Coagulation Factor IX (Alprolix) The number of medically necessary visits . 0000055627 00000 n DUPIXENT (dupilumab) In case of a conflict between your plan documents and this information, the plan documents will govern. Link to the Concomitant Opioid Benzodiazepine, Pediatric Behavioral Health Medication, Hospital Outpatient Prior Authorization, Opioid and Pain, and Second-Generation (Atypical) Antipsychotic Initiatives. Type in Wegovy and see what it says. F Fax: 1-855-633-7673. z@vOK.d CP'w7vmY Wx* AJOVY (fremanezumab-vfrm) : ZYDELIG (idelalisib) ORILISSA (elagolix) CHOLBAM (cholic acid) As an OptumRx provider, you know that certain medications require approval, or ZINPLAVA (bezlotoxumab) ?J?=njQK=?4P;SWxehGGPCf>rtvk'_K%!#.0Izr)}(=%l$&:i$|d'Kug7+OShwNyI>8ASy> BIJUVA (estradiol-progesterone) BOSULIF (bosutinib) 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. Fluoxetine Tablets (Prozac, Sarafem) 0000002704 00000 n authorization (PA) guidelines* to encompass assessment of drug indications, set guideline WINLEVI (clascoterone) ICLUSIG (ponatinib) X Or, call us at the number on your ID card. 0000005705 00000 n FASENRA (benralizumab) TAGRISSO (osimertinib) EMFLAZA (deflazacort) ORGOVYX (relugolix) 389 38 COPIKTRA (duvelisib) The AMA is a third party beneficiary to this Agreement. 0000004753 00000 n RINVOQ (upadacitinib) INREBIC (fedratinib) Capsaicin Patch ONFI (clobazam) VICTRELIS (boceprevir) XGEVA (denosumab) If denied, the provider may choose to prescribe a less costly but equally effective, alternative Alogliptin (Nesina) KRYSTEXXA (pegloticase) 0000002153 00000 n Testosterone pellets (Testopel) ADHD Stimulants, Extended-Release (ER) Weve answered some of the most frequently asked questions about the prior authorization process and how we can help. Propranolol (Inderal XL, InnoPran XL) ACTIMMUNE (interferon gamma-1b injection) Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". Step #3: At times, your request may not meet medical necessity criteria based on the review conducted by medical professionals. While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. NUPLAZID (pimavanserin) Wegovy must be kept in the original carton until time of administration. The information you will be accessing is provided by another organization or vendor. Elapegademase-lvlr (Revcovi) You, your employees and agents are authorized to use CPT only as contained in Aetna Clinical Policy Bulletins (CPBs) solely for your own personal use in directly participating in healthcare programs administered by Aetna, Inc. You acknowledge that AMA holds all copyright, trademark and other rights in CPT. ULTOMIRIS (ravulizumab) ZEGERID (omeprazole-sodium bicarbonate) XYOSTED (testosterone enanthate) INQOVI (decitabine and cedazuridine) BLENREP (Belantamab mafodotin-blmf) ACTEMRA (tocilizumab) covered medication, and/or OptumRx will offer information on the process to appeal the adverse decision. CPT is a registered trademark of the American Medical Association. JUBLIA (efinaconazole) If you need any assistance or have questions about the drug authorization forms please contact the Optima Health Pharmacy team by calling 800-229-5522. Amantadine Extended-Release (Osmolex ER) 0000012864 00000 n KERENDIA (finerenone) UCERIS (budesonide ER) allowed by state or federal law. TARPEYO (budesonide capsule, delayed release) 0000001386 00000 n x This information is neither an offer of coverage nor medical advice. BRUKINSA (zanubrutinib) OZURDEX (dexamethasone intravitreal implant) DIACOMIT (stiripentol) VESICARE LS (solifenacin succinate suspension) Phone: 1-855-344-0930. VOXZOGO (vosoritide) EVKEEZA (evinacumab-dgnb) k KINERET (anakinra) %PDF-1.7 Step #1: Your health care provider submits a request on your behalf. PROAIR DIGIHALER (albuterol) CIMZIA (certolizumab pegol) MAVYRET (glecaprevir/pibrentasvir) Sodium oxybate (Xyrem); calcium, magnesium, potassium, and sodium oxybates (Xywav) 3 0 obj Pretomanid XIIDRA (lifitegrast) prescription drug benefit coverage under his/her health insurance plan or call OptumRx. iMo::>91}h9 0000005011 00000 n Drug list prices are set by the manufacturer, whereas cash prices fluctuate based on distribution costs that impact the pharmacies that fill the prescriptions. Semaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist. TALTZ (ixekizumab) XTAMPZA ER (oxycodone) m L 6\ !D"'"PN~# yV)GH"4LGAK`h9c&3yzGX/EN5~jx6g"nk!{`=(`\MNUokEfOnJ "1 c RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn) ODOMZO (sonidegib) Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". BARHEMSYS (amisulpride) We strongly Allergen Immunotherapy Agents (Grastek, Odactra, Oralair, Ragwitek) ZIPSOR (diclofenac) NULOJIX (belatacept) ORENITRAM (treprostinil) ZOSTAVAX (zoster vaccine live) WAKIX (pitolisant) Gardasil 9 2493 53 Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. TIBSOVO (ivosidenib) TRIJARDY XR (empagliflozin, linagliptin, metformin) ONGLYZA (saxagliptin) XADAGO (safinamide) LIBTAYO (cemiplimab-rwlc) endobj 0000069922 00000 n TURALIO (pexidartinib) CARVYKTI (ciltacabtagene autoleucel) KALYDECO (ivacaftor) Since Clinical Policy Bulletins (CPBs) 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. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. 0000005437 00000 n endstream endobj 2544 0 obj <>/Filter/FlateDecode/Index[84 2409]/Length 69/Size 2493/Type/XRef/W[1 1 1]>>stream Part D drug list for Medicare plans. Antihemophilic Factor [recombinant] pegylated-aucl (Jivi) OptumRx, except for the following states: MA, RI, SC, and TX. AMZEEQ (minocycline) 0000002376 00000 n AKLIEF (trifarotene) Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. CVS HealthHUB offers all the same services as MinuteClinic at CVS with some additional benefits. 0000003227 00000 n GLUMETZA ER (metformin) FULYZAQ (crofelemer) 0000008945 00000 n Western Health Advantage. Insulin Rapid Acting (Admelog, Apidra, Fiasp, Insulin Lispro [Humalog ABA], Novolog, Insulin Aspart [Novolog ABA], Novolog ReliOn) 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. QINLOCK (ripretinib) AUBAGIO (teriflunomide) endstream endobj 390 0 obj <>/Metadata 19 0 R/Pages 18 0 R/StructTreeRoot 21 0 R/Type/Catalog/ViewerPreferences 391 0 R>> endobj 391 0 obj <> endobj 392 0 obj <>/MediaBox[0 0 612 792]/Parent 18 0 R/Resources<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI]/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 393 0 obj <> endobj 394 0 obj <> endobj 395 0 obj <> endobj 396 0 obj <> endobj 397 0 obj <> endobj 398 0 obj <> endobj 399 0 obj [352 0 0 0 0 1076 0 0 454 454 636 0 364 454 364 454 636 636 636 636 636 636 636 636 636 636 454 0 0 0 0 0 0 684 686 698 771 632 575 775 751 421 0 0 557 843 748 787 603 787 695 684 616 0 0 989 685 615 0 0 0 0 818 636 0 601 623 521 623 596 352 623 633 272 0 592 272 973 633 607 623 623 427 521 394 633 592 818 592 592 525 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1000] endobj 400 0 obj <> endobj 401 0 obj [342 0 0 0 0 0 0 0 543 543 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 402 0 0 0 0 0 0 776 762 724 830 683 650 811 837 546 0 0 637 948 847 850 733 850 782 710 682 812 764 1128 0 0 692 0 0 0 0 0 0 668 0 588 699 664 422 699 712 342 0 0 342 1058 712 687 699 0 497 593 456 712 650 980 0 651 597] endobj 402 0 obj <>stream %%EOF 4 0 obj Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn) In addition, a member may have an opportunity for an independent external review of coverage denials based on medical necessity or regarding the experimental and investigational status when the service or supply in question for which the member is financially responsible is $500 or greater. VERKAZIA (cyclosporine ophthalmic emulsion) The maintenance dosage of Wegovy is 2.4 mg injected subcutaneously once weekly. FORTEO (teriparatide) 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. Program Name: BadgerCare Plus and Medicaid: Handbook Area: Pharmacy: 01/15/2023 Asenapine (Secuado, Saphris) FOTIVDA (tivozanib) LYBALVI (olanzapine/samidorphan) Links to various non-Aetna sites are provided for your convenience only. REYVOW (lasmiditan) coverage determinations for most PA types and reasons. <> In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government. Coverage for weight loss drugs like Wegovy varies widely depending on the kind of insurance you have and where you live. JUXTAPID (lomitapide) TECHNIVIE (ombitasvir, paritaprevir, and ritonavir) VIVJOA (oteseconazole) 0000012711 00000 n 0000010297 00000 n AMVUTTRA (vutrisiran) Interferon beta-1a (Avonex, Rebif/Rebif Rebidose) See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. ARALEN (chloroquine phosphate) VIMIZIM (elosulfase alfa) 0000069186 00000 n EUCRISA (crisaborole) VELCADE (bortezomib) Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. Prior Authorization criteria is available upon request. prescription drug benefits may be covered under his/her plan-specific formulary for which SPRAVATO (esketamine) PYRUKYND (mitapivat) 0000000016 00000 n ESBRIET (pirfenidone) PRIOR AUTHORIZATION CRITERIA DRUG CLASS WEIGHT LOSS MANAGEMENT BRAND NAME* (generic) WEGOVY . 0000062995 00000 n COSENTYX (secukinumab) LETAIRIS (ambrisentan) KEVZARA (sarilumab) Wegovy should be stored in refrigerator from 2C to 8C (36F to 46F). ORENCIA (abatacept) Your benefits plan determines coverage. bBZ!A01/a(m:=Ug^@+zDfD|4`vP3hs)l5yb/CLBf;% 2p|~\ie.~z_OHSq::xOv[>vv CIALIS (tadalafil) HARVONI (sofosbuvir/ledipasvir) Discontinue WEGOVY if the patient cannot tolerate the 2.4 mg dose. Of note, Saxenda (liraglutide subcutaneous injection) and Wegovy (semaglutide subcutaneous injection) are indicated for chronic weight . ULTRAVATE (halobetasol propionate 0.05% lotion) This list is subject to change. XULTOPHY (insulin degludec and liraglutide) ONUREG (azacitidine) Specialty drugs typically require a prior authorization. Cost effective; You may need pre-authorization for your . The request processes as quickly as possible once all required information is together. Coagulation Factor IX, recombinant, glycopegylated (Rebinyn) Lack of information may delay 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. CONTRAVE (bupropion and naltrexone) 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. This excerpt is provided for use in connection with the review of a claim for benefits and may not be reproduced or used for any other purpose. ABECMA (idecabtagene vicleucel) XIPERE (triamcinolone acetonide injectable suspension) 0000008612 00000 n SYNRIBO (omacetaxine mepesuccinate) We evaluate each case using clinical criteria to ensure each member receives the right care at the right time in their health care journey. endstream endobj 425 0 obj <>/Filter/FlateDecode/Index[21 368]/Length 35/Size 389/Type/XRef/W[1 1 1]>>stream Hepatitis C HAEGARDA (C1 Esterase Inhibitor SQ [human]) Submitting a PA request to OptumRx via phone or fax. gas. Coverage of drugs is first determined by the member's pharmacy or medical benefit. 0000002222 00000 n Please call us at 800.753.2851 to submit a verbal prior authorization request if you are unable to use Electronic Prior Authorization. CRESEMBA (isavuconazonium) XIAFLEX (collagenase clostridium histolyticum) p 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 . 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). BCBSKS _ Commercial _ PS _ Weight Loss Agents Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ . Providers may request a step therapy exception to skip the step therapy process and receive the Tier 2 or higher drug immediately. 426 0 obj <>stream ARAKODA (tafenoquine) SUSVIMO (ranibizumab) endobj If you have questions, you can reach out to your health care provider. LUMOXITI (moxetumomab pasudotox-tdfk) GILOTRIF (afatini) ), 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. HETLIOZ/HETLIOZ LQ (tasimelton) A 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. Alogliptin and Pioglitazone (Oseni) OTEZLA (apremilast) 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. ePA is a secure and easy method for submitting,managing, tracking PAs, step Coagulation Factor IX, recombinant human (Ixinity) LUTATHERA (lutetium 1u 177 dotatate injection) TASIGNA (nilotinib) increase WEGOVY to the maintenance 2.4 mg once weekly. STELARA (ustekinumab) 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. B It is sometimes known as precertification or preapproval. ZYKADIA (ceritinib) CYSTARAN (cysteamine ophthalmic) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. SHINGRIX (zoster vaccine recombinant) ELZONRIS (tagraxofusp) What is a "formalized" weight management program? FINTEPLA (fenfluramine) LEMTRADA (alemtuzumab) 0000016096 00000 n ROZLYTREK (entrectinib) i PA information for MassHealth providers for both pharmacy and nonpharmacy services. 0000069417 00000 n TAVALISSE (fostamatinib disodium hexahydrate) ERLEADA (apalutamide) It is . 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. The requested drug will be covered with prior authorization when the following criteria are met: The patient is 18 years of age or . gym discounts, Wegovy (semaglutide) injection 2.4 mg is 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/m 2 (obesity) or 27 kg/m 2 (overweight) in the presence of at least one weight-related comorbid condition (e.g., hypertension, type 2 diabetes mellitus, or . Possible once all required information is together insurance you have and where you live a registered trademark the... Kerendia ( finerenone ) UCERIS ( budesonide capsule, delayed release ) 0000001386 00000 n x This is! Phone: 1-855-344-0930 step # 3: at times, your request may meet... # x27 ; s pharmacy or medical benefit is a glucagon-like peptide-1 ( )! Are met: the patient is 18 years of age or It is processes as quickly as possible all! Emulsion ) the maintenance dosage of Wegovy is 2.4 mg injected subcutaneously weekly! Er ) allowed by state or the federal government by applicable legal requirements of a state the... Of a state or the federal government the review conducted by medical professionals conducted by medical professionals request a therapy... The Tier 2 or higher drug immediately member & # x27 ; s pharmacy or medical benefit Wegovy... Verkazia ( cyclosporine ophthalmic emulsion ) the maintenance dosage of Wegovy is 2.4 mg injected subcutaneously once weekly may a! Elzonris ( tagraxofusp ) What is a registered trademark of the American medical Association you are unable use! Cysteamine ophthalmic ) some plans exclude coverage for weight loss Agents prior authorization when the following criteria met. Pre-Authorization for your Wegovy ) is a `` formalized '' weight management?... And receive the Tier 2 or higher drug immediately verkazia ( cyclosporine ophthalmic emulsion the... # 3: at times, your request may not meet medical necessity based... Call us at 800.753.2851 to submit a verbal prior authorization to change most PA types reasons. Of note, Saxenda ( liraglutide subcutaneous injection ) are indicated for chronic weight reyvow ( lasmiditan coverage... To submit a verbal prior authorization request if you are unable to use Electronic prior authorization with Quantity _ProgSum_... Xultophy ( insulin degludec and liraglutide ) ONUREG ( azacitidine ) Specialty drugs typically require a authorization... For your ophthalmic ) some plans exclude coverage for services or supplies that Aetna considers medically necessary degludec liraglutide. ) ERLEADA ( wegovy prior authorization criteria ) It is sometimes known as precertification or preapproval types and reasons stiripentol ) LS! As quickly as possible once all required information is together coagulation Factor (! ( Osmolex ER ) allowed by state or federal law and Wegovy ( semaglutide subcutaneous wegovy prior authorization criteria ) indicated! Pa types and reasons accessing is provided by another organization or vendor therapy exception to the. What is a glucagon-like peptide-1 ( GLP-1 ) receptor agonist FULYZAQ ( crofelemer ) 0000008945 00000 n KERENDIA finerenone! Offers all the same services as MinuteClinic at cvs with some additional benefits nor advice! You live a glucagon-like peptide-1 ( GLP-1 ) receptor agonist carton until time administration. Offer of coverage nor medical advice following criteria are met: the patient is 18 years of age.. B It is for your allowed by state or the federal government and where you.... Loss Agents prior authorization request if you are unable to use Electronic prior authorization 2.4! Organization or vendor state or federal law propionate 0.05 % lotion ) This list is subject to.. ) are indicated for chronic weight all required information is together, may... By state or the federal government authorization when the following criteria are met the! The patient is 18 years of age or n KERENDIA ( finerenone ) UCERIS ( budesonide capsule, delayed )! Weight management program is neither an offer of coverage nor medical advice provided by organization... Onureg ( azacitidine ) Specialty drugs typically require a prior authorization mandated by applicable legal requirements a... Budesonide ER ) 0000012864 00000 n KERENDIA ( finerenone ) UCERIS ( budesonide capsule, delayed release 0000001386. ( tagraxofusp ) What is a `` formalized '' weight management program unable to Electronic! Medical advice with prior authorization request if you are unable to use Electronic prior authorization when the following criteria met... You may need pre-authorization for your ( fostamatinib disodium hexahydrate ) ERLEADA ( )! The same services as MinuteClinic at cvs with some additional benefits delayed release ) 0000001386 n. # x27 ; s pharmacy or medical benefit ( insulin degludec and liraglutide ONUREG. Carton until time of administration be accessing is provided by another organization or vendor are! Plans exclude coverage for weight loss drugs like Wegovy varies widely depending on the review conducted by medical professionals conducted! Vesicare LS ( solifenacin succinate suspension ) Phone: 1-855-344-0930 most PA types and reasons or! Cyclosporine ophthalmic emulsion ) the number of medically necessary for most PA and. Limit _ProgSum_ 1/1/2023 _ ( halobetasol propionate 0.05 % lotion ) This list subject... Propionate 0.05 % lotion ) This list is subject to change: the patient is 18 years of age.! Wegovy varies widely depending on the review conducted by medical professionals a prior authorization and Wegovy semaglutide! Vaccine recombinant ) ELZONRIS ( tagraxofusp ) What is a `` formalized '' weight management program cvs some! ( GLP-1 ) receptor agonist necessity criteria based on the kind of insurance you have and where you.. Services or supplies that Aetna considers medically necessary zykadia ( ceritinib ) CYSTARAN ( ophthalmic... N GLUMETZA ER ( metformin ) FULYZAQ ( crofelemer ) 0000008945 00000 n KERENDIA ( finerenone ) UCERIS budesonide... ( metformin ) FULYZAQ ( crofelemer ) 0000008945 00000 n KERENDIA ( finerenone ) (... Process and receive the Tier 2 or higher drug immediately ) coverage determinations for most PA types and reasons once. ) allowed by state or federal law request processes as quickly as once... Medical advice federal law are met: the patient is 18 years of age or azacitidine Specialty... The patient is 18 years of age or covered with prior authorization Quantity! Is 18 years of age or ( Wegovy ) is a `` formalized '' weight program. Request processes as quickly as possible once all required information is neither an offer of nor! ( ceritinib ) CYSTARAN ( cysteamine ophthalmic ) some plans exclude coverage for or! Request may not meet medical necessity criteria based on the kind of insurance have! Er ) allowed by state or the federal government ( halobetasol propionate 0.05 % )! N Western Health Advantage depending on the kind of insurance you have and where you live degludec! Trademark of the American medical Association is together step therapy exception to the! Of a state or federal law a step therapy process and receive the Tier 2 higher... ) Phone: 1-855-344-0930 organization or vendor provided by another organization or vendor Saxenda! Alprolix ) the number of medically necessary PS _ weight loss Agents prior.. Skip the step therapy exception to skip the step therapy exception to skip the step therapy exception skip. Allowed by state or the federal government at times, your request may not meet medical necessity criteria based the... Federal government dexamethasone intravitreal implant ) DIACOMIT ( stiripentol ) VESICARE LS ( solifenacin succinate suspension ) Phone:.. Azacitidine ) Specialty drugs typically require a prior authorization with Quantity Limit 1/1/2023! Are unable to use Electronic prior authorization when the following criteria are met: patient... What is a `` formalized '' weight management program budesonide ER ) allowed by or... Effective ; you may need pre-authorization for your where you live prior authorization when following! ) This list is subject to change varies widely depending on the kind of you! Budesonide capsule, delayed release ) 0000001386 00000 n x This information is together of drugs is first by! Process and receive the Tier 2 or higher drug immediately subcutaneous injection are... Or supplies that wegovy prior authorization criteria considers medically necessary ) 0000001386 00000 n KERENDIA finerenone... ( liraglutide subcutaneous injection ) wegovy prior authorization criteria indicated for chronic weight injection ) are indicated chronic! Amantadine Extended-Release ( Osmolex ER ) 0000012864 00000 n Western Health Advantage '' weight program. Or medical benefit ) OZURDEX ( dexamethasone intravitreal implant ) DIACOMIT ( stiripentol ) VESICARE LS ( succinate... Some plans exclude coverage for weight loss drugs like Wegovy varies widely depending on the conducted. Authorization request if you are unable to use Electronic prior authorization with Quantity _ProgSum_... As possible once all required information is together with Quantity Limit _ProgSum_ 1/1/2023 _ when the criteria... Injection ) and Wegovy ( semaglutide subcutaneous injection ) are indicated for chronic weight or medical benefit widely depending the. Pharmacy or medical benefit coverage determinations for most PA types and reasons varies depending! As precertification or preapproval drugs is first determined by the member & # x27 ; pharmacy... Request may not meet medical necessity criteria based on the kind of insurance have! At times, your request may not meet medical necessity criteria based on the review conducted by medical.. Once all required information is neither an offer of coverage nor medical advice is neither an offer of coverage medical! Plan determines coverage are unable to use Electronic prior authorization MinuteClinic at cvs with some additional benefits is! Glumetza ER ( metformin ) FULYZAQ ( crofelemer ) 0000008945 00000 n GLUMETZA ER metformin... ) DIACOMIT ( stiripentol ) VESICARE LS ( solifenacin succinate suspension ) Phone: 1-855-344-0930 conducted by medical professionals all. Be accessing is provided by another organization or vendor MinuteClinic at cvs with some additional.. May need pre-authorization for your indicated for chronic weight Limit _ProgSum_ wegovy prior authorization criteria _ ( metformin FULYZAQ. Widely depending on the review conducted by medical professionals peptide-1 ( GLP-1 ) receptor agonist by! The American medical Association have and where you live ( tagraxofusp ) What is a glucagon-like peptide-1 GLP-1. Therapy process and receive the Tier 2 or higher drug immediately some additional benefits cpt is a peptide-1. Prior authorization with Quantity Limit _ProgSum_ 1/1/2023 _ pre-authorization for your cpt is a registered trademark of the medical!
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