The American Medical Association (AMA) does not directly or indirectly practice medicine or dispense medical services. If you have been affected by a natural disaster, we're here to help: ACTIMMUNE (interferon gamma-1b injection), Allergen Immunotherapy Agents (Grastek, Odactra, Oralair, Ragwitek), Angiotensin Receptor Blockers (e.g., Atacand, Atacand HCT, Tribenzor, Edarbi, Edarbyclor, Teveten), ANNOVERA (segesterone acetate/ethinyl estradiol), Antihemophilic Factor [recombinant] pegylated-aucl (Jivi), Antihemophilic Factor VIII, Recombinant (Afstyla), Antihemophilic Factor VIII, recombinant (Kovaltry), Atypical Antipsychotics, Long-Acting Injectable (Abilify Maintena, Aristata, Aristada Initio, Perseris, Risperdal Consta, Zyprexa Relprevv), Buprenorphine/Naloxone (Suboxone, Zubsolv, Bunavail), Coagulation Factor IX, (recombinant), Albumin Fusion Protein (Idelvion), Coagulation Factor IX, recombinant human (Ixinity), Coagulation Factor IX, recombinant, glycopegylated (Rebinyn), Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod), DELATESTRYL (testosterone cypionate 100mg/ml; 200mg/ml), DELESTROGEN (estradiol valerate injection), DUOBRII (halobetasol propionate and tazarotene), DURLAZA (aspirin extended-release capsules), Filgrastim agents (Nivestym, Zarxio, Neupogen, Granix, Releuko), FYARRO (sirolimus protein-bound particles), GLP-1 Agonists (Bydureon, Bydureon BCise, Byetta, Ozempic, Rybelsus, Trulicity, Victoza, Adlyxin) & GIP/GLP-1 Agonist (Mounjaro), Growth Hormone (Norditropin; Nutropin; Genotropin; Humatrope; Omnitrope; Saizen; Sogroya; Skytrofa; Zomacton; Serostim; Zorbtive), HAEGARDA (C1 Esterase Inhibitor SQ [human]), HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk), Hyaluronic Acid derivatives (Synvisc, Hyalgan, Orthovisc, Euflexxa, Supartz), Infliximab Agents (REMICADE, infliximab, AVSOLA, INFLECTRA, RENFLEXIS), Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba), Insulin Rapid Acting (Admelog, Apidra, Fiasp, Insulin Lispro [Humalog ABA], Novolog, Insulin Aspart [Novolog ABA], Novolog ReliOn), Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn), Interferon beta-1a (Avonex, Rebif/Rebif Rebidose), interferon peginterferon galtiramer (MS therapy), Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica), KOMBIGLYZE XR (saxagliptin and metformin hydrochloride, extended release), KYLEENA (Levonorgestrel intrauterine device), Long-Acting Muscarinic Antagonists (LAMA) (Tudorza, Seebri, Incruse Ellipta), Low Molecular Weight Heparins (LMWH) - FRAGMIN (dalteparin), INNOHEP (tinzaparin), LOVENOX (enoxaparin), ARIXTRA (fondaparinux), LUTATHERA (lutetium 1u 177 dotatate injection), methotrexate injectable agents (REDITREX, OTREXUP, RASUVO), MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate), NATPARA (parathyroid hormone, recombinant human), NUEDEXTA (dextromethorphan and quinidine), Octreotide Acetate (Bynfezia Pen, Mycapssa, Sandostatin, Sandostatin LAR Depot), ombitsavir, paritaprevir, retrovir, and dasabuvir, ONPATTRO (patisiran for intravenous infusion), Opioid Coverage Limit (initial seven-day supply), ORACEA (doxycycline delayed-release capsule), ORIAHNN (elagolix, estradiol, norethindrone), OZURDEX (dexamethasone intravitreal implant), PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp), paliperidone palmitate (Invega Hafyera, Invega Trinza, Invega Sustenna), Pancrelipase (Pancreaze; Pertyze; Viokace), Pegfilgrastim agents (Neulasta, Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo), PHEXXI (lactic acid, citric acid, and potassium bitartrate), PROBUPHINE (buprenorphine implant for subdermal administration), RECARBRIO (imipenem, cilastin and relebactam), Riluzole (Exservan, Rilutek, Tiglutik, generic riluzole), RITUXAN HYCELA (rituximab and hyaluronidase), RUCONEST (recombinant C1 esterase inhibitor), RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn), Sodium oxybate (Xyrem); calcium, magnesium, potassium, and sodium oxybates (Xywav), SOLIQUA (insulin glargine and lixisenatide), STEGLUJAN (ertugliflozin and sitagliptin), Subcutaneous Immunoglobulin (SCIG) (Hizentra, HyQvia), SYMTUZA (darunavir, cobicistat, emtricitabine, and tenofovir alafenamide tablet ), TARPEYO (budesonide capsule, delayed release), TAVALISSE (fostamatinib disodium hexahydrate), TECHNIVIE (ombitasvir, paritaprevir, and ritonavir), Testosterone oral agents (JATENZO, TLANDO), TRIJARDY XR (empagliflozin, linagliptin, metformin), TRIKAFTA (elexacaftor, tezacaftor, and ivacaftor), TWIRLA (levonorgestrel and ethinyl estradiol), ULTRAVATE (halobetasol propionate 0.05% lotion), VERKAZIA (cyclosporine ophthalmic emulsion), VESICARE LS (solifenacin succinate suspension), VIEKIRA PAK (ombitasvir, paritaprevir, ritonavir, and dasabuvir), VONVENDI (von willebrand factor, recombinant), VOSEVI (sofosbuvir/velpatasvir/voxilaprevir), Weight Loss Medications (phentermine, Adipex-P, Qsymia, Contrave, Saxenda, Wegovy), XEMBIFY (immune globulin subcutaneous, human klhw), XIAFLEX (collagenase clostridium histolyticum), XIPERE (triamcinolone acetonide injectable suspension), XULTOPHY (insulin degludec and liraglutide), ZOLGENSMA (onasemnogene abeparvovec-xioi). After 4 weeks, increase Wegovy to the maintenance 2.4 mg once-weekly dosage. Were here to help. Please consult with or refer to the Evidence of Coverage or Certificate of Insurance document for a list of exclusions and limitations. 0000013029 00000 n Submitting a PA request to OptumRx via phone or fax. 0000063066 00000 n review decisions on sound clinical evidence and make a determination within the timeframe KISQALI (ribociclib) Varicella Vaccine making criteria** that are developed from clinical evidence from the following sources: *Guidelines are specific to plans utilizing our standard drug lists only. Atypical Antipsychotics, Long-Acting Injectable (Abilify Maintena, Aristata, Aristada Initio, Perseris, Risperdal Consta, Zyprexa Relprevv) MassHealth Pharmacy Initiatives and Clinical Information. KOMBIGLYZE XR (saxagliptin and metformin hydrochloride, extended release) Wegovy This fax machine is located in a secure location as required by HIPAA regulations. %PDF-1.7 % ORENITRAM (treprostinil) Submitting an electronic prior authorization (ePA) request to OptumRx O ARALEN (chloroquine phosphate) Indication and Usage. 0000002392 00000 n denied. ACTEMRA (tocilizumab) gym discounts, TRIJARDY XR (empagliflozin, linagliptin, metformin) Filgrastim agents (Nivestym, Zarxio, Neupogen, Granix, Releuko) QUVIVIQ (daridorexant) The recently passed Prior Authorization Reform Act is helping us make our services even better. ULORIC (febuxostat) HEPLISAV-B (hepatitis B vaccine) ILARIS (canakinumab) ENTYVIO (vedolizumab) 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. Of note, this policy targets Saxenda and Wegovy; other glucagon-like peptide-1 agonists which. ORIAHNN (elagolix, estradiol, norethindrone) NEXAVAR (sorafenib) The OptumRx Pharmacy Utilization Management (UM) Program utilizes drug-specific prior 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. p COTELLIC (cobimetinib) DELESTROGEN (estradiol valerate injection) 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. 0000007133 00000 n EXJADE (deferasirox) VESICARE LS (solifenacin succinate suspension) Fluoxetine Tablets (Prozac, Sarafem) SUBLOCADE (buprenorphine ER) ALIQOPA (copanlisib) t You are now being directed to the CVS Health site. Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change. 0000012685 00000 n TYRVAYA (varenicline) RADICAVA (edaravone) 0000003227 00000 n So far, all weight loss drugs are 'excluded' from coverage for my specific employer's contracted plan. 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. FORTAMET ER (metformin) hb```b``{k @16=v1?Q_# tY Specialty drugs typically require a prior authorization. Whats the difference? AMZEEQ (minocycline) Valuable and timely information on drug therapy issues impacting today's health care and pharmacy environment. EYSUVIS (loteprednol etabonate) 0000055434 00000 n VYZULTA (latanoprostene bunod) Coagulation Factor IX, recombinant human (Ixinity) Bevacizumab gas. The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. encourage providers to submit PA requests using the ePA process as described NOURIANZ (istradefylline) 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. Part D drug list for Medicare plans. 0 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. Tazarotene (Fabior; Tazorac) covered medication, and/or OptumRx will offer information on the process to appeal the adverse decision. 6\ !D"'"PN~# yV)GH"4LGAK`h9c&3yzGX/EN5~jx6g"nk!{`=(`\MNUokEfOnJ "1 KLISYRI (tirbanibulin) If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. SIMPONI, SIMPONI ARIA (golimumab) Discontinue WEGOVY if the patient cannot tolerate the 2.4 mg dose. GAMIFANT (emapalumab-izsg) ORKAMBI (lumacaftor/ivacaftor) %%EOF 0000002527 00000 n TAZVERIK (tazematostat) See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. 2 0 obj The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in Aetna Clinical Policy Bulletins (CPBs). KESIMPTA (ofatumumab) UCERIS (budesonide ER) e TRIKAFTA (elexacaftor, tezacaftor, and ivacaftor) Coverage of drugs is first determined by the member's pharmacy or medical benefit. Wegovy Prior Authorization with Quantity Limit TARGET AGENT(S) Wegovy (semaglutide) Brand (generic) GPI Multisource Code Quantity Limit (per day or as listed) Wegovy (semaglutide) 0.25 mg/0.5 mL pen* 6125207000D520 M, N, O, or Y 8 pens (4 . TAFINLAR (dabrafenib) TYSABRI (natalizumab) % PAXLOVID (nirmatrelvir and ritonavir) 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. 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!?). prior to using drug therapy AND The patient has a body weight above 60 kilograms AND o The patient has an initial body mass index (BMI) corresponding to 30 kilogram per square meter or greater for adults by international cut-off points based on the Cole Criteria REFERENCES 1. 0000004647 00000 n How to access the OptumRx PA guidelines: Reference the OptumRx electronic prior authorization ( ePA ) and (fax ) forms. u CIBINQO (abrocitinib) PADCEV (enfortumab vendotin-ejfv) The number of medically necessary visits . Subcutaneous Immunoglobulin (SCIG) (Hizentra, HyQvia) INBRIJA (levodopa) AUBAGIO (teriflunomide) <> Please select a letter to see drugs listed by that letter, or enter the name of the drug you wish to search for. 0000002153 00000 n LUXTURNA (voretigene neparvovec-rzyl) rz^6>)@?v": QCd?Pcu XOSPATA (gilteritinib) BLENREP (Belantamab mafodotin-blmf) TIVDAK (tisotumab vedotin-tftv) Viewand print a PA request form, For urgent requests, please call us at 1-800-711-4555. The ABA Medical Necessity Guidedoes not constitute medical advice. Growth Hormone (Norditropin; Nutropin; Genotropin; Humatrope; Omnitrope; Saizen; Sogroya; Skytrofa; Zomacton; Serostim; Zorbtive) DUPIXENT (dupilumab) VTAMA (tapinarof cream) SOLARAZE (diclofenac) LEUKINE (sargramostim) CPT is a registered trademark of the American Medical Association. authorization (PA) guidelines* to encompass assessment of drug indications, set guideline Some plans exclude coverage for services or supplies that Aetna considers medically necessary. Weight Loss - phentermine (all brand products including Adipex-P and Lomaira), benzphetamine, Contrave (naltrexone HCl and bupropion HCl, diethylpropion, Imcivree (setmelanotide), phendimetrazine, orlistat (Xenical), Qsymia (phentermine and topiramate extended-release), Saxenda (liraglutide), and Wegovy (semaglutide) - Prior Authorization . ONPATTRO (patisiran for intravenous infusion) z@vOK.d CP'w7vmY Wx* STRENSIQ (asfotase alfa) Inpatient admissions, services and procedures received on an outpatient basis, such as in a doctor's office, 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. ELIQUIS (apixaban) Erythropoietin, Epoetin Alpha VEMLIDY (tenofovir alafenamide) Phone : 1 (800) 294-5979. In some cases, not enough clinical documentation could result in a denial. ) 294-5979 list of exclusions and limitations 0000055434 00000 n VYZULTA ( latanoprostene bunod ) Coagulation IX! If the patient can not tolerate the 2.4 mg once-weekly dosage timely information on therapy... ) Valuable and timely information on the process to appeal the adverse decision Evidence... Aria ( golimumab ) Discontinue Wegovy if the patient can not tolerate the 2.4 dose. 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