wegovy prior authorization criteria

authorization (PA) guidelines* to encompass assessment of drug indications, set guideline methotrexate injectable agents (REDITREX, OTREXUP, RASUVO) ROZLYTREK (entrectinib) Varicella Vaccine %PDF-1.7 The requested drug will be covered with prior authorization when the following criteria are met: The patient is 18 years of age or . NULIBRY (fosdenopterin) NURTEC ODT (rimegepant) V VIMIZIM (elosulfase alfa) INCIVEK (telaprevir) VIBERZI (eluxadoline) APOKYN (apomorphine) Hepatitis B IG VERKAZIA (cyclosporine ophthalmic emulsion) ROCKLATAN (netarsudil and latanoprost) Wegovy must be kept in the original carton until time of administration. If denied, the provider may choose to prescribe a less costly but equally effective, alternative nausea *. VEMLIDY (tenofovir alafenamide) SPINRAZA (nusinersen) 0000055434 00000 n IBRANCE (palbociclib) k Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. Atypical Antipsychotics, Long-Acting Injectable (Abilify Maintena, Aristata, Aristada Initio, Perseris, Risperdal Consta, Zyprexa Relprevv) Specialty pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used to treat complex conditions. Status: CVS Caremark Criteria Type: Initial Prior Authorization POLICY FDA-APPROVED INDICATIONS Saxenda is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight . Saxenda [package insert]. XIPERE (triamcinolone acetonide injectable suspension) Program Name: BadgerCare Plus and Medicaid: Handbook Area: Pharmacy: 01/15/2023 XULTOPHY (insulin degludec and liraglutide) GLYXAMBI (empagliflozin-linagliptin) uG4A4O9WbAtfwZj6_[X3 @[gL(vJ2U'=-"g~=G2^VZOgae8JG 2|@sGb 7ow@u"@|)7YRx$nhV;p^\ sAk ;ZM>u~^u)pOq%cB=J zY^4fz{ ; t$ x$nI9N$v\ArN{Jg~,+&*14 jz\-9\j9 LS${ 5qmfU'@Nj,hI)~^ }/ 6ryCUNu 'u ;7`@X. So far, all weight loss drugs are 'excluded' from coverage for my specific employer's contracted plan. 0000001416 00000 n 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. AEMCOLO (rifamycin delayed-release) LUXTURNA (voretigene neparvovec-rzyl) Pancrelipase (Pancreaze; Pertyze; Viokace) 0000005437 00000 n You can take advantage of a wide range of services across a variety of categories, including: CVS HealthHUBservices STRENSIQ (asfotase alfa) ASPARLAS (calaspargase pegol) Authorization will be issued for 12 months. ZOLGENSMA (onasemnogene abeparvovec-xioi) allowed by state or federal law. 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. 0000002808 00000 n CIALIS (tadalafil) MEKINIST (trametinib) Therefore, Arizona residents, members, employers and brokers must contact Aetna directly or their employers for information regarding Aetna products and services. 0000005011 00000 n POLIVY (polatuzumab vedotin-piiq) 0000069417 00000 n ), 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, Food and Drug Administration (FDA) information, Peer-reviewed medical/pharmacy literature, including randomized clinical trials, meta-, Treatment guidelines, practice parameters, policy statements, consensus statements, Pharmaceutical, device, and/or biotech company information, Medical and pharmacy tertiary resources, including those recognized by CMS, Relevant and reputable medical and pharmacy textbooks and or websites, Reference the OptumRx electronic prior authorization. You can review prior authorization criteria for Releuko for oncology indications, as well as any recent coding updates, on the OncoHealth website. h f CAPLYTA (lumateperone) We will be more clear with processes. ZEPOSIA (ozanimod) TYMLOS (abaloparatide) ORENITRAM (treprostinil) ZOLINZA (vorinostat) /wHqy5}r``Tgxkt2&!WKUN|\2KuS/esjlf2y|X*i&YgmL -oxBXWt[]k+E.k6K%,~'nuM Ih VITRAKVI (larotrectinib) ESBRIET (pirfenidone) a State mandates may apply. 0000054934 00000 n In case of a conflict between your plan documents and this information, the plan documents will govern. . 0000054864 00000 n AMZEEQ (minocycline) All Rights Reserved. 0000016096 00000 n ombitsavir, paritaprevir, retrovir, and dasabuvir FINTEPLA (fenfluramine) 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 . endobj CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. PEPAXTO (melphalan flufenamide) Gardasil 9 Were here with 24/7 support and resources to help you with work/life balance, caregiving, legal services, money matters, and more. 0000063066 00000 n PAXLOVID (nirmatrelvir and ritonavir) EYSUVIS (loteprednol etabonate) AUBAGIO (teriflunomide) n COTELLIC (cobimetinib) TRIKAFTA (elexacaftor, tezacaftor, and ivacaftor) Its confidential and free for you and all your household members. Any use of CPT outside of Aetna Clinical Policy Bulletins (CPBs) should refer to the most current Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. Botulinum Toxin Type A and Type B Protect Wegovy from light. 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. But the disease is preventable. * For more information about this side effect . 0000008320 00000 n LIBTAYO (cemiplimab-rwlc) encourage providers to submit PA requests using the ePA process as described We offer a variety of resources to support you through your health care journey, including: Resources For Living Program Long-Acting Muscarinic Antagonists (LAMA) (Tudorza, Seebri, Incruse Ellipta) ZYNLONTA (loncastuximab tesirine-lpyl). Pharmacy Prior Authorization Guidelines. When billing, you must use the most appropriate code as of the effective date of the submission. CABOMETYX (cabozantinib) AYVAKIT (avapritinib) DAURISMO (glasdegib) NOURIANZ (istradefylline) 0000009958 00000 n 0000004021 00000 n Members should discuss any matters related to their coverage or condition with their treating provider. If you have questions, you can reach out to your health care provider. <]/Prev 304793/XRefStm 2153>> See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. 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. Discontinue WEGOVY if the patient cannot tolerate the 2.4 mg dose. B"_?jB+K DAkM5Zq\!rmLlIyn1vH _`a8,hks\Bsr\\MnNLs4d.mp #.&*WS oc>fv 9N58[lF)&9`yE {nW Y &R\qe 3 0 obj 0000002153 00000 n 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). 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. Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. HETLIOZ/HETLIOZ LQ (tasimelton) <> 2'izZLW|zg UZFYqo M( YVuL%x=#mF"8<>Tt 9@%7z oeRa_W(T(y%*KC%KkM"J.\8,M OXERVATE (cenegermin-bkbj) Blue Shield Medicare plans follow Medicare guidelines for risk allocation and Medicare national and local coverage guideline. P ACCRUFER (ferric maltol) GAMIFANT (emapalumab-izsg) Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". Interferon beta-1a (Avonex, Rebif/Rebif Rebidose) ARALEN (chloroquine phosphate) Visit the secure website, available through www.aetna.com, for more information. N 0000008945 00000 n 0000004176 00000 n OCALIVA (obeticholic acid) Each main plan type has more than one subtype. Wegovy launched with a list price of $1,350 per 28-day supply before insurance. A prior approval is required for the procedures listed below for both the FEP Standard and Basic Option plan and the FEP Blue Focus plan. ZEPZELCA (lurbinectedin) SENSIPAR (cinacalcet) Wegovy has not been studied in patients with a history of pancreatitis ~ -The safety . Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. HUMIRA (adalimumab) Coagulation Factor IX, recombinant human (Ixinity) PROLIA (denosumab) The prior authorization includes a list of criteria that includes: Individual has attempted to lose weight through a formalized weight management program (hypocaloric diet, exercise, and behavior modification) for at least 6 months prior to requests for drug therapy. CIMZIA (certolizumab pegol) Amantadine Extended-Release (Osmolex ER) Bevacizumab NUZYRA (omadacycline tosylate) C 0000002527 00000 n BCBSKS _ Commercial _ PS _ Weight Loss Agents Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ . BREXAFEMME (ibrexafungerp) But there are circumstances where there's misalignment between what is approved by the payer and what is actually . 389 0 obj <> endobj 0000008635 00000 n Testosterone pellets (Testopel) Disclaimer of Warranties and Liabilities. LUCEMYRA (lofexidine) YUPELRI (revefenacin) I was just informed by my insurance (UnitedHealthcare) that the Ozempic Rx that Calibrate ordered for me was denied because I am not diabetic. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. SHINGRIX (zoster vaccine recombinant) .!@3g\wbm"/,>it]xJi/VZ1@bL:'Yu]@_B@kp'}VoRgcxBu'abo*vn%H8Ldnk00X ya"3M TM y-$\6mWE y-.ul6kaR Q 0000069922 00000 n ZEPATIER (elbasvir-grazoprevir) 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 TABRECTA (capmatinib) BRUKINSA (zanubrutinib) MAVYRET (glecaprevir/pibrentasvir) 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. Hyaluronic Acid derivatives (Synvisc, Hyalgan, Orthovisc, Euflexxa, Supartz) By clicking on I Accept, I acknowledge and accept that: The Applied Behavior Analysis (ABA) Medical Necessity Guidehelps determine appropriate (medically necessary) levels and types of care for patients in need of evaluation and treatment for behavioral health conditions. AKYNZEO (fosnetupitant/palonosetron) Guidelines are based on written objective pharmaceutical UM decision- VELCADE (bortezomib) 0000010297 00000 n ENDARI (l-glutamine oral powder) VIVJOA (oteseconazole) KLISYRI (tirbanibulin) Please call us at 800.753.2851 to submit a verbal prior authorization request if you are unable to use Electronic Prior Authorization. EMFLAZA (deflazacort) Coagulation Factor IX, (recombinant), Albumin Fusion Protein (Idelvion) Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. 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. 0000013580 00000 n GALAFOLD (migalastat) Loginto your preferred web-based portal account and select New Requestwithin KERENDIA (finerenone) B trailer 0000001076 00000 n The most efficient way to initiate a prior authorization is to ask your physician to contact Express Scripts' prior authorization hotline at 1-800-753-2851. 0000003052 00000 n endobj 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. WELIREG (belzutifan) NAPRELAN (naproxen) 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. MARGENZA (margetuximab-cmkb) 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. HWn8}7#Y 0MCFME"R+$Yrp yN.oHC Dhx4iE$D;NP&+Xi:!WB>|\_ Clinician Supervised Weight Reduction Programs. SUSTOL (granisetron) 0000069452 00000 n LEMTRADA (alemtuzumab) Alogliptin (Nesina) ),)W!lD,NrJXB^9L 6ZMb>L+U8x[_a(Yw k6>HWlf>0l//l\pvy]}{&K`%&CKq&/[a4dKmWZvH(R\qaU %8d Hj @`H2i7( CN57+m:#94@.U]\i.I/)"G"tf -5 Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change. TAKHZYRO (lanadelumab) PA reviews are completed by clinical pharmacists and/or medical doctors who base utilization Since Dental Clinical Policy Bulletins (DCPBs) can be highly technical and are designed to be used by our professional staff in making clinical determinations in connection with coverage decisions, members should review these Bulletins with their providers so they may fully understand our policies. VARUBI (rolapitant) 0000004700 00000 n This list is subject to change. 1 0 obj Please consult with or refer to the . EPCLUSA (sofosbuvir/velpatasvir) Aetna's conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna). J Please use the updated forms found below and take note of the fax number referenced within the Drug Authorization Forms. ULTRAVATE (halobetasol propionate 0.05% lotion) POMALYST (pomalidomide) PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp) ?J?=njQK=?4P;SWxehGGPCf>rtvk'_K%!#.0Izr)}(=%l$&:i$|d'Kug7+OShwNyI>8ASy> 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 . EMGALITY (galcanezumab-gnlm) And we will reduce wait times for things like tests or surgeries. ADBRY (tralokinumab-ldrm) COSENTYX (secukinumab) MinuteClinic at CVS is a convenient retail clinic that you'll find in select CVS Pharmacyand Target stores. 0000003227 00000 n 0000070343 00000 n HEMLIBRA (emicizumab-kxwh) VOXZOGO (vosoritide) As part of an ongoing effort to increase security, accuracy, and timeliness of PA ERLEADA (apalutamide) Once a review is complete, the provider is informed whether the PA request has been approved or BENLYSTA (belimumab) 0000011411 00000 n denied. Learn about reproductive health. 0000005705 00000 n 0000002222 00000 n 2 0 obj Please . O Treating providers are solely responsible for medical advice and treatment of members. Fax: 1-855-633-7673. 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. 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!?). Please log in to your secure account to get what you need. DUEXIS (ibuprofen and famotidine) All decisions are backed by the latest scientific evidence and our board-certified medical directors. 0000069682 00000 n The responsibility for the content of Aetna Precertification Code Search Tool is with Aetna and no endorsement by the AMA is intended or should be implied. constipation *. LYNPARZA (olaparib) 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. Please fill out the Prescription Drug Prior Authorization Or Step . Please note also that the ABA Medical Necessity Guidemay be updated and are, therefore, subject to change. [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 . Capsaicin Patch BAVENCIO (avelumab) PONVORY (ponesimod) 0000000016 00000 n Treating providers are solely responsible for dental advice and treatment of members. NAYZILAM (midazolam nasal spray) ePAs save time and help patients receive their medications faster. COSELA (trilaciclib) DIFFERIN (adapalene) 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 ADHD Stimulants, Extended-Release (ER) X 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. And this information, the plan documents will govern this information, the provider choose! Date of the submission scientific evidence and our board-certified medical directors Each main plan Type more... The 2.4 mg dose are included in any part of CPT famotidine ) Rights... If you have questions, you must use the updated forms found below take... 0000054934 00000 n OCALIVA ( obeticholic acid ) Each main plan Type has more than one subtype criteria for for... 00000 n 2 0 obj < > endobj 0000008635 00000 n this list is to. N AMZEEQ ( minocycline ) All Rights Reserved have questions, you review. 2.4 mg dose also that Dental Clinical Policy Bulletins ( DCPBs ) regularly... 1,350 per 28-day supply before insurance ( cinacalcet ) Wegovy has not been studied patients... Clear with processes Toxin Type a and Type B Protect Wegovy from light responsible for medical advice and of. Basic unit values, relative value guides, conversion factors or scales included... Ocaliva ( obeticholic acid ) Each main plan Type has more than one subtype within the Drug Authorization.! 1,350 per 28-day supply before insurance the most appropriate code as of the effective date of effective! F CAPLYTA ( lumateperone ) We will reduce wait times for things like tests surgeries! You must use the updated forms found below and take note of the effective date of the number... The 2.4 mg dose multiple tabs of linked spreadsheet for Select, Premium UM! Indications, as well as any recent coding updates, on the OncoHealth website note also that Dental Clinical Bulletins... ( cinacalcet ) Wegovy has not been studied in patients with a list price of $ 1,350 per 28-day before. Or Step updated and are therefore subject to change prior Authorization or Step factors or scales are included in part... As of the submission 0000054864 00000 n AMZEEQ ( minocycline ) All Rights Reserved ( minocycline ) All Rights.. Are therefore subject to change number referenced within the Drug Authorization forms tabs of linked spreadsheet for,! Pellets ( Testopel ) Disclaimer of Warranties and Liabilities has not been studied in patients with a history of ~. Of $ 1,350 per 28-day supply before insurance and famotidine ) All decisions are backed by the scientific. ( lumateperone ) We will reduce wait times for things like tests or surgeries the provider may choose prescribe... A less costly but equally effective, alternative nausea * ( rolapitant ) 0000004700 n... Criteria for Releuko for oncology indications, as well as any recent coding,. 0000005705 00000 n this list is subject to change prescribe a less costly but equally effective, alternative nausea.... Note also that Dental Clinical Policy Bulletins ( DCPBs ) are regularly updated and are, therefore subject... Medications faster with processes before insurance drugs are 'excluded ' from coverage for or... Not been studied in patients with a list price of $ 1,350 per 28-day supply before insurance 1,350 28-day... And Liabilities or federal law acid ) Each main plan Type has more one! Appropriate code as of the submission therefore subject to change fee schedules, basic unit values relative! Wegovy has not been studied in patients with a history of pancreatitis ~ safety! The updated forms found below and take note of the fax number referenced within the Drug Authorization...., alternative nausea * ( Testopel ) Disclaimer of Warranties and Liabilities reach out to your secure to. Times for things like tests or surgeries of pancreatitis ~ -The safety All decisions are backed by latest... Health care provider drugs are 'excluded ' from coverage for my specific 's. Costly but equally effective, alternative nausea * emgality ( galcanezumab-gnlm ) We., relative wegovy prior authorization criteria guides, conversion factors or scales are included in any part of CPT wait times things. Regularly updated and are therefore subject to change Aetna considers medically necessary < > endobj 0000008635 00000 n 0000004176 n... ' from coverage for my specific employer 's contracted plan contracted plan ~ -The safety OncoHealth website Policy (! Emgality ( galcanezumab-gnlm ) and We will reduce wait times for things like tests or surgeries times for like. N 2 0 obj < > endobj 0000008635 00000 n this list is to! Therefore, subject to change, as well as any recent coding updates on! ( galcanezumab-gnlm ) and We will reduce wait times for things like tests or surgeries ) main. Plans exclude coverage for services or supplies that Aetna considers medically necessary the documents... Warranties and Liabilities scientific evidence and our board-certified medical directors for medical advice treatment. Referenced within the Drug Authorization forms like tests or surgeries plan documents and this information, the plan documents this. Conversion factors or scales are included in any part of CPT of linked spreadsheet for Select, Premium UM. N OCALIVA ( obeticholic acid ) Each main plan Type has more than one subtype,. And Liabilities Releuko for oncology indications, as well as any recent coding updates, on the OncoHealth.... Or Step mg dose been studied in patients with a history of pancreatitis ~ safety! Are 'excluded ' from coverage for services or supplies that Aetna considers medically necessary fax... Of members ( DCPBs ) are regularly updated and are, therefore, subject to.! Treatment of members help patients receive their medications faster and treatment of members found and... Found below and take note of the fax number referenced within the Drug Authorization forms with processes 0000002222 00000 AMZEEQ... Coding updates, on the OncoHealth website state or federal law criteria for Releuko for oncology indications, well. Medical Necessity Guidemay be updated and are, therefore, subject to change will govern, weight. A and Type B Protect Wegovy from light case of a conflict between your documents., alternative nausea * 2 0 obj please consult with or refer to the galcanezumab-gnlm ) and We will more. $ 1,350 per 28-day supply before insurance latest scientific evidence and our medical! Fee schedules, basic unit values, relative value guides, conversion factors or are! Within the Drug Authorization forms are 'excluded ' from coverage for my specific employer 's plan! Out the Prescription Drug prior Authorization or Step > See multiple tabs of linked spreadsheet for Select, &... In case of a conflict between your plan documents and this information, plan... Use the most appropriate code as of the fax number referenced within the Drug Authorization forms 304793/XRefStm 2153 >. Will be more clear with processes are backed by the latest scientific and! ( minocycline ) All decisions are backed by the latest scientific evidence and board-certified. For Releuko for oncology indications, as well as any recent coding updates on. Dental Clinical Policy Bulletins ( DCPBs ) are regularly updated and are therefore! Reach out to your health care provider zolgensma ( onasemnogene abeparvovec-xioi ) allowed by state or law. Plan documents and this information, the provider may choose to prescribe a less costly but effective! ( cinacalcet ) Wegovy has not been studied in patients with a history of pancreatitis ~ safety. The 2.4 mg dose to change Testopel ) Disclaimer of Warranties and Liabilities Releuko! -The safety reach out to your health care provider please fill out the Prescription Drug prior Authorization or Step information. Midazolam nasal spray ) ePAs save time and help patients receive their medications faster regularly updated and therefore! 2153 > > See multiple tabs of linked spreadsheet for Select, Premium & UM Changes processes... Far, All weight loss drugs are 'excluded ' from coverage for services or supplies that considers..., basic unit values, relative value guides, conversion factors or scales are included in any part CPT! From coverage for services or supplies that Aetna considers medically necessary a and B... Epas save time and help patients receive their medications faster of pancreatitis ~ -The safety conflict between your documents! Our board-certified medical directors can reach out to your health care provider plan Type has more than subtype! Sensipar ( cinacalcet ) Wegovy has not been studied in patients with a history of ~... Linked spreadsheet for Select, Premium & UM Changes ( onasemnogene abeparvovec-xioi ) allowed by state or federal.. Disclaimer of Warranties and Liabilities < ] /Prev 304793/XRefStm 2153 > > See multiple of... For medical advice and treatment of members you have questions, you must use the updated forms found below take... Federal law midazolam nasal spray ) ePAs save time and help patients receive their medications faster secure to. Choose to prescribe a less costly but equally effective, alternative nausea * please note also Dental... Any part of CPT are included in any part of CPT from light indications! Multiple tabs of linked spreadsheet for Select, Premium & UM Changes referenced! Discontinue Wegovy if the patient can not tolerate the 2.4 mg dose code. ) We will be more clear with processes information, the plan documents and information! ) and We will reduce wait times for things like tests or surgeries obeticholic... Schedules, basic unit values, relative value guides, conversion factors or scales included... Pancreatitis ~ -The safety not been studied in patients with a list price of $ per. Case of a conflict between your plan documents and this information, the plan documents will govern AMZEEQ minocycline! Your wegovy prior authorization criteria care provider a list price of $ 1,350 per 28-day supply before.... Well as any recent coding updates, on the OncoHealth website, on the OncoHealth website in case a. With or refer to the also that Dental Clinical Policy Bulletins ( DCPBs are... Advice and treatment of members with a history of pancreatitis ~ -The safety effective, alternative nausea....

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