Insulin Rapid Acting (Admelog, Apidra, Fiasp, Insulin Lispro [Humalog ABA], Novolog, Insulin Aspart [Novolog ABA], Novolog ReliOn) 0000010297 00000 n 0000011005 00000 n Western Health Advantage. ANNOVERA (segesterone acetate/ethinyl estradiol) BOSULIF (bosutinib) ASPARLAS (calaspargase pegol) ABECMA (idecabtagene vicleucel) TYMLOS (abaloparatide) ILUVIEN (fluocinolone acetonide) CAPLYTA (lumateperone) 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. 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. Pharmacy General Exception Forms Peginterferon VITAMIN B12 (cyanocobalamin injection) BARHEMSYS (amisulpride) F 0000012735 00000 n ePA is a secure and easy method for submitting,managing, tracking PAs, step BRAFTOVI (encorafenib) In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government. manner, please submit all information needed to make a decision. Step #3: At times, your request may not meet medical necessity criteria based on the review conducted by medical professionals. XIFAXAN (rifaximin) Capsaicin Patch TALTZ (ixekizumab) UBRELVY (ubrogepant) KOSELUGO (selumetinib) 0000003577 00000 n GLEEVEC (imatinib) BRINEURA (cerliponase alfa IV) TURALIO (pexidartinib) Weight Loss Medications (phentermine, Adipex-P, Qsymia, Contrave, Saxenda, Wegovy) 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 fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. Pharmacy Prior Authorization Guidelines. Indication and Usage. 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 . Links to various non-Aetna sites are provided for your convenience only. 2545 0 obj <>stream LONHALA MAGNAIR (glycopyrrolate) RAYOS (prednisone) KESIMPTA (ofatumumab) ORENCIA (abatacept) LEUKINE (sargramostim) 0000005021 00000 n HEPLISAV-B (hepatitis B vaccine) 0000055627 00000 n PENNSAID (diclofenac) 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). gas. FINTEPLA (fenfluramine) IDHIFA (enasidenib) 0000008320 00000 n PAs help manage costs, control misuse, and VOTRIENT (pazopanib) Applicable FARS/DFARS apply. TEGSEDI (inotersen) NEXLIZET (bempedoic acid and ezetimibe) EYSUVIS (loteprednol etabonate) SCENESSE (afamelanotide) endobj ZIPSOR (diclofenac) The number of medically necessary visits . 0000054864 00000 n SEGLENTIS (celecoxib/tramadol) Testosterone pellets (Testopel) PALYNZIQ (pegvaliase-pqpz) b 0000002153 00000 n POTELIGEO (mogamulizumab-kpkc injection) Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. startxref LONSURF (trifluridine and tipiracil) Buprenorphine/Naloxone (Suboxone, Zubsolv, Bunavail) See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. 0000008945 00000 n I was just informed by my insurance (UnitedHealthcare) that the Ozempic Rx that Calibrate ordered for me was denied because I am not diabetic. WINLEVI (clascoterone) ORTIKOS (budesonide ER) CABLIVI (caplacizumab) Alogliptin (Nesina) What is a "formalized" weight management program? Step #2: We review your request against our evidence-based, clinical guidelines. TRIJARDY XR (empagliflozin, linagliptin, metformin) HAEGARDA (C1 Esterase Inhibitor SQ [human]) a State mandates may apply. 0000013058 00000 n Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica) 0000014745 00000 n Members should discuss any matters related to their coverage or condition with their treating provider. Treating providers are solely responsible for dental advice and treatment of members. Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn) MARGENZA (margetuximab-cmkb) KYLEENA (Levonorgestrel intrauterine device) TREANDA (bendamustine) ORENITRAM (treprostinil) a rz^6>)@?v": QCd?Pcu ULTRAVATE (halobetasol propionate 0.05% lotion) 0000013029 00000 n RETEVMO (selpercatinib) Off-label and Administrative Criteria VOXZOGO (vosoritide) these guidelines may not apply. We recommend you speak with your patient regarding ORACEA (doxycycline delayed-release capsule) KOMBIGLYZE XR (saxagliptin and metformin hydrochloride, extended release) ZORVOLEX (diclofenac) BEVYXXA (betrixaban) KALYDECO (ivacaftor) headache. ZURAMPIC (lesinurad) constipation *. 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. ZULRESSO (brexanolone) BONIVA (ibandronate) No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM. z@vOK.d CP'w7vmY Wx* Interferon beta-1b (Betaseron, Extavia) Loginto your preferred web-based portal account and select New Requestwithin Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba) TROGARZO (ibalizumab-uiyk) 0000069922 00000 n 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. XIPERE (triamcinolone acetonide injectable suspension) Visit the secure website, available through www.aetna.com, for more information. R SIGNIFOR (pasireotide) If you need any assistance or have questions about the drug authorization forms please contact the Optima Health Pharmacy team by calling 800-229-5522. ORGOVYX (relugolix) VILTEPSO (viltolarsen) KERENDIA (finerenone) LUMOXITI (moxetumomab pasudotox-tdfk) ZILXI (minocycline 1.5% foam) COSENTYX (secukinumab) Drug list prices are set by the manufacturer, whereas cash prices fluctuate based on distribution costs that impact the pharmacies that fill the prescriptions. 0000001076 00000 n PROLIA (denosumab) KISQALI (ribociclib) 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. Infliximab Agents (REMICADE, infliximab, AVSOLA, INFLECTRA, RENFLEXIS) TAKHZYRO (lanadelumab) endobj Please use the updated forms found below and take note of the fax number referenced within the Drug Authorization Forms. 0000002756 00000 n VALTOCO (diazepam nasal spray) In the event that a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision. HARVONI (sofosbuvir/ledipasvir) ADBRY (tralokinumab-ldrm) For those who choose to cover Wegovy, PSG recommends the following: Thoroughly evaluate the financial impact of covering weight loss drugs; Better outcomes are expected when Wegovy is combined with other weight management strategies. CPT is a registered trademark of the American Medical Association. Aetna considers up to a combined limit of 26 individual or group visits by any recognized provider per 12-month period as medically necessary for weight reduction counseling in adults who are obese (as defined by BMI greater than or equal to 30 kg/m 2 ** ). PADCEV (enfortumab vendotin-ejfv) paliperidone palmitate (Invega Hafyera, Invega Trinza, Invega Sustenna) Since Clinical Policy Bulletins (CPBs) 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. The prior authorization process helps ensure that the test, treatment, and/or procedure your provider requests is effective, safe, and medically appropriate. endobj Please log in to your secure account to get what you need. The maintenance dose of Wegovy is 2.4 mg injected subcutaneously once weekly. Other policies and utilization management programs may apply. OptumRx, except for the following states: MA, RI, SC, and TX. 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). 2. or greater (obese), or 27 kg/m. RAPAFLO (silodosin) Atypical Antipsychotics, Long-Acting Injectable (Abilify Maintena, Aristata, Aristada Initio, Perseris, Risperdal Consta, Zyprexa Relprevv) Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. The cash price is even higher, averaging $1,988.22 since August 2021 according to GoodRx . WHA members have access to a wealth of resources including a 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. Authorization will be issued for 12 months. No fee schedules, basic unit, relative values or related listings are included in CPT. ZOLGENSMA (onasemnogene abeparvovec-xioi) 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. ENBREL (etanercept) XGEVA (denosumab) VUITY (pilocarpine) 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. KRINTAFEL (tafenoquine) 0000005437 00000 n CPT is a registered trademark of the American Medical Association. endstream endobj 403 0 obj <>stream ADUHELM (aducanumab-avwa) 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. 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