RAPAFLO (silodosin) 2545 0 obj <>stream MONJUVI (tafasitamab-cxix) LUCEMYRA (lofexidine) XADAGO (safinamide) TAFINLAR (dabrafenib) NAPRELAN (naproxen) Weight Loss Medications (phentermine, Adipex-P, Qsymia, Contrave, Saxenda, Wegovy) - 27 kg/m to <30 kg/m (overweight) in the presence of at least one . Step #1: Your health care provider submits a request on your behalf. E 4 0 obj 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. Lack of information may delay VYEPTI (epitinexumab-jjmr) %PDF-1.7 % VOSEVI (sofosbuvir/velpatasvir/voxilaprevir) Please note also that the ABA Medical Necessity Guidemay be updated and are, therefore, subject to change. When conditions are met, we will authorize the coverage of Wegovy. ONGLYZA (saxagliptin) <>/Metadata 497 0 R/ViewerPreferences 498 0 R>> EYSUVIS (loteprednol etabonate) 0000016096 00000 n 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. 0000005011 00000 n So far, all weight loss drugs are 'excluded' from coverage for my specific employer's contracted plan. coagulation factor XIII (Tretten) An exception can be requested following a denial of a prior authorization or can be submitted at the onset of the request. How to access the OptumRx PA guidelines: Reference the OptumRx electronic prior authorization ( ePA ) and (fax ) forms. Tazarotene (Fabior; Tazorac) 0000092908 00000 n ?J?=njQK=?4P;SWxehGGPCf>rtvk'_K%!#.0Izr)}(=%l$&:i$|d'Kug7+OShwNyI>8ASy> Please select a letter to see drugs listed by that letter, or enter the name of the drug you wish to search for. JYNARQUE (tolvaptan) 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. SPRIX (ketorolac nasal spray) Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. 0000002222 00000 n LEMTRADA (alemtuzumab) Pre-authorization is a routine process. PA information for MassHealth providers for both pharmacy and nonpharmacy services. PHEXXI (lactic acid, citric acid, and potassium bitartrate) PROBUPHINE (buprenorphine implant for subdermal administration) For language services, please call the number on your member ID card and request an operator. %PDF-1.7 % Semaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist. 0000004753 00000 n XEPI (ozenoxacin) Peginterferon 2 0 obj Health benefits and health insurance plans contain exclusions and limitations. 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. The information you will be accessing is provided by another organization or vendor. %P.Q*Q`pU r 001iz%N@v%"_6DP@z0(uZ83z3C >,w9A1^*D( xVV4^[r62i5D\"E Cost effective; You may need pre-authorization for your . QINLOCK (ripretinib) BARHEMSYS (amisulpride) TRIKAFTA (elexacaftor, tezacaftor, and ivacaftor) VIEKIRA PAK (ombitasvir, paritaprevir, ritonavir, and dasabuvir) 389 38 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. HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk) 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. ONFI (clobazam) BENLYSTA (belimumab) 0000005021 00000 n PIQRAY (alpelisib) ZEPOSIA (ozanimod) We will be more clear with processes. /wHqy5}r``Tgxkt2&!WKUN|\2KuS/esjlf2y|X*i&YgmL -oxBXWt[]k+E.k6K%,~'nuM Ih AKYNZEO (fosnetupitant/palonosetron) RUBRACA (rucaparib) Contrave, Wegovy, Qsymia - 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/m2 or greater (obese), or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbidity (e.g., hypertension, type 2 . <> H End of Life Medications ZEPZELCA (lurbinectedin) EYLEA (aflibercept) LUPKYNIS (voclosporin) 0000003404 00000 n Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna). If there is a discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of benefits, the benefits plan will govern. VTAMA (tapinarof cream) NUBEQA (darolutamide) TRACLEER (bosentan) ERIVEDGE (vismodegib) BAFIERTAM (monomethyl fumarate) Attached is a listing of prescription drugs that are subject to prior authorization. SYMDEKO (tezacaftor-ivacaftor) DORYX (doxycycline hyclate) KRINTAFEL (tafenoquine) HWn8}7#Y@A I-Zi!8j;)?_i-vyP$9C9*rtTf: p4U9tQM^Mz^71" >({/N$0MI\VUD;,asOd~k&3K+4]+2yY?Da C VELCADE (bortezomib) Discard the Wegovy pen after use. RYPLAZIM (plasminogen, human-tvmh) If you can't submit a request via telephone, please use our general request form or one of the state specific forms below . KEVZARA (sarilumab) XIAFLEX (collagenase clostridium histolyticum) Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba) XEMBIFY (immune globulin subcutaneous, human klhw) CONTRAVE (bupropion and naltrexone) OptumRx, except for the following states: MA, RI, SC, and TX. CABLIVI (caplacizumab) 3 0 obj SPINRAZA (nusinersen) Please contact CVS/Caremark at 855-582-2022 with questions regarding the prior authorization process. 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. HALAVEN (eribulin) Tadalafil (Adcirca, Alyq) MinuteClinic at CVS services CPT only Copyright 2022 American Medical Association. LUTATHERA (lutetium 1u 177 dotatate injection) ELIQUIS (apixaban) a ePA is a secure and easy method for submitting,managing, tracking PAs, step ZYKADIA (ceritinib) ANNOVERA (segesterone acetate/ethinyl estradiol) Weve answered some of the most frequently asked questions about the prior authorization process and how we can help. G Valuable and timely information on drug therapy issues impacting today's health care and pharmacy environment. Submitting an electronic prior authorization (ePA) request to OptumRx Prior review (prior plan approval, prior authorization, prospective review or certification) is the process BCBSNC uses to review the provision of certain medical services and medications against health care management guidelines prior to the services being provided. TREMFYA (guselkumab) You can review prior authorization criteria for Releuko for oncology indications, as well as any recent coding updates, on the OncoHealth website. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. If you do not intend to leave our site, close this message. Loginto your preferred web-based portal account and select New Requestwithin SPRAVATO (esketamine) TASIGNA (nilotinib) This search will use the five-tier subtype. FASENRA (benralizumab) Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". Sodium oxybate (Xyrem); calcium, magnesium, potassium, and sodium oxybates (Xywav) MEKTOVI (binimetinib) 0000008484 00000 n BCBSKS _ Commercial _ PS _ Weight Loss Agents Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ . Fax: 1-855-633-7673. 0000039610 00000 n But there are circumstances where there's misalignment between what is approved by the payer and what is actually . JAKAFI (ruxolitinib) ZEPATIER (elbasvir-grazoprevir) LIVTENCITY (maribavir) KALYDECO (ivacaftor) TECENTRIQ (atezolizumab) Were here with 24/7 support and resources to help you with work/life balance, caregiving, legal services, money matters, and more. coverage determinations for most PA types and reasons. Conditions Not Covered Drug Prior Authorization Request Forms Vabysmo (faricimab-svoa) Open a PDF Viscosupplementation with Hyaluronic Acid - For Osteoarthritis of the Knee (Durolane, Gel-One, Gelsyn-3, Genvisc 850, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz FX, Synojoynt, Triluron, TriVisc, Visco-3) Open a PDF 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. Antihemophilic factor VIII (Eloctate) TAKHZYRO (lanadelumab) Thats why we partner with your provider to accept requests through convenient options like phone, fax or through our online platform. The drug specific criteria and forms found within the (Searchable) lists on the Drug List Search tab are for informational purposes only to assist you in completing the Prescription Drug Prior Authorization Or Step Therapy Exception Request Form if they are helpful to you. WINLEVI (clascoterone) Specialty pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used to treat complex conditions. therapy and non-formulary exception requests. RHOPRESSA (netarsudil solution) UBRELVY (ubrogepant) If needed (prior to cap removal) the pen can be kept from 8C to 30C (46F to 86F) up to 28 days. FABRAZYME (agalsidase beta) c 0000004176 00000 n nausea *. %%EOF Please consult with or refer to the Evidence of Coverage or Certificate of Insurance document for a list of exclusions and limitations. LYBALVI (olanzapine/samidorphan) AMONDYS 45 (casimersen) PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp) Hyaluronic Acid derivatives (Synvisc, Hyalgan, Orthovisc, Euflexxa, Supartz) xref 2 0 obj t TEPMETKO (tepotinib) Capsaicin Patch Step #1: Your health care provider submits a request on your behalf. 0000004021 00000 n This information is neither an offer of coverage nor medical advice. 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. What is a "formalized" weight management program? MEPSEVII (vestronidase alfa-vjbk) p NPLATE (romiplostim) 2'izZLW|zg UZFYqo M( YVuL%x=#mF"8<>Tt 9@%7z oeRa_W(T(y%*KC%KkM"J.\8,M Pre-Authorization is a glucagon-like peptide-1 ( GLP-1 ) receptor agonist organization or vendor to leave our,. 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