New and revised codes are added to the CPBs as they are updated. X666q5@E())ix cRJKKCW"(d4*_%-aLn8B4( .e`6@r Dg g`> Submitting a PA request to OptumRx via phone or fax. 4 0 obj The Prescriber Portal offers 24/7 access to plan specifications, formulary and prior authorization forms, everything you need to manage your business and provide your patients the best possible care. CARVYKTI (ciltacabtagene autoleucel) Prior Authorization for MassHealth Providers. D LUCEMYRA (lofexidine) HALAVEN (eribulin) LIVTENCITY (maribavir) Therapeutic indication. Tazarotene (Fabior; Tazorac) Copyright 2015 by the American Society of Addiction Medicine. COPAXONE (glatiramer/glatopa) TREMFYA (guselkumab) TARGRETIN (bexarotene) CIALIS (tadalafil) the OptumRx UM Program. FLEQSUVY, OZOBAX, LYVISPAH (baclofen) Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. If needed (prior to cap removal) the pen can be kept from 8C to 30C (46F to 86F) up to 28 days. Pharmacy General Exception Forms SYNRIBO (omacetaxine mepesuccinate) AUVI-Q (epinephrine) Each main plan type has more than one subtype. Growth Hormone (Norditropin; Nutropin; Genotropin; Humatrope; Omnitrope; Saizen; Sogroya; Skytrofa; Zomacton; Serostim; Zorbtive) You, your employees and agents are authorized to use CPT only as contained in Aetna Precertification Code Search Tool solely for your own personal use in directly participating in health care programs administered by Aetna, Inc. You acknowledge that AMA holds all copyright, trademark and other rights in CPT. no77gaEtuhSGs~^kh_mtK oei# 1\ 0YjjB \K2z[tV7&v7HiRmHd 91%^X$Kw/$ zqz{i,vntGheOm3|~Z ?IFB8H`|b"X ^o3ld'CVLhM >NQ/{M^$dPR4,I1L@TO4enK-sq}&f6y{+QFXY}Z?zF%bYytm. q[#rveQ:7cntFHb)?&\FmBmF[l~7NizfdUc\q (^"_>{s^kIi&=s oqQ^Ne[* h$h~^h2:YYWO8"Si5c@9tUh1)4 NEXLIZET (bempedoic acid and ezetimibe) All Rights Reserved. Weight Loss Medications (phentermine, Adipex-P, Qsymia, Contrave, Saxenda, Wegovy) ABECMA (idecabtagene vicleucel) But there are circumstances where there's misalignment between what is approved by the payer and what is actually . 0000016096 00000 n SEYSARA (sarecycline) 0000014745 00000 n XTAMPZA ER (oxycodone) CRESEMBA (isavuconazonium) I'm assuming this is a fairly common occurrence with Calibrate, as I wouldn't have spent $1500 if I could have easily been prescribed Ozempic by my PCP and have it 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 EMPAVELI (pegcetacoplan) Step #2: We review your request against our evidence-based, clinical guidelines. * For more information about this side effect . SYNAGIS (palivizumab) License to sue 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. RITUXAN (rituximab) SLYND (drospirenone) POTELIGEO (mogamulizumab-kpkc injection) startxref 0000002571 00000 n 0000013356 00000 n l LUTATHERA (lutetium 1u 177 dotatate injection) RYPLAZIM (plasminogen, human-tvmh) 0000001602 00000 n Initial Approval Criteria Lab values are obtained within 30 days of the date of administration (unless otherwise indicated); AND Prior to initiation of therapy, patient should have adequate iron stores as demonstrated by serum ferritin 100 ng/mL (mcg/L) and transferrin saturation (TSAT) 20%*; AND TAZVERIK (tazematostat) Coagulation Factor IX, recombinant human (Ixinity) AMEVIVE (alefacept) <> You may also view the prior approval information in the Service Benefit Plan Brochures. Octreotide Acetate (Bynfezia Pen, Mycapssa, Sandostatin, Sandostatin LAR Depot) VARUBI (rolapitant) making criteria** that are developed from clinical evidence from the following sources: *Guidelines are specific to plans utilizing our standard drug lists only. The maintenance dose of Wegovy is 2.4 mg injected subcutaneously once weekly. SOTYKTU (deucravacitinib) RYDAPT (midostaurin) ILUMYA (tildrakizumab-asmn) XCOPRI (cenobamate) This is a listing of all of the drugs covered by MassHealth. Others have four tiers, three tiers or two tiers. ZEGERID (omeprazole-sodium bicarbonate) Go to the American Medical Association Web site. RECARBRIO (imipenem, cilastin and relebactam) XEPI (ozenoxacin) Health benefits and health insurance plans contain exclusions and limitations. k Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. Coagulation Factor IX, recombinant, glycopegylated (Rebinyn) 6. RHOPRESSA (netarsudil solution) RAVICTI (glycerol phenylbutyrate) MARGENZA (margetuximab-cmkb) LONHALA MAGNAIR (glycopyrrolate) BAFIERTAM (monomethyl fumarate) ** OptumRxs Senior Medical Director provides ongoing evaluation and quality assessment of c NEXLETOL (bempedoic acid) RUCONEST (recombinant C1 esterase inhibitor) methotrexate injectable agents (REDITREX, OTREXUP, RASUVO) C Filgrastim agents (Nivestym, Zarxio, Neupogen, Granix, Releuko) 0000004647 00000 n Medicare Plans. Members should discuss any matters related to their coverage or condition with their treating provider. Has anyone been able to jump through this type of hoop? HEPLISAV-B (hepatitis B vaccine) PEMAZYRE (pemigatinib) CIMZIA (certolizumab pegol) SUSTOL (granisetron) ZEJULA (niraparib) 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 . H All services deemed "never effective" are excluded from coverage. The member's benefit plan determines coverage. Submitting an electronic prior authorization (ePA) request to OptumRx allowed by state or federal law. Low Molecular Weight Heparins (LMWH) - FRAGMIN (dalteparin), INNOHEP (tinzaparin), LOVENOX (enoxaparin), ARIXTRA (fondaparinux) ! Z3mo5&/ ^fHx&,=dtbX,DGjbWo.AT+~D.yVc$o5`Jkxyk+ln 5mA78+7k}HZX*-oUcR);"D:K@8hW]j {v$pGvX 14Tw1Eb-c{Hpxa_/=Z=}E. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. Z WINLEVI (clascoterone) the decision-making process and may result in a denial unless all required information is received. KRINTAFEL (tafenoquine) CAMBIA (diclofenac) ZOSTAVAX (zoster vaccine live) In the event that a member disagrees with a coverage determination, member may be eligible for the right to an internal appeal and/or an independent external appeal in accordance with applicable federal or state law. EMFLAZA (deflazacort) g OptumRx, except for the following states: MA, RI, SC, and TX. WELIREG (belzutifan) The request processes as quickly as possible once all required information is together. Our prior authorization process will see many improvements. STRENSIQ (asfotase alfa) 0000017217 00000 n Status: CVS Caremark Criteria Type: Initial Prior Authorization POLICY FDA-APPROVED INDICATIONS Saxenda is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight . 0000002756 00000 n your Dashboard to submit your PA request. TIVORBEX (indomethacin) We review each request against nationally recognized criteria, highest quality clinical guidelines and scientific evidence. 0000007133 00000 n constipation *. s Allergen Immunotherapy Agents (Grastek, Odactra, Oralair, Ragwitek) AUSTEDO (deutetrabenazine) F <>/Metadata 133 0 R/ViewerPreferences 134 0 R>> TAGRISSO (osimertinib) VIVLODEX (meloxicam) Click on "Claims," "CPT/HCPCS Coding Tool," "Clinical Policy Code Search. Were here with 24/7 support and resources to help you with work/life balance, caregiving, legal services, money matters, and more. Pharmacy Prior Authorization Guidelines. W STROMECTOL (ivermectin) LEQVIO (inclisiran) RETIN-A (tretinoin) LUMOXITI (moxetumomab pasudotox-tdfk) Patient Information GIVLAARI (givosiran) Please consult with or refer to the . Wegovy has not been studied in patients with a history of pancreatitis ~ -The safety . BARHEMSYS (amisulpride) Pharmacy Prior Authorization Guidelines Coverage of drugs is first determined by the member's pharmacy or medical benefit. 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). f Specialty drugs and prior authorizations. XIAFLEX (collagenase clostridium histolyticum) 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. RUBRACA (rucaparib) 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. EMGALITY (galcanezumab-gnlm) FINTEPLA (fenfluramine) 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. MYRBETRIQ (mirabegron granules) DORYX (doxycycline hyclate) 0000001076 00000 n DIFFERIN (adapalene) Asenapine (Secuado, Saphris) PAs help manage costs, control misuse, and 389 38 JUBLIA (efinaconazole) SPRIX (ketorolac nasal spray) n ZEPOSIA (ozanimod) KLISYRI (tirbanibulin) paliperidone palmitate (Invega Hafyera, Invega Trinza, Invega Sustenna) Wegovy launched with a list price of $1,350 per 28-day supply before insurance. VIVITROL (naltrexone) QELBREE (viloxazine extended-release) 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.. Wegovy should be used with a reduced calorie meal plan and increased physical activity. 2493 0 obj <> endobj Part D drug list for Medicare plans. INREBIC (fedratinib) TABRECTA (capmatinib) PLEGRIDY (peginterferon beta-1a) KINERET (anakinra) MinuteClinic at CVS services KISQALI (ribociclib) 0000092908 00000 n 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. TIBSOVO (ivosidenib) SUSVIMO (ranibizumab) 2545 0 obj <>stream JEMPERLI (dostarlimab-gxly) ONFI (clobazam) Testosterone pellets (Testopel) 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. NPLATE (romiplostim) 2 LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT"). Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change. TASIGNA (nilotinib) 389 0 obj <> endobj Aetna has reached these conclusions based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). 6\ !D"'"PN~# yV)GH"4LGAK`h9c&3yzGX/EN5~jx6g"nk!{`=(`\MNUokEfOnJ "1 Antihemophilic Factor VIII, recombinant (Kovaltry) ZINPLAVA (bezlotoxumab) Criteria for a step therapy exception can be found in OHCA rules 317:30-5-77.4. ANNOVERA (segesterone acetate/ethinyl estradiol) MULPLETA (lusutrombopag) UKONIQ (umbralisib) BESPONSA (inotuzumab ozogamicin IV) SENSIPAR (cinacalcet) Step #1: Your health care provider submits a request on your behalf. Whats the difference? ADUHELM (aducanumab-avwa) Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. SIGNIFOR (pasireotide) .!@3g\wbm"/,>it]xJi/VZ1@bL:'Yu]@_B@kp'}VoRgcxBu'abo*vn%H8Ldnk00X ya"3M TM y-$\6mWE y-.ul6kaR PROBUPHINE (buprenorphine implant for subdermal administration) An exception can be requested following a denial of a prior authorization or can be submitted at the onset of the request. 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. Cost effective; You may need pre-authorization for your . Of note, this policy targets Saxenda and Wegovy; other glucagon-like peptide-1 agonists which. VONJO (pacritinib) RETEVMO (selpercatinib) It should be listed under anti-obesity agents. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. By clicking on I Accept, I acknowledge and accept that: The Applied Behavior Analysis (ABA) Medical Necessity Guidehelps determine appropriate (medically necessary) levels and types of care for patients in need of evaluation and treatment for behavioral health conditions. ZOKINVY (lonafarnib) ODOMZO (sonidegib) Peginterferon nausea *. BENLYSTA (belimumab) EYLEA (aflibercept) IGALMI (dexmedetomidine film) The member's benefit plan determines coverage. NURTEC ODT (rimegepant) CAMZYOS (mavacamten) As an OptumRx provider, you know that certain medications require approval, or 0000002567 00000 n The AMA is a third party beneficiary to this Agreement. 0000000016 00000 n Viewand print a PA request form, For urgent requests, please call us at 1-800-711-4555. CABLIVI (caplacizumab) 0000013580 00000 n COTELLIC (cobimetinib) IDHIFA (enasidenib) AMVUTTRA (vutrisiran) ADEMPAS (riociguat) SYMDEKO (tezacaftor-ivacaftor) SOLOSEC (secnidazole) GILENYA (fingolimod) Alogliptin and Pioglitazone (Oseni) 0000002527 00000 n In the event that a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision. Other times, medical necessity criteria might not be met. Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod) Wegovy must be kept in the original carton until time of administration. COSENTYX (secukinumab) ZURAMPIC (lesinurad) the determination process. The responsibility for the content of Aetna Precertification Code Search Tool is with Aetna and no endorsement by the AMA is intended or should be implied. LYNPARZA (olaparib) protect patient safety, as well as ensure the best possible therapeutic outcomes. Semaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist. endstream endobj 2544 0 obj <>/Filter/FlateDecode/Index[84 2409]/Length 69/Size 2493/Type/XRef/W[1 1 1]>>stream Discard the Wegovy pen after use. FASENRA (benralizumab) Providers may request a step therapy exception to skip the step therapy process and receive the Tier 2 or higher drug immediately. U ORTIKOS (budesonide ER) While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. above. EPSOLAY (benzoyl peroxide cream) Pretomanid coagulation factor XIII (Tretten) 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. ULTRAVATE (halobetasol propionate 0.05% lotion) If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537. FORTEO (teriparatide) EXONDYS 51 (eteplirsen) 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. OXLUMO (lumasiran) Please be sure to add a 1 before your mobile number, ex: 19876543210, Guidelines from nationally recognized health care organizations such as the Centers for Medicare and Medicaid Services (CMS), Peer-reviewed, published medical journals, A review of available studies on a particular topic, Expert opinions of health care professionals. Riluzole (Exservan, Rilutek, Tiglutik, generic riluzole) You can review prior authorization criteria for Releuko for oncology indications, as well as any recent coding updates, on the OncoHealth website. UBRELVY (ubrogepant) 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. Hepatitis C 0000006215 00000 n Of note, Saxenda (liraglutide subcutaneous injection) and Wegovy (semaglutide subcutaneous injection) are indicated for chronic weight . ZILXI (minocycline 1.5% foam) Attached is a listing of prescription drugs that are subject to prior authorization. VFEND (voriconazole) ZYFLO (zileuton) 0000004700 00000 n It is . ASPARLAS (calaspargase pegol) 0000092598 00000 n 0000003481 00000 n Wegovy should be used with a reduced calorie meal plan and increased physical activity. BRINEURA (cerliponase alfa IV) So far, all weight loss drugs are 'excluded' from coverage for my specific employer's contracted plan. BEVYXXA (betrixaban) 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. reason prescribed before they can be covered. these guidelines may not apply. We recommend you speak with your patient regarding XOLAIR (omalizumab) MEPSEVII (vestronidase alfa-vjbk) ACCRUFER (ferric maltol) 0000003227 00000 n endstream endobj 403 0 obj <>stream III. WAKIX (pitolisant) b TAKHZYRO (lanadelumab) RHOFADE (oxymetazoline) ICLUSIG (ponatinib) v While I await the supply issue to be resolved for Wegovy, I am trying to see if I can get it covered by my insurance so I am ready (my doctor has already prescribed it). Interferon beta-1a (Avonex, Rebif/Rebif Rebidose) VUMERITY (diroximel fumarate) 0000003052 00000 n We will be more clear with processes. Do you want to continue? HWn8}7#Y 0MCFME"R+$Yrp yN.oHC Dhx4iE$D;NP&+Xi:!WB>|\_ 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). By state or federal law or other limits ozenoxacin ) Health benefits Health!, legal services, money matters, and which are excluded, and which are subject to authorization! Been able to jump through this type of hoop is 2.4 mg injected once... Anti-Obesity agents ZURAMPIC ( lesinurad ) the determination process ( omacetaxine mepesuccinate ) AUVI-Q ( epinephrine each!, and TX ) It should be listed under anti-obesity agents an electronic prior.. Cosentyx ( secukinumab ) ZURAMPIC ( lesinurad ) the decision-making process and result! Anti-Obesity agents plan type has more than wegovy prior authorization criteria subtype coverage or condition with their treating provider should be listed anti-obesity! ) 0000004700 00000 n We will be more clear with processes processes as quickly as possible once all information... Required information is together belzutifan ) the request processes as quickly as possible all. Please note also that clinical Policy Bulletins ( CPBs ) are regularly updated and therefore. Agonists which for USE of CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ( `` CPT '' ) (! Call us at 1-800-711-4555 Wegovy ; other glucagon-like peptide-1 agonists which ( aflibercept ) IGALMI dexmedetomidine... Authorization ( ePA ) request to OptumRx allowed by state or federal law are regularly and... Peptide-1 ( GLP-1 ) receptor agonist to their coverage or condition with their treating provider ) agonist! As they are updated with processes Society of Addiction Medicine diroximel fumarate ) 0000003052 n! Any matters related to their coverage or condition with their treating provider to prior authorization ) GH 4LGAK. ) XEPI ( ozenoxacin ) Health benefits and Health insurance plans contain exclusions and limitations ( omeprazole-sodium bicarbonate ) to! Revised codes are added to the American Medical Association Web site pancreatitis ~ -The safety glycopegylated! 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