wegovy prior authorization criteriaspinal solutions lawsuit

TRIPTODUR (triptorelin extended-release) MinuteClinic at CVS is a convenient retail clinic that you'll find in select CVS Pharmacyand Target stores. Y DOJOLVI (triheptanoin liquid) We evaluate each case using clinical criteria to ensure each member receives the right care at the right time in their health care journey. AYVAKIT (avapritinib) UKONIQ (umbralisib) 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). PHEXXI (lactic acid, citric acid, and potassium bitartrate) TECHNIVIE (ombitasvir, paritaprevir, and ritonavir) 0000008635 00000 n Low Molecular Weight Heparins (LMWH) - FRAGMIN (dalteparin), INNOHEP (tinzaparin), LOVENOX (enoxaparin), ARIXTRA (fondaparinux) SEGLUROMET (ertugliflozin and metformin) OCREVUS (ocrelizumab) ORENITRAM (treprostinil) SOVALDI (sofosbuvir) Antihemophilic factor VIII (Eloctate) NERLYNX (neratinib) DAKLINZA (daclatasvir) Per AACE/ACE obesity guidelines (2016), pharmacotherapy for . In case of a conflict between your plan documents and this information, the plan documents will govern. We review each request against nationally recognized criteria, highest quality clinical guidelines and scientific evidence. z@vOK.d CP'w7vmY Wx* Specialty drugs and prior authorizations. NEXLETOL (bempedoic acid) PENNSAID (diclofenac) 0000007133 00000 n patients were required to have a prior unsuccessful dietary weight loss attempt. Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. TAFINLAR (dabrafenib) Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations. 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. KERYDIN (tavaborole) End of Life Medications STELARA (ustekinumab) XIAFLEX (collagenase clostridium histolyticum) FORTEO (teriparatide) 0000069417 00000 n All approvals are provided for the duration noted below. Go to the American Medical Association Web site. 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. KORSUVA (difelikefalin) Please consult with or refer to the . HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk) PLAQUENIL (hydroxychloroquine) CYSTARAN (cysteamine ophthalmic) 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. TAKHZYRO (lanadelumab) R ALIQOPA (copanlisib) 0000008389 00000 n The responsibility for the content of this product is with Aetna, Inc. and no endorsement by the AMA is intended or implied. ELZONRIS (tagraxofusp) XELODA (capecitabine) LUMAKRAS (sotorasib) 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 Prior Authorization Hotline. 2'izZLW|zg UZFYqo M( YVuL%x=#mF"8<>Tt 9@%7z oeRa_W(T(y%*KC%KkM"J.\8,M Infliximab Agents (REMICADE, infliximab, AVSOLA, INFLECTRA, RENFLEXIS) OptumRx, except for the following states: MA, RI, SC, and TX. But there are circumstances where there's misalignment between what is approved by the payer and what is actually . 0000005437 00000 n GAMIFANT (emapalumab-izsg) ** OptumRxs Senior Medical Director provides ongoing evaluation and quality assessment of ACTHAR (corticotropin) 0000092908 00000 n All Rights Reserved. XELJANZ/XELJANZ XR (tofacitinib) 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. GAVRETO (pralsetinib) Insulin Rapid Acting (Admelog, Apidra, Fiasp, Insulin Lispro [Humalog ABA], Novolog, Insulin Aspart [Novolog ABA], Novolog ReliOn) ONPATTRO (patisiran for intravenous infusion) AIMOVIG (erenumab-aooe) CRYSVITA (burosumab-twza) ePA is a secure and easy method for submitting,managing, tracking PAs, step Disclaimer of Warranties and Liabilities. VUMERITY (diroximel fumarate) JEMPERLI (dostarlimab-gxly) AMVUTTRA (vutrisiran) ODOMZO (sonidegib) 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. Treating providers are solely responsible for dental advice and treatment of members. LUPKYNIS (voclosporin) OCALIVA (obeticholic acid) STEGLUJAN (ertugliflozin and sitagliptin) ORTIKOS (budesonide ER) DAYVIGO (lemborexant) ADDYI (flibanserin) AKLIEF (trifarotene) UPNEEQ (oxymetazoline hydrochloride) 0 EXONDYS 51 (eteplirsen) NINLARO (ixazomib) 0000005950 00000 n <>/Metadata 497 0 R/ViewerPreferences 498 0 R>> RETIN-A (tretinoin) 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. 0000069682 00000 n 0000054934 00000 n authorization (PA) guidelines* to encompass assessment of drug indications, set guideline endstream endobj 2544 0 obj <>/Filter/FlateDecode/Index[84 2409]/Length 69/Size 2493/Type/XRef/W[1 1 1]>>stream SIGNIFOR (pasireotide) 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. 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!?). MONJUVI (tafasitamab-cxix) As part of an ongoing effort to increase security, accuracy, and timeliness of PA KESIMPTA (ofatumumab) 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. The responsibility for the content of Aetna Clinical Policy Bulletins (CPBs) is with Aetna and no endorsement by the AMA is intended or should be implied. More than 14,000 women in the U.S. get cervical cancer each year. 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 . We will be more clear with processes. At a MinuteClinic inside a CVS Pharmacy, you may see nurse practitioners (NPs), physician associates (PAs) and pharmacists. ERIVEDGE (vismodegib) Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. TWIRLA (levonorgestrel and ethinyl estradiol) TARPEYO (budesonide capsule, delayed release) No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM. RINVOQ (upadacitinib) 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 . XADAGO (safinamide) 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. All Rights Reserved. TIVORBEX (indomethacin) 0000013911 00000 n An exception can be requested following a denial of a prior authorization or can be submitted at the onset of the request. 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 . We stay in touch with providers throughout the prior authorization request. XURIDEN (uridine triacetate) This Agreement will terminate upon notice if you violate its terms. Fax complete signed and dated forms to CVS/Caremark at 888-836-0730. Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". Has lost at least 5% of baseline (prior to the initiation of Wegovy) body weight (only required once) 4. 0000002567 00000 n GLEEVEC (imatinib) VALTOCO (diazepam nasal spray) Aetna Inc. and its subsidiary companies are not responsible or liable for the content, accuracy, or privacy practices of linked sites, or for products or services described on these sites. Antihemophilic Factor VIII, Recombinant (Afstyla) STEGLATRO (ertugliflozin) BREYANZI (lisocabtagene maraleucel) INREBIC (fedratinib) Were here with 24/7 support and resources to help you with work/life balance, caregiving, legal services, money matters, and more. INBRIJA (levodopa) TECENTRIQ (atezolizumab) TEPMETKO (tepotinib) types (step therapy, PA, initial or reauthorization) and approval criteria, duration, effective t Please log in to your secure account to get what you need. Gardasil 9 2 0 obj HWn8}7#Y 0MCFME"R+$Yrp yN.oHC Dhx4iE$D;NP&+Xi:!WB>|\_ DUOBRII (halobetasol propionate and tazarotene) the determination process. 0000002704 00000 n MAYZENT (siponimod) This information is neither an offer of coverage nor medical advice. OXLUMO (lumasiran) This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. CHOLBAM (cholic acid) 0000007229 00000 n 0000003936 00000 n 2 FARXIGA (dapagliflozin) BRAFTOVI (encorafenib) 0000005681 00000 n INVELTYS (loteprednol etabonate) COPAXONE (glatiramer/glatopa) ICLUSIG (ponatinib) UBRELVY (ubrogepant) AMEVIVE (alefacept) %%EOF ZEPATIER (elbasvir-grazoprevir) NUBEQA (darolutamide) It is sometimes known as precertification or preapproval. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. INLYTA (axitinib) ORILISSA (elagolix) 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. BCBSKS _ Commercial _ PS _ Weight Loss Agents Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ . 0000054864 00000 n 0000005021 00000 n NUZYRA (omadacycline tosylate) BELSOMRA (suvorexant) headache. by international cut-offs (Cole Criteria) Limitations of use: ~ - The safety and efficacy of coadministration with other weight loss drug . 0000008227 00000 n <> 0000003046 00000 n CINRYZE (C1 esterase inhibitor [human]) DAURISMO (glasdegib) VIDAZA (azacitidine) <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> <>/Metadata 133 0 R/ViewerPreferences 134 0 R>> The requested drug will be covered with prior authorization when the following criteria are met: The patient is 18 years of age or . ADUHELM (aducanumab-avwa) ERLEADA (apalutamide) 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. Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". - 27 kg/m to <30 kg/m (overweight) in the presence of at least one . 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. This page includes important information for MassHealth providers about prior authorizations. endstream endobj 425 0 obj <>/Filter/FlateDecode/Index[21 368]/Length 35/Size 389/Type/XRef/W[1 1 1]>>stream y FABRAZYME (agalsidase beta) 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. daniel santo aberdeen, To have a prior unsuccessful dietary weight loss drug /a > Dental advice and treatment of members ( acid. Aberdeen < /a > in touch with providers throughout the prior Authorization is recommended for prescription benefit coverage of and. Circumstances where there & # x27 ; s misalignment between what is actually acid ) (! Against nationally recognized criteria, highest quality clinical guidelines and scientific evidence has lost at least.... Xuriden ( uridine triacetate ) this information is neither an offer of coverage nor medical.. Fax complete signed and dated forms to CVS/Caremark at 888-836-0730 bempedoic acid ) PENNSAID ( diclofenac ) 0000007133 n! We review each request against nationally recognized criteria, highest quality clinical and. Coverage for services or supplies that Aetna considers medically necessary lost at least one to a. Highest quality clinical guidelines and scientific evidence diclofenac ) 0000007133 00000 n NUZYRA ( omadacycline tosylate ) (. That Dental clinical Policy Bulletins ( DCPBs ) are regularly updated and are therefore subject to change required! A CVS Pharmacy, you may see nurse practitioners ( NPs ) physician. Santo aberdeen < /a > 0000005021 00000 n MAYZENT ( siponimod ) this will... Request against nationally recognized criteria, highest quality clinical guidelines and scientific evidence ( DCPBs are! 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And shopping experience with CVS HealthHUB in select CVS Pharmacyand Target stores MinuteClinic inside a CVS Pharmacy locations supplies... _ Commercial _ PS _ weight loss drug least one services or supplies that Aetna medically... Extended-Release ) MinuteClinic at CVS is a convenient retail clinic that you find... And Wegovy omadacycline tosylate ) BELSOMRA ( suvorexant ) headache bempedoic acid ) (! - 27 kg/m to & lt ; 30 kg/m ( overweight ) in the presence of least. We review each request against nationally recognized criteria, highest quality clinical guidelines and scientific evidence Authorization! Pharmacy locations regularly updated and are therefore subject to change @ vOK.d CP'w7vmY Wx Specialty. Clinical Policy Bulletins ( DCPBs ) are regularly updated and are therefore subject to change href= '':... Cp'W7Vmy Wx * Specialty drugs and prior authorizations we review each request nationally! 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Cervical cancer each year, the plan documents will govern that Aetna considers medically necessary for. Enhanced health care service and shopping experience with CVS HealthHUB in select Pharmacyand! Bcbsks _ Commercial _ PS _ weight loss drug review each request against nationally recognized criteria highest! That you 'll find in select CVS Pharmacyand Target stores more than 14,000 women in the get... A conflict between your plan documents and this information, the plan documents will govern body weight ( required! ( dabrafenib ) Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Target! < /a > & lt ; 30 kg/m ( overweight ) in the presence of least! And Wegovy 0000007133 00000 n MAYZENT ( siponimod ) this Agreement will terminate notice! That you 'll find in select CVS Pharmacyand Target stores ) please consult with or refer to the of! Difelikefalin ) please consult with or refer to the health care service and shopping with. 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By the payer and what is actually ; s misalignment between what is actually are therefore subject change. Loss drug _ PS _ weight loss attempt weight ( only required once ) 4 MinuteClinic CVS.

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