Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod) We use it to make sure your prescription drug is: Safe; Effective; Medically necessary To be medically necessary means it is appropriate, reasonable, and adequate for your condition. TUKYSA (tucatinib) KERENDIA (finerenone) 0000008945 00000 n BRAFTOVI (encorafenib) ICLUSIG (ponatinib) ZIPSOR (diclofenac) Alogliptin (Nesina) Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change. XURIDEN (uridine triacetate) ONUREG (azacitidine) All approvals are provided for the duration noted below. OPSUMIT (macitentan) RANEXA, ASPRUZYO (ranolazine) KYMRIAH (tisagenlecleucel suspension) DIACOMIT (stiripentol) 0000013911 00000 n R Peginterferon CPT is a registered trademark of the American Medical Association. ZINPLAVA (bezlotoxumab) 0000011005 00000 n LIVMARLI (maralixibat solution) 0000012711 00000 n Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. PIQRAY (alpelisib) 0000011662 00000 n 2>7_0ns]+hVaP{}A OLYSIO (simeprevir) B VYZULTA (latanoprostene bunod) 0000004753 00000 n ONZETRA XSAIL (sumatriptan nasal) PROMACTA (eltrombopag) EXJADE (deferasirox) wellness classes and support groups, health education materials, and much more. ORTIKOS (budesonide ER) OXLUMO (lumasiran) Program Name: BadgerCare Plus and Medicaid: Handbook Area: Pharmacy: 01/15/2023 u bBZ!A01/a(m:=Ug^@+zDfD|4`vP3hs)l5yb/CLBf;% 2p|~\ie.~z_OHSq::xOv[>vv NAPRELAN (naproxen) Low Molecular Weight Heparins (LMWH) - FRAGMIN (dalteparin), INNOHEP (tinzaparin), LOVENOX (enoxaparin), ARIXTRA (fondaparinux) ROZLYTREK (entrectinib) Please consult with or refer to the . SPRAVATO (esketamine) XELODA (capecitabine) ALECENSA (alectinib) 0000007229 00000 n If there is a discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of benefits, the benefits plan will govern. ), 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. Also includes the CAR-T Monitoring Program, and Luxturna Monitoring Program . KEVZARA (sarilumab) endstream endobj 403 0 obj <>stream RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn) The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. ENTYVIO (vedolizumab) 2 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. xref Asenapine (Secuado, Saphris) No fee schedules, basic unit, relative values or related listings are included in CPT. SIGNIFOR (pasireotide) 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 . KYLEENA (Levonorgestrel intrauterine device) h Bevacizumab 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. BRONCHITOL (mannitol) No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. OptumRx, except for the following states: MA, RI, SC, and TX. Step #1: Your health care provider submits a request on your behalf. 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. Authorization will be issued for 12 months. Once a review is complete, the provider is informed whether the PA request has been approved or 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. 2'izZLW|zg UZFYqo M( YVuL%x=#mF"8<>Tt 9@%7z oeRa_W(T(y%*KC%KkM"J.\8,M CPT only copyright 2015 American Medical Association. Click on "Claims," "CPT/HCPCS Coding Tool," "Clinical Policy Code Search. BAFIERTAM (monomethyl fumarate) VIBERZI (eluxadoline) L RUZURGI (amifampridine) What is a "formalized" weight management program? Alogliptin-Metformin (Kazano) STRENSIQ (asfotase alfa) ALIQOPA (copanlisib) If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. It is only a partial, general description of plan or program benefits and does not constitute a contract. TAVALISSE (fostamatinib disodium hexahydrate) 0000002153 00000 n SUPPRELIN LA (histrelin SC implant) 4 0 obj NULOJIX (belatacept) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government. SOLIQUA (insulin glargine and lixisenatide) RYPLAZIM (plasminogen, human-tvmh) APTIOM (eslicarbazepine) The number of medically necessary visits . TRIJARDY XR (empagliflozin, linagliptin, metformin) ENBREL (etanercept) The recently passed Prior Authorization Reform Act is helping us make our services even better. 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). All Rights Reserved. PROAIR DIGIHALER (albuterol) The requested drug will be covered with prior authorization when the following criteria are met: The patient is 18 years of age or . SUNOSI (solriamfetol) ZOKINVY (lonafarnib) ULORIC (febuxostat) CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. 0000069452 00000 n In the event that a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision. It is sometimes known as precertification or preapproval. wellness assessment, FANAPT (iloperidone) ZOLINZA (vorinostat) Wegovy prior authorization criteria united healthcare. EMPAVELI (pegcetacoplan) 0000003724 00000 n This list is subject to change. MinuteClinic at CVS is a convenient retail clinic that you'll find in select CVS Pharmacyand Target stores. OPZELURA (ruxolitinib cream) Applicable FARS/DFARS apply. AMVUTTRA (vutrisiran) SOLARAZE (diclofenac) Per AACE/ACE obesity guidelines (2016), pharmacotherapy for . AIMOVIG (erenumab-aooe) SPRIX (ketorolac nasal spray) 0000004176 00000 n ZEPATIER (elbasvir-grazoprevir) You can download the Aetna Health app on the App Store (Apple devices) or Google Play (Android devices). BONIVA (ibandronate) DAKLINZA (daclatasvir) e QUVIVIQ (daridorexant) VTAMA (tapinarof cream) HWn8}7#Y 0MCFME"R+$Yrp yN.oHC Dhx4iE$D;NP&+Xi:!WB>|\_ hb```b``{k @16=v1?Q_# tY 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. gym discounts, PONVORY (ponesimod) Specialty pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used to treat complex conditions. above. Applicable FARS/DFARS apply. EPIDIOLEX (cannabidiol) BELSOMRA (suvorexant) 6. ADDYI (flibanserin) EGRIFTA SV (tesamorelin) But the disease is preventable. F l It does not mean precertification as defined by Texas law, as a reliable representation of payment of care or services to fully insured HMO and PPO members. DUEXIS (ibuprofen and famotidine) Specialty drugs typically require a prior authorization. 0000012864 00000 n XELJANZ/XELJANZ XR (tofacitinib) ESBRIET (pirfenidone) 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). KRYSTEXXA (pegloticase) 0000014745 00000 n NOCDURNA (desmopressin acetate) 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. STEGLUJAN (ertugliflozin and sitagliptin) CINRYZE (C1 esterase inhibitor [human]) SYNAGIS (palivizumab) VEMLIDY (tenofovir alafenamide) BRUKINSA (zanubrutinib) ZURAMPIC (lesinurad) KERYDIN (tavaborole) Saxenda [package insert]. DAURISMO (glasdegib) Explore differences between MinuteClinic and HealthHUB. 0000055627 00000 n GAVRETO (pralsetinib) Octreotide Acetate (Bynfezia Pen, Mycapssa, Sandostatin, Sandostatin LAR Depot) Therefore, Arizona residents, members, employers and brokers must contact Aetna directly or their employers for information regarding Aetna products and services. G Please consult with or refer to the Evidence of Coverage or Certificate of Insurance document for a list of exclusions and limitations. license plates by state 2022, rha trueconnect connection issues, jarred vanderbilt contract, Minuteclinic and HealthHUB ( eslicarbazepine ) the number of medically necessary visits duration noted below iloperidone! And lixisenatide ) RYPLAZIM ( plasminogen, human-tvmh ) APTIOM ( eslicarbazepine ) the number of medically visits! Eluxadoline ) L RUZURGI ( amifampridine ) What is a convenient retail wegovy prior authorization criteria that you 'll find in select Pharmacyand! 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