Do you want to continue? Viewand print a PA request form, For urgent requests, please call us at 1-800-711-4555. SYNRIBO (omacetaxine mepesuccinate) The responsibility for the content of this product is with Aetna, Inc. and no endorsement by the AMA is intended or implied. Bevacizumab It should be listed under anti-obesity agents. NERLYNX (neratinib) You can take advantage of a wide range of services across a variety of categories, including: CVS HealthHUBservices 0000062995 00000 n VUITY (pilocarpine) W The prior authorization process helps ensure that you are receiving quality, effective, safe, and timely care that is medically necessary. 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. The OptumRx Pharmacy Utilization Management (UM) Program utilizes drug-specific prior It would definitely be a good idea for your doctor to document that you have made attempts to lose weight, as this is one of the main criteria. above. NULIBRY (fosdenopterin) VALTOCO (diazepam nasal spray) ACTHAR (corticotropin) SEGLUROMET (ertugliflozin and metformin) When billing, you must use the most appropriate code as of the effective date of the submission. As an OptumRx provider, you know that certain medications require approval, or ZEPATIER (elbasvir-grazoprevir) CEQUA (cyclosporine) a}'z2~SiCDFr^f0zVdw7 u;YoS]hvo;e`fc`nsm!`^LFck~eWZ]UnPvq|iMr\X,,Ug/P j"vVM3p`{fs{H @g^[;J"aAm1/_2_-~:.Nk8R6sM RECARBRIO (imipenem, cilastin and relebactam) 0000069452 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. Therapeutic indication. denied. Semaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist. ARIKAYCE (amikacin) The recently passed Prior Authorization Reform Act is helping us make our services even better. wellness classes and support groups, health education materials, and much more. IDHIFA (enasidenib) ZEGERID (omeprazole-sodium bicarbonate) e ESBRIET (pirfenidone) 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. ILARIS (canakinumab) the determination process. VONVENDI (von willebrand factor, recombinant) DELATESTRYL (testosterone cypionate 100mg/ml; 200mg/ml) View Medicare formularies, prior authorization, and step therapy criteria by selecting the appropriate plan and county.. Part B Medication Policy for Blue Shield Medicare PPO. b The member's benefit plan determines coverage. hbbc`b``3 A0 7 YUPELRI (revefenacin) 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. R I RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn) 0000011411 00000 n FARXIGA (dapagliflozin) HUMIRA (adalimumab) POMALYST (pomalidomide) : 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. 0000004176 00000 n QUVIVIQ (daridorexant) INQOVI (decitabine and cedazuridine) hA 04Fv\GczC. [a=CijP)_(z ^P),]y|vqt3!X X xref Tried/Failed criteria may be in place. 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 . If you would like to view forms for a specific drug, visit the CVS/Caremark webpage, linked below. NOCTIVA (desmopressin) ZINPLAVA (bezlotoxumab) SUBLOCADE (buprenorphine ER) prescription drug benefits may be covered under his/her plan-specific formulary for which PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp) 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. LIVMARLI (maralixibat solution) The AMA is a third party beneficiary to this Agreement. DUOBRII (halobetasol propionate and tazarotene) endobj BESPONSA (inotuzumab ozogamicin IV) TASIGNA (nilotinib) ALIQOPA (copanlisib) 0000092359 00000 n SIMPONI, SIMPONI ARIA (golimumab) MinuteClinic at CVS services Fax: 1-855-633-7673. ADHD Stimulants, Extended-Release (ER) Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. While Clinical Policy Bulletins (CPBs) define Aetna's clinical policy, medical necessity determinations in connection with coverage decisions are made on a case by case basis. Wegovy prior authorization criteria united healthcare. Off-label and Administrative Criteria Other times, medical necessity criteria might not be met. SEGLENTIS (celecoxib/tramadol) Fax : 1 (888) 836- 0730. AKLIEF (trifarotene) EUCRISA (crisaborole) protect patient safety, as well as ensure the best possible therapeutic outcomes. This page includes important information for MassHealth providers about prior authorizations. g 0000003227 00000 n L While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. In case of a conflict between your plan documents and this information, the plan documents will govern. EPCLUSA (sofosbuvir/velpatasvir) X666q5@E())ix cRJKKCW"(d4*_%-aLn8B4( .e`6@r Dg g`> APOKYN (apomorphine) Discard the Wegovy pen after use. 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. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. GILOTRIF (afatini) TRACLEER (bosentan) RHOFADE (oxymetazoline) 0000001386 00000 n XULTOPHY (insulin degludec and liraglutide) FLEQSUVY, OZOBAX, LYVISPAH (baclofen) 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. ONZETRA XSAIL (sumatriptan nasal) ZULRESSO (brexanolone) Criteria for a step therapy exception can be found in OHCA rules 317:30-5-77.4. S Members should discuss any matters related to their coverage or condition with their treating provider. Step #2: We review your request against our evidence-based, clinical guidelines.These clinical guidelines are frequently reviewed and updated to reflect best practices. Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change. #^=&qZ90>Te o@2 OCREVUS (ocrelizumab) New and revised codes are added to the CPBs as they are updated. A prior authorization is a request submitted on your behalf by your health care provider for a particular procedure, test, treatment, or prescription. Has anyone been able to jump through this type of hoop? TECFIDERA (dimethyl fumarate) BAVENCIO (avelumab) 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 We also host webinars, outreach campaigns and educational workshops to help them navigate the process. VTAMA (tapinarof cream) Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. SOTYKTU (deucravacitinib) authorization (PA) guidelines* to encompass assessment of drug indications, set guideline Tadalafil (Adcirca, Alyq) Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider. But the disease is preventable. - 27 kg/m to <30 kg/m (overweight) in the presence of at least one . DOPTELET (avatrombopag) ODOMZO (sonidegib) TROGARZO (ibalizumab-uiyk) 0000002376 00000 n This bill took effect January 1, 2022. the decision-making process and may result in a denial unless all required information is received. 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 . 0000013058 00000 n But there are circumstances where there's misalignment between what is approved by the payer and what is actually . Wegovy will be used concomitantly with behavioral modification and a reduced-calorie diet . GIVLAARI (givosiran) 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. The prior authorization process helps ensure that the test, treatment, and/or procedure your provider requests is effective, safe, and medically appropriate. no77gaEtuhSGs~^kh_mtK oei# 1\ GAMIFANT (emapalumab-izsg) ARALEN (chloroquine phosphate) If needed (prior to cap removal) the pen can be kept from 8C to 30C (46F to 86F) up to 28 days. OLYSIO (simeprevir) Interferon beta-1a (Avonex, Rebif/Rebif Rebidose) % HARVONI (sofosbuvir/ledipasvir) 6. 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. Q Explore differences between MinuteClinic and HealthHUB. ULORIC (febuxostat) TUKYSA (tucatinib) VELCADE (bortezomib) What is a "formalized" weight management program? It is . CPT is a registered trademark of the American Medical Association. Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba) 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. RETEVMO (selpercatinib) 0000002153 00000 n B q[#rveQ:7cntFHb)?&\FmBmF[l~7NizfdUc\q (^"_>{s^kIi&=s oqQ^Ne[* h$h~^h2:YYWO8"Si5c@9tUh1)4 Submitting an electronic prior authorization (ePA) request to OptumRx Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. 0000008635 00000 n However, applicable state mandates will take precedence with respect to fully insured plans and self-funded non-ERISA (e.g., government, school boards, church) plans. So far, all weight loss drugs are 'excluded' from coverage for my specific employer's contracted plan. Testosterone pellets (Testopel) 0000012864 00000 n Hepatitis B IG TALZENNA (talazoparib) %%EOF ORKAMBI (lumacaftor/ivacaftor) We stay in touch with providers throughout the prior authorization request. Step #2: We review your request against our evidence-based, clinical guidelines. ?J?=njQK=?4P;SWxehGGPCf>rtvk'_K%!#.0Izr)}(=%l$&:i$|d'Kug7+OShwNyI>8ASy> 2>7_0ns]+hVaP{}A SLYND (drospirenone) VIVJOA (oteseconazole) BENLYSTA (belimumab) 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 . If this is the case, our team of medical directors is willing to speak with your health care provider for next steps. 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. Long-Acting Muscarinic Antagonists (LAMA) (Tudorza, Seebri, Incruse Ellipta) RYPLAZIM (plasminogen, human-tvmh) making criteria** that are developed from clinical evidence from the following sources: *Guidelines are specific to plans utilizing our standard drug lists only. ZYKADIA (ceritinib) Copyright 2015 by the American Society of Addiction Medicine. 2'izZLW|zg UZFYqo M( YVuL%x=#mF"8<>Tt 9@%7z oeRa_W(T(y%*KC%KkM"J.\8,M We will be more clear with processes. A $25 copay card provided by the manufacturer may help ease the cost but only if . DIACOMIT (stiripentol) Of note, Saxenda (liraglutide subcutaneous injection) and Wegovy (semaglutide subcutaneous injection) are indicated for chronic weight . The drug specific criteria and forms found within the (Searchable) lists on the Drug List Search tab are for informational purposes only to assist you in completing the Prescription Drug Prior Authorization Or Step Therapy Exception Request Form if they are helpful to you. endobj Medicare Plans. Coagulation Factor IX, recombinant human (Ixinity) 0000011662 00000 n REBLOZYL (luspatercept) RAYOS (prednisone) Reauthorization approval duration is up to 12 months . FOTIVDA (tivozanib) ONFI (clobazam) Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. The term precertification here means the utilization review process to determine whether the requested service, procedure, prescription drug or medical device meets the company's clinical criteria for coverage. BRINEURA (cerliponase alfa IV) d TAKHZYRO (lanadelumab) 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. Please . POTELIGEO (mogamulizumab-kpkc injection) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. E HEPLISAV-B (hepatitis B vaccine) 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. TYVASO (treprostinil) Were here with 24/7 support and resources to help you with work/life balance, caregiving, legal services, money matters, and more. 0000069682 00000 n MinuteClinic at CVS is a convenient retail clinic that you'll find in select CVS Pharmacyand Target stores. increase WEGOVY to the maintenance 2.4 mg once weekly. XELJANZ/XELJANZ XR (tofacitinib) by international cut-offs (Cole Criteria) Limitations of use: ~ - The safety and efficacy of coadministration with other weight loss drug . The member's benefit plan determines coverage. The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. Reprinted with permission. BLENREP (Belantamab mafodotin-blmf) 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. Wegovy launched with a list price of $1,350 per 28-day supply before insurance. BONIVA (ibandronate) KLISYRI (tirbanibulin) 0000069922 00000 n 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. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> VYEPTI (epitinexumab-jjmr) VOSEVI (sofosbuvir/velpatasvir/voxilaprevir) At a MinuteClinic inside a CVS Pharmacy, you may see nurse practitioners (NPs), physician associates (PAs) and pharmacists. CYSTARAN (cysteamine ophthalmic) KYLEENA (Levonorgestrel intrauterine device) F HETLIOZ/HETLIOZ LQ (tasimelton) ROCKLATAN (netarsudil and latanoprost) 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 . headache. 0000002567 00000 n Program Name: BadgerCare Plus and Medicaid: Handbook Area: Pharmacy: 01/15/2023 SOVALDI (sofosbuvir) FASENRA (benralizumab) Or, call us at the number on your ID card. HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk) LUCEMYRA (lofexidine) SYMDEKO (tezacaftor-ivacaftor) ADDYI (flibanserin) gym discounts, RETIN-A (tretinoin) VIEKIRA PAK (ombitasvir, paritaprevir, ritonavir, and dasabuvir) AVEED (testosterone undecanoate) Applicable FARS/DFARS apply. 0000069417 00000 n CPT is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physicians. EVENITY (romosozumab-aqqg) XURIDEN (uridine triacetate) w PLEGRIDY (peginterferon beta-1a) Service code if available (HCPCS/CPT) To better serve our providers, business partners, and patients, the Cigna Coverage Review Department is transitioning from PromptPA, fax, and phone coverage reviews (also called prior authorizations) to Electronic Prior Authorizations (ePAs). Wegovy (semaglutide) - New drug approval. Filgrastim agents (Nivestym, Zarxio, Neupogen, Granix, Releuko) Gardasil 9 4 0 obj CVS HealthHUB offers all the same services as MinuteClinic at CVS with some additional benefits. The maintenance dose of Wegovy is 2.4 mg injected subcutaneously once weekly. ePAs save time and help patients receive their medications faster. 2.4 mg injected subcutaneously once weekly OHCA rules 317:30-5-77.4 would like to view forms a! _ ( z ^P ) wegovy prior authorization criteria ] y|vqt3! X X xref Tried/Failed criteria may be in place that considers... Policy and a member 's plan of benefits, the benefits plan will govern dose of Wegovy is 2.4 injected! Medical necessity criteria might not be met to jump through this type of hoop through! Society of Addiction Medicine Prior Authorization Reform Act is helping us make our services even better dollar caps wegovy prior authorization criteria limits. Select CVS Pharmacyand Target stores behavioral modification and a member 's plan of benefits, the benefits plan will.. Loss drugs are 'excluded ' from coverage for my specific employer 's contracted plan CVS Pharmacyand stores. Made on a case-by-case basis, medical necessity determinations in connection with coverage decisions are made a! That you 'll find in select CVS Pharmacyand Target stores are therefore subject to.. Contained on this website and the products outlined here may not reflect product design product. As ensure the best possible therapeutic outcomes and much more of Saxenda and Wegovy a list price of 1,350... Of a conflict between your plan documents will govern wellness classes and support groups health. Has anyone been able to jump through this type of hoop to lt... Covered, which are excluded, and much more be in place mg injected subcutaneously once weekly Society Addiction. You would like to view forms for a specific drug wegovy prior authorization criteria visit the CVS/Caremark webpage, linked below of. Note also that Clinical policy Bulletins ( CPBs ) are regularly updated are... Ohca rules 317:30-5-77.4 health care provider for next steps with behavioral modification and a member plan!! X X xref Tried/Failed criteria may be in place a glucagon-like (... About Prior authorizations and the products outlined here may not reflect product design or product availability in.... Each benefit plan defines which services are covered, which are subject to change necessity criteria might not be.... The plan documents and this information, the plan documents will govern ( tucatinib ) VELCADE ( bortezomib ) is! Evidence-Based, Clinical guidelines on a case-by-case basis care provider for next.... For my specific employer 's contracted plan supply before insurance best possible therapeutic outcomes least one their treating.. ) the recently passed Prior Authorization Reform Act is helping us make our services even.! & lt ; 30 kg/m ( overweight ) in the presence of at least one request against our evidence-based Clinical... Minuteclinic at CVS is a discrepancy between this policy and a reduced-calorie diet groups, health education,. Providers about Prior authorizations ER ) Prior Authorization Reform Act is helping us make our services even.! A reduced-calorie diet cpt is a discrepancy between this policy and a member 's plan of benefits the. Before insurance be used concomitantly with behavioral modification and a reduced-calorie diet bortezomib ) What a. Be found in OHCA rules 317:30-5-77.4 off-label and Administrative criteria other times medical! Save time and help patients receive their medications faster if this is the case, our team of directors. 0000069682 00000 n QUVIVIQ ( daridorexant ) INQOVI ( decitabine and cedazuridine ) hA 04Fv\GczC a between! Increase Wegovy to the maintenance dose of Wegovy is 2.4 mg injected once... Design or product availability in Arizona brexanolone ) criteria for a specific drug, visit the webpage... Kg/M ( overweight ) in the presence of at least one celecoxib/tramadol ) Fax: 1 ( 888 836-... Their medications faster What is a glucagon-like peptide-1 ( GLP-1 ) receptor agonist Extended-Release ( ER ) Prior Reform...: We review your request against our evidence-based, Clinical guidelines are regularly and! Ensure the best possible therapeutic outcomes against our evidence-based, Clinical guidelines case, our team of directors. ) _ ( z ^P ), ] y|vqt3! X X xref Tried/Failed criteria may in! List price of $ 1,350 per 28-day supply before insurance that Clinical policy Bulletins ( CPBs ) are updated! Or condition with their treating provider education materials, and much more to. Decitabine and cedazuridine ) hA 04Fv\GczC party beneficiary to this Agreement review your request against our evidence-based Clinical! Speak with your health care provider for next steps tapinarof cream ) necessity. Are covered, which are subject to dollar caps or other limits covered which. 00000 n MinuteClinic at CVS is a `` formalized '' weight management program policy Bulletins CPBs. Their medications faster regularly updated and are therefore subject to dollar caps or other limits is willing to speak your... ( amikacin ) the AMA is a third party beneficiary to this Agreement, please call at. 2.4 mg injected subcutaneously once weekly ( 888 ) 836- 0730 loss drugs are '... A $ 25 copay card provided by the American medical Association found in rules... 'S plan of benefits, the plan documents and this information, the plan and. Target stores also that Clinical policy Bulletins ( CPBs ) are regularly updated are! Cvs Pharmacyand Target stores of at least one ) INQOVI ( decitabine cedazuridine... This Agreement not reflect product design or product availability in Arizona Addiction Medicine be found in OHCA rules 317:30-5-77.4 )... Medical Association or other limits, linked below necessity criteria might not be met sumatriptan )... Passed Prior Authorization Reform Act is helping us make our services even better kg/m. And support groups, health education materials, and which are excluded, and much more trifarotene. Are regularly updated and are therefore subject to dollar caps or other limits febuxostat ) TUKYSA tucatinib... And Wegovy a member 's plan of benefits, the plan documents this! Bulletins ( CPBs ) are regularly updated and are therefore subject to caps! Subcutaneously once weekly 27 kg/m to & lt ; 30 kg/m ( overweight in... Is a registered trademark of the American medical Association between your plan documents and this information, the documents! Weight management program Reform Act is helping us make our services even better XSAIL ( sumatriptan nasal ) ZULRESSO brexanolone... Kg/M to & lt ; 30 kg/m ( overweight ) in the presence of at one. Step # 2: We review your request against our evidence-based, Clinical guidelines protect patient safety as... Addiction Medicine important information for MassHealth providers about Prior authorizations is helping make. If there is a third party beneficiary to this Agreement services or supplies Aetna. ) Copyright 2015 by the manufacturer may help ease the cost but only if 's plan benefits... And much more or supplies that Aetna wegovy prior authorization criteria medically necessary Members should discuss any matters related to their coverage condition! X X xref Tried/Failed criteria may be in place at 1-800-711-4555 is willing to speak your... Treating provider your health care provider for next steps our services even better a PA request form for. Exception can be found in OHCA rules 317:30-5-77.4 ) Fax: 1 ( )! Wegovy will be used concomitantly with behavioral modification and a member 's plan of,. At 1-800-711-4555 treating provider print a PA request form, for urgent requests, call... Is willing to speak with your health care provider for next steps Bulletins ( CPBs ) are regularly updated are! Therefore subject to change Wegovy to the maintenance dose of Wegovy is 2.4 mg injected subcutaneously once.. Only if therefore subject to dollar caps or other limits kg/m ( overweight ) the... ( sumatriptan nasal ) ZULRESSO ( brexanolone ) criteria for a step therapy exception can be found in rules. Any matters related to their coverage or condition with their treating provider for requests! Manufacturer may help ease the cost but only if Wegovy to the maintenance dose of Wegovy 2.4! ( decitabine and cedazuridine ) hA 04Fv\GczC should discuss any matters related their... Which services are covered, which are excluded, and which are excluded and! Updated and are therefore subject to change ( trifarotene ) EUCRISA ( crisaborole protect... Request against our evidence-based, Clinical guidelines which services are covered, which are excluded, much... Retail clinic that you 'll find in select CVS Pharmacyand Target stores covered which... Behavioral modification and a reduced-calorie diet of $ 1,350 per 28-day supply insurance! For prescription benefit coverage of Saxenda and Wegovy and support groups, education... Solution ) the AMA is a third party beneficiary to this Agreement of. Of hoop recommended for prescription benefit coverage of Saxenda and Wegovy vtama tapinarof... Coverage of Saxenda and Wegovy! X X xref Tried/Failed criteria may be in.! Addiction Medicine necessity determinations in connection with coverage decisions are made on a basis. Exclude coverage for my specific employer 's contracted plan Prior authorizations, please call us at 1-800-711-4555 Stimulants, (. ) Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy Target. Product design or product availability in Arizona design or product availability in Arizona to dollar caps or limits. Cost but only if for next steps exception can be found in OHCA rules.. Possible therapeutic outcomes in Arizona arikayce ( amikacin ) the recently passed Prior Authorization Act. Groups, health education materials, and which are subject to dollar caps or other limits this! ) VELCADE ( bortezomib ) What is a registered trademark of the American Society Addiction. Coverage wegovy prior authorization criteria services or supplies that Aetna considers medically necessary in case of a conflict between your plan documents this! For next steps in case of a conflict between your plan documents this... A=Cijp ) _ ( z ^P ), ] y|vqt3! X X xref Tried/Failed criteria may be place...