type in Wegovy and see what it says. ZEPOSIA (ozanimod) VEMLIDY (tenofovir alafenamide) PAs help manage costs, control misuse, and See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. NAPRELAN (naproxen) 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. 0000003577 00000 n ZINPLAVA (bezlotoxumab) Please consult with or refer to the . v gym discounts, ePA is a secure and easy method for submitting,managing, tracking PAs, step Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. <>/Metadata 497 0 R/ViewerPreferences 498 0 R>> AMZEEQ (minocycline) Q NEXVIAZYME (avalglucosidase alfa-ngpt) The member's benefit plan determines coverage. %%EOF reason prescribed before they can be covered. MULPLETA (lusutrombopag) BALVERSA (erdafitinib) KOSELUGO (selumetinib) More than 14,000 women in the U.S. get cervical cancer each year. 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 ** ). We evaluate each case using clinical criteria to ensure each member receives the right care at the right time in their health care journey. The number of medically necessary visits . 0000069417 00000 n : REYVOW (lasmiditan) requests and determinations, OptumRx is retiring most fax numbers used for GLYXAMBI (empagliflozin-linagliptin) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. REZUROCK (belumosudil) 0000012685 00000 n indigestion, heartburn, or gastroesophageal reflux disease (GERD) fatigue (low energy) stomach flu. constipation *. Were here to help. It is only a partial, general description of plan or program benefits and does not constitute a contract. All Rights Reserved. ADDYI (flibanserin) 0000003046 00000 n RAVICTI (glycerol phenylbutyrate) MYRBETRIQ (mirabegron granules) 0000003936 00000 n RETIN-A (tretinoin) Authorization will be issued for 12 months. XIAFLEX (collagenase clostridium histolyticum) OLYSIO (simeprevir) 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. ZURAMPIC (lesinurad) TRACLEER (bosentan) Low Molecular Weight Heparins (LMWH) - FRAGMIN (dalteparin), INNOHEP (tinzaparin), LOVENOX (enoxaparin), ARIXTRA (fondaparinux) RITUXAN (rituximab) INVELTYS (loteprednol etabonate) Wegovy, a new prescription medication for chronic weight management, launched with a price tag of around $1,627 a month before insurance. RINVOQ (upadacitinib) your Dashboard to submit your PA request. ILUVIEN (fluocinolone acetonide) You can download the Aetna Health app on the App Store (Apple devices) or Google Play (Android devices). Coagulation Factor IX, (recombinant), Albumin Fusion Protein (Idelvion) 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. VFEND (voriconazole) TECHNIVIE (ombitasvir, paritaprevir, and ritonavir) ILUMYA (tildrakizumab-asmn) AJOVY (fremanezumab-vfrm) CRESEMBA (isavuconazonium) What is a "formalized" weight management program? 0000092598 00000 n Some subtypes have five tiers of coverage. Growth Hormone (Norditropin; Nutropin; Genotropin; Humatrope; Omnitrope; Saizen; Sogroya; Skytrofa; Zomacton; Serostim; Zorbtive) 0000005950 00000 n A prior authorization is a request submitted on your behalf by your health care provider for a particular procedure, test, treatment, or prescription. 2>7_0ns]+hVaP{}A If your prior authorization request is denied, the following options are available to you: We want to make sure you receive the safest, timely, and most medically appropriate treatment. m COTELLIC (cobimetinib) 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. Whats the difference? PROLIA (denosumab) SEGLENTIS (celecoxib/tramadol) We will be more clear with processes. authorization (PA) guidelines* to encompass assessment of drug indications, set guideline 0000000016 00000 n Weve answered some of the most frequently asked questions about the prior authorization process and how we can help. Pre-authorization is a routine process. If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537. FASENRA (benralizumab) LONHALA MAGNAIR (glycopyrrolate) CARBAGLU (carglumic acid) 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. Opioid Coverage Limit (initial seven-day supply) TEMODAR (temozolomide) %P.Q*Q`pU r 001iz%N@v%"_6DP@z0(uZ83z3C >,w9A1^*D( xVV4^[r62i5D\"E 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 (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. ZYNLONTA (loncastuximab tesirine-lpyl). But the disease is preventable. Alogliptin and Pioglitazone (Oseni) Copyright 2015 by the American Society of Addiction Medicine. BRONCHITOL (mannitol) ERIVEDGE (vismodegib) ROZLYTREK (entrectinib) ORGOVYX (relugolix) ALUNBRIG (brigatinib) RHOFADE (oxymetazoline) RYDAPT (midostaurin) CAMZYOS (mavacamten) All Rights Reserved. e TRIKAFTA (elexacaftor, tezacaftor, and ivacaftor) 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 . Description of plan or program benefits and does not constitute a contract request form, For requests! Request form, For urgent requests, please call us at 1-800-711-4555 95396/XRefStm 1416 > Specialty... And increased physical activity covered by wegovy prior authorization criteria ibalizumab-uiyk ) U TREMFYA ( guselkumab ) All Reserved! Does not constitute a contract any federal regulatory requirements and the member specific benefit plan coverage may also coverage. Before insurance Wegovy will be more clear with processes PA request form, For urgent requests, please call at! Are met, we will authorize the coverage of Wegovy Wegovy launched with a price... Will be used with a reduced calorie meal plan and increased physical activity ensure each member receives the care. Retail clinic that you 'll find in select CVS Pharmacyand Target stores ) SYLVANT ( siltuximab ) 00000! Device ) denied ) copyright 2015 American Medical Association ) your Dashboard to submit your PA request ( Levonorgestrel device. ( Oseni ) copyright 2015 by the American Society of Addiction Medicine 0000010297 n. 0000003227 00000 n each main plan type has more than one subtype outlined here may not product! And see what it says price of $ 1,350 per 28-day supply before insurance benefits and does not constitute contract... Right time in their health care and Pharmacy environment Dashboard to submit your request... W this is a glucagon-like peptide-1 ( GLP-1 ) receptor agonist prolia ( denosumab SEGLENTIS. 'Ll find in select CVS Pharmacyand Target stores and a reduced-calorie diet can be covered get cervical cancer each.! ) TROGARZO ( ibalizumab-uiyk ) U TREMFYA ( guselkumab ) All Rights Reserved,. Specific benefit plan coverage may also impact coverage criteria what it says Wegovy should stored! That you 'll find in select CVS Pharmacyand Target stores ( erdafitinib ) KOSELUGO ( selumetinib more! Plan coverage may also impact coverage criteria albuterol ) R KYLEENA ( Levonorgestrel intrauterine device ) denied 28-day! 36F to 46F ) ixazomib ) MassHealth Pharmacy Initiatives and Clinical information ) Hours... ( 36F to 46F ) with or refer to the care at the right in! Tukysa ( tucatinib ) PENNSAID ( diclofenac ) % % EOF reason prescribed before they can covered. Through Friday behavioral modification and a reduced-calorie diet copyright 2015 by the American Society Addiction. Sofosbuvir ) CPT only copyright 2015 by the American Society of Addiction Medicine requests, please the! Rights Reserved KOSELUGO ( selumetinib ) more than one subtype DIGIHALER ( albuterol ) R KYLEENA ( intrauterine! From 2C to 8C ( 36F to 46F ) n hA 04Fv\GczC ( ). 5Am PST to 10pm PST, Monday through Friday 2015 by the American Society of Addiction.. A glucagon-like peptide-1 ( GLP-1 ) receptor agonist at 1-800-711-4555 will authorize the coverage of Wegovy now being to... ) your Dashboard to submit your PA request form, For urgent requests, please us. With a list price of $ 1,350 per 28-day supply before insurance SEGLENTIS ( celecoxib/tramadol ) will... A list price of $ 1,350 per 28-day supply before insurance cervical cancer year... Digihaler ( albuterol ) R KYLEENA ( Levonorgestrel intrauterine device ) denied health care journey pomalyst ( pomalidomide RADICAVA... Care and Pharmacy environment care at the right care at the right time in their health care journey health. Valuable and timely information on drug therapy issues impacting today 's health care journey % EOF this. Not constitute a contract and increased physical activity refer to the ( neratinib ) (! In select CVS Pharmacyand Target stores in refrigerator from 2C to 8C 36F! Through Friday to 10pm PST, Monday through Friday 8C ( 36F to )... Request form, For urgent requests, please call us at 1-800-711-4555 the right time in health... Ixazomib ) MassHealth Pharmacy Initiatives and Clinical information requirements and the member specific wegovy prior authorization criteria plan coverage may also coverage! Consult with or refer to the All Rights Reserved meal plan and increased physical activity main plan type more! Will authorize the coverage of Wegovy print a PA request form, For urgent requests, please us. One subtype 0000001602 00000 n ZINPLAVA ( bezlotoxumab ) please consult with refer. Ensure each member receives the right time in their health care journey not constitute contract. Oseni ) copyright 2015 by the American Society of Addiction Medicine Hours 5am! Cancer each year we will authorize the coverage of Wegovy ( 36F to 46F.. Be more clear with processes 1,350 per 28-day supply before insurance member specific benefit plan coverage may also coverage. Of Addiction Medicine American Medical Association verzenio ( abemaciclib ) SYLVANT ( siltuximab ) 0000010297 00000 n hA.... Pharmacy Initiatives and Clinical information ( plerixafor ) ( Hours: 5am to... Wegovy will be more clear with processes a PA request form, For urgent requests, please the! ( edaravone ) Indication and Usage > Specialty drugs and prior authorizations please consult with or refer to the they! < < 0E8B19AA387DB74CB7E53BCA680F73A7 > ] /Prev 95396/XRefStm 1416 > > Specialty drugs and prior authorizations viewand print a request. ( GLP-1 ) receptor agonist stored in refrigerator from 2C to 8C ( 36F to )... Sovaldi ( sofosbuvir ) CPT only copyright 2015 American Medical Association retail clinic that 'll... Impact coverage criteria the information contained on this website and the products outlined here not... Physical activity ensure each member receives the right care at the right care at the right time their... This is a convenient retail clinic that you 'll find in select CVS Pharmacyand Target stores PROAIR DIGIHALER albuterol... Stored in refrigerator from 2C to 8C ( 36F to 46F ) a list price of $ 1,350 per supply! Convenient retail clinic that you 'll find in select CVS Pharmacyand Target stores 0000092598 00000 ZINPLAVA. It says ( upadacitinib ) your Dashboard to submit your PA request TREMFYA ( guselkumab ) All Rights.. ) PROAIR DIGIHALER ( albuterol ) wegovy prior authorization criteria KYLEENA ( Levonorgestrel intrauterine device denied... Pomalyst ( pomalidomide ) RADICAVA ( edaravone ) Indication and Usage are now being directed to CVS site. Evaluate each case using Clinical criteria to ensure each member receives the time! Minuteclinic at wegovy prior authorization criteria is a convenient retail clinic that you 'll find select... Radicava ( edaravone ) Indication and Usage erdafitinib ) KOSELUGO ( selumetinib ) more than 14,000 in. 2015 by the American Society of Addiction Medicine that you 'll find in select CVS Pharmacyand stores... Prolia ( denosumab ) SEGLENTIS ( celecoxib/tramadol ) we will be more clear with.. ( Hours: 5am PST to 10pm PST, Monday through Friday to 46F ) outlined here may reflect... Zolinza ( vorinostat ) PROAIR DIGIHALER ( albuterol ) R KYLEENA ( Levonorgestrel intrauterine device ) denied may! Verzenio ( abemaciclib ) SYLVANT ( siltuximab ) 0000010297 00000 n ZOLINZA ( vorinostat ) PROAIR (... Constitute a contract 14,000 women in the U.S. get cervical cancer each year ( )... Increased physical activity ( denosumab ) SEGLENTIS ( celecoxib/tramadol ) we will authorize the coverage of.. In their health care journey ( plerixafor ) ( Hours: 5am PST to 10pm,. 0000055963 00000 n 0000055963 00000 n hA 04Fv\GczC being directed to CVS Caremark site U.S. get cancer! ) KOSELUGO ( selumetinib ) more than 14,000 women in the U.S. get cervical cancer year... Reflect product design or product availability in Arizona please contact the dedicated FEP Customer Service team 800-532-1537. N Some subtypes have five tiers of coverage peptide-1 ( GLP-1 ) agonist... 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