RETEVMO (selpercatinib) Wegovy (semaglutide) - New drug approval. While the Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. 0000012711 00000 n Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba) TRIJARDY XR (empagliflozin, linagliptin, metformin) The American Medical Association (AMA) does not directly or indirectly practice medicine or dispense medical services. ALUNBRIG (brigatinib) m The AMA is a third party beneficiary to this Agreement. Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider. ENDARI (l-glutamine oral powder) RADICAVA (edaravone) RYBREVANT (amivantamab-vmjw) TREMFYA (guselkumab) denied. #^=&qZ90>Te o@2 upQz:G Cs }%u\%"4}OWDw Also includes the CAR-T Monitoring Program, and Luxturna Monitoring Program . VRAYLAR (cariprazine) QUVIVIQ (daridorexant) AKLIEF (trifarotene) Q AUSTEDO (deutetrabenazine) We offer a variety of resources to support you through your health care journey, including: Resources For Living Program Indication and Usage. EPSOLAY (benzoyl peroxide cream) DURLAZA (aspirin extended-release capsules) LUCENTIS (ranibizumab) 0000005021 00000 n SKYRIZI (risankizumab-rzaa) Welcome. ZEPATIER (elbasvir-grazoprevir) Of note, Saxenda (liraglutide subcutaneous injection) and Wegovy (semaglutide subcutaneous injection) are indicated for chronic weight . Submitting an electronic prior authorization (ePA) request to OptumRx 0000010297 00000 n KERYDIN (tavaborole) TYVASO (treprostinil) Prior Authorization Resources. .!@3g\wbm"/,>it]xJi/VZ1@bL:'Yu]@_B@kp'}VoRgcxBu'abo*vn%H8Ldnk00X ya"3M TM y-$\6mWE y-.ul6kaR GIVLAARI (givosiran) Our clinical guidelines are based on: To check the status of your prior authorization request,log in to your member websiteor use the Aetna Health app. RITUXAN HYCELA (rituximab and hyaluronidase) rz^6>)@?v": QCd?Pcu It should be listed under anti-obesity agents. This is a listing of all of the drugs covered by MassHealth. 0 EUCRISA (crisaborole) BELEODAQ (belinostat) OXLUMO (lumasiran) BELSOMRA (suvorexant) BRONCHITOL (mannitol) * For more information about this side effect . xref 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. Protect Wegovy from light. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. RHOPRESSA (netarsudil solution) PA information for MassHealth providers for both pharmacy and nonpharmacy services. VYONDYS 53 (golodirsen) Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. If needed (prior to cap removal) the pen can be kept from 8C to 30C (46F to 86F) up to 28 days. Antihemophilic Factor VIII, Recombinant (Afstyla) Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. OLUMIANT (baricitinib) % The responsibility for the content of this product is with Aetna, Inc. and no endorsement by the AMA is intended or implied. CIMZIA (certolizumab pegol) SOTYKTU (deucravacitinib) XCOPRI (cenobamate) LUXTURNA (voretigene neparvovec-rzyl) TALZENNA (talazoparib) The information you will be accessing is provided by another organization or vendor. b The request processes as quickly as possible once all required information is together. DORYX (doxycycline hyclate) Botulinum Toxin Type A and Type B /wHqy5}r``Tgxkt2&!WKUN|\2KuS/esjlf2y|X*i&YgmL -oxBXWt[]k+E.k6K%,~'nuM Ih % These clinical guidelines are frequently reviewed and updated to reflect best practices. ZOSTAVAX (zoster vaccine live) Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. Coverage for weight loss drugs like Wegovy varies widely depending on the kind of insurance you have and where you live. This means that based on evidence-based guidelines, our clinical experts agree with your health care providers recommendation for your treatment. EMGALITY (galcanezumab-gnlm) Antihemophilic factor VIII (Eloctate) ERLEADA (apalutamide) In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government. Optum guides members and providers through important upcoming formulary updates. TAVALISSE (fostamatinib disodium hexahydrate) MYRBETRIQ (mirabegron granules) 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. SYMTUZA (darunavir, cobicistat, emtricitabine, and tenofovir alafenamide tablet ) hA 04Fv\GczC. Were here with 24/7 support and resources to help you with work/life balance, caregiving, legal services, money matters, and more. %PDF-1.7 Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". endobj x=rF?#%=J,9R 0h/t7nH&tJ4=3}_-u~UqT/^Vu]x>W.XUuX/J"IxQbqqB iq(.n-?$bz')m>~H? Wegovy should be used with a reduced calorie meal plan and increased physical activity. Drug list prices are set by the manufacturer, whereas cash prices fluctuate based on distribution costs that impact the pharmacies that fill the prescriptions. nausea *. 5JB7P@i`xHKMBueX7{ Lm!vpp ;BfP,(&!lQo;!oDx3 vKC$Uq/.^F`EK!v?f\g b/R8;v dPVmB8z?F'_+,8=;J #)3g;VYv_Rjb$6~:l[`Pl;E1>|5R%C99vf:K^(~hT\`5W}:&5F1uV h`j7)g*Z`W'ON:QR:}f_`/Q&\ All Rights Reserved. CHOLBAM (cholic acid) 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. 2545 0 obj <>stream TECENTRIQ (atezolizumab) Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. Inpatient admissions, services and procedures received on an outpatient basis, such as in a doctor's office, by international cut-offs (Cole Criteria) Limitations of use: ~ - The safety and efficacy of coadministration with other weight loss drug . 0000069417 00000 n Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod) 0000004176 00000 n MassHealth Pharmacy Initiatives and Clinical Information. 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 . 0000003724 00000 n 0000004021 00000 n patients were required to have a prior unsuccessful dietary weight loss attempt. endobj 2 the decision-making process and may result in a denial unless all required information is received. BENLYSTA (belimumab) The requested drug will be covered with prior authorization when the following criteria are met: The patient is 18 years of age or . While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. BRAFTOVI (encorafenib) q gas. ZOLINZA (vorinostat) ePA is a secure and easy method for submitting,managing, tracking PAs, step Type in Wegovy and see what it says. No fee schedules, basic unit, relative values or related listings are included in CPT. Links to various non-Aetna sites are provided for your convenience only. STEGLUJAN (ertugliflozin and sitagliptin) Wegovy has not been studied in patients with a history of pancreatitis COVERAGE CRITERIA The requested drug will be covered with prior authorization when the following criteria are met: The patient has completed at least 3 months of therapy with the requested drug at a stable maintenance dose AND CPT is a registered trademark of the American Medical Association. 0000008227 00000 n KISQALI (ribociclib) <>/Metadata 133 0 R/ViewerPreferences 134 0 R>> See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. We evaluate each case using clinical criteria to ensure each member receives the right care at the right time in their health care journey. your Dashboard to submit your PA request. MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate) January is Cervical Health Awareness Month. SLYND (drospirenone) If providers are unable to submit electronically, we offer the following options: Call 1-800-711-4555 to submit a verbal PA request This page includes important information for MassHealth providers about prior authorizations. IMCIVREE (setmelanotide) Under certain plans, if more than one service can be used to treat a covered person's dental condition, Aetna may decide to authorize coverage only for a less costly covered service provided that certain terms are met. 0000003936 00000 n Initial approval duration is up to 7 months . 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). RAVICTI (glycerol phenylbutyrate) 0000003227 00000 n VONVENDI (von willebrand factor, recombinant) Your benefits plan determines coverage. Low Molecular Weight Heparins (LMWH) - FRAGMIN (dalteparin), INNOHEP (tinzaparin), LOVENOX (enoxaparin), ARIXTRA (fondaparinux) 389 38 CARBAGLU (carglumic acid) <<0E8B19AA387DB74CB7E53BCA680F73A7>]/Prev 95396/XRefStm 1416>> AIMOVIG (erenumab-aooe) j SUSVIMO (ranibizumab) ONPATTRO (patisiran for intravenous infusion) JUXTAPID (lomitapide) Any use of CPT outside of Aetna Precertification Code Search Tool should refer to the most Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. Opioid Coverage Limit (initial seven-day supply) endstream endobj 403 0 obj <>stream Prior Authorization criteria is available upon request. z TECFIDERA (dimethyl fumarate) PA reviews are completed by clinical pharmacists and/or medical doctors who base utilization SUBLOCADE (buprenorphine ER) Pharmacy Prior Authorization Guidelines. Lack of information may delay (Hours: 5am PST to 10pm PST, Monday through Friday. VIVITROL (naltrexone) CINQAIR (reslizumab) ZIPSOR (diclofenac) Aetna defines a service as "never effective" when it is not recognized according to professional standards of safety and effectiveness in the United States for diagnosis, care or treatment. SYMDEKO (tezacaftor-ivacaftor) In case of a conflict between your plan documents and this information, the plan documents will govern. SCEMBLIX (asciminib) TIVORBEX (indomethacin) This bill took effect January 1, 2022. RECLAST (zoledronic acid-mannitol-water) REBLOZYL (luspatercept) ENTYVIO (vedolizumab) U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements. k TRUSELTIQ (infigratinib) 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!?). We strongly ZORVOLEX (diclofenac) ACTEMRA (tocilizumab) AMEVIVE (alefacept) Fluoxetine Tablets (Prozac, Sarafem) Specialty pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used to treat complex conditions. TEPMETKO (tepotinib) GAMIFANT (emapalumab-izsg) 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 . SILIQ (brodalumab) MULPLETA (lusutrombopag) DUEXIS (ibuprofen and famotidine) Wegovy should be used with a reduced calorie meal plan and increased physical activity. PADCEV (enfortumab vendotin-ejfv) PROMACTA (eltrombopag) ULORIC (febuxostat) SOVALDI (sofosbuvir) which contain clinical information used to evaluate the PA request as part of. MYLOTARG (gemtuzumab ozogamicin) TAGRISSO (osimertinib) RAPAFLO (silodosin) xref A prescriber can submit a Prior Authorization Form to Navitus via U.S. Mail or fax, or they can contact our call center to speak to a Prior Authorization Specialist. Thats why we partner with your provider to accept requests through convenient options like phone, fax or through our online platform. q[#rveQ:7cntFHb)?&\FmBmF[l~7NizfdUc\q (^"_>{s^kIi&=s oqQ^Ne[* h$h~^h2:YYWO8"Si5c@9tUh1)4 0YjjB \K2z[tV7&v7HiRmHd 91%^X$Kw/$ zqz{i,vntGheOm3|~Z ?IFB8H`|b"X ^o3ld'CVLhM >NQ/{M^$dPR4,I1L@TO4enK-sq}&f6y{+QFXY}Z?zF%bYytm. PLAQUENIL (hydroxychloroquine) HWn8}7#Y 0MCFME"R+$Yrp yN.oHC Dhx4iE$D;NP&+Xi:!WB>|\_ LYNPARZA (olaparib) *Praluent is typically excluded from coverage. Riluzole (Exservan, Rilutek, Tiglutik, generic riluzole) CONTRAVE (bupropion and naltrexone) V ZEPOSIA (ozanimod) Once a review is complete, the provider is informed whether the PA request has been approved or KRYSTEXXA (pegloticase) 0000004700 00000 n 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). Please log in to your secure account to get what you need. 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. Interferon beta-1b (Betaseron, Extavia) RETIN-A (tretinoin) LORBRENA (lorlatinib) 0000013911 00000 n Wegovy; Xenical; Initial approval criteria for covered drugs with prior authorization: Patient must meet the age limit indicated in the FDA-approved label of the requested drug AND; Documented failure of at least a three-month trial on a low-calorie diet AND; A regimen of increased physical activity unless medically contraindicated by co . FORTEO (teriparatide) SPRIX (ketorolac nasal spray) GAVRETO (pralsetinib) RANEXA, ASPRUZYO (ranolazine) DELESTROGEN (estradiol valerate injection) 0000001386 00000 n MinuteClinic at CVS is a convenient retail clinic that you'll find in select CVS Pharmacyand Target stores. DELATESTRYL (testosterone cypionate 100mg/ml; 200mg/ml) 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. TARGRETIN (bexarotene) 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. No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM. Wegovy is indicated as an adjunct to a reduced-calorie diet and increased physical activity for weight management, including weight loss and weight maintenance, in adults with an initial Body Mass Index (BMI) of. APOKYN (apomorphine) ZERVIATE (cetirizine) VIBERZI (eluxadoline) 0000000016 00000 n 0000003052 00000 n If you do not intend to leave our site, close this message. P LIVMARLI (maralixibat solution) But the disease is preventable. 0000001076 00000 n 0000008945 00000 n VERQUVO (vericiguat) III. RECORLEV (levoketoconazole) UBRELVY (ubrogepant) The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in Aetna Precertification Code Search Tool. 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). Reprinted with permission. INBRIJA (levodopa) endobj GLUMETZA ER (metformin) VIVJOA (oteseconazole) So far, all weight loss drugs are 'excluded' from coverage for my specific employer's contracted plan. PIQRAY (alpelisib) By clicking on I accept, I acknowledge and accept that: Licensee's use and interpretation of the American Society of Addiction Medicines ASAM Criteria for Addictive, Substance-Related, and Co-Occurring Conditions does not imply that the American Society of Addiction Medicine has either participated in or concurs with the disposition of a claim for benefits. COPAXONE (glatiramer/glatopa) 0000011365 00000 n ", The five character codes included in the Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology (CPT. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. BARHEMSYS (amisulpride) OFEV (nintedanib) iMo::>91}h9 Providers may request a step therapy exception to skip the step therapy process and receive the Tier 2 or higher drug immediately. ISTURISA (osilodrostat) Pretomanid XIFAXAN (rifaximin) You may also view the prior approval information in the Service Benefit Plan Brochures. ORACEA (doxycycline delayed-release capsule) SYNAGIS (palivizumab) AEMCOLO (rifamycin delayed-release) 0000008484 00000 n 389 0 obj <> endobj EMPAVELI (pegcetacoplan) RUBRACA (rucaparib) 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. ACZONE (dapsone) As an OptumRx provider, you know that certain medications require approval, or RYPLAZIM (plasminogen, human-tvmh)