";s:4:"text";s:39740:" SPRAVATO (esketamine)
Of note, this policy targets Saxenda and Wegovy; other glucagon-like peptide-1 agonists which do not carry an FDA-approved indication for weight loss are not targeted in this policy. methotrexate injectable agents (REDITREX, OTREXUP, RASUVO)
Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. /wHqy5}r``Tgxkt2&!WKUN|\2KuS/esjlf2y|X*i&YgmL
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Submitting a PA request to OptumRx via phone or fax. 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.
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. VIBERZI (eluxadoline)
hA 04Fv\GczC. 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. 0000062995 00000 n
HARVONI (sofosbuvir/ledipasvir)
SOVALDI (sofosbuvir)
In doing so, CVS/Caremark will be able to decide whether or not the requested prescription is included in the patient's insurance plan.
GLUMETZA ER (metformin)
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
Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn)
NAYZILAM (midazolam nasal spray)
The Food and Drug Administration (FDA) approved Vaxneuvance (pneumococcal 15-valent conjugate vaccine) for active immunization for the prevention of invasive disease caused by Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, 22F, 23F and 33F in adults 18 years of age and older. You can download the Aetna Health app on the App Store (Apple devices) or Google Play (Android devices). 0000005021 00000 n
DIACOMIT (stiripentol)
Step #1: Your health care provider submits a request on your behalf.
In the event that a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision. 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 . Prior Authorization Resources. VERQUVO (vericiguat)
0000003404 00000 n
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0000001794 00000 n
TECFIDERA (dimethyl fumarate)
by international cut-offs (Cole Criteria) Limitations of use: ~ - The safety and efficacy of coadministration with other weight loss drug . Please .
NULIBRY (fosdenopterin)
SOLIQUA (insulin glargine and lixisenatide)
ULORIC (febuxostat)
Allergen Immunotherapy Agents (Grastek, Odactra, Oralair, Ragwitek)
INREBIC (fedratinib)
QTERN (dapagliflozin and saxagliptin)
q
0000069922 00000 n
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VERKAZIA (cyclosporine ophthalmic emulsion)
0000003724 00000 n
Specialty pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used to treat complex conditions. Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod)
Amantadine Extended-Release (Osmolex ER)
ANNOVERA (segesterone acetate/ethinyl estradiol)
AKYNZEO (fosnetupitant/palonosetron)
TAKHZYRO (lanadelumab)
Prior Authorization Criteria Author: CAMBIA (diclofenac)
ORGOVYX (relugolix)
BAVENCIO (avelumab)
AUVI-Q (epinephrine)
Interferon beta-1b (Betaseron, Extavia)
FDA Approved Indication(s) Wegovy is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index (BMI) of: 30 kg/m. ZURAMPIC (lesinurad)
KYMRIAH (tisagenlecleucel suspension)
DUPIXENT (dupilumab)
Contrave, Wegovy, Qsymia - 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/m2 or greater (obese), or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbidity (e.g., hypertension, type 2 . 0000008635 00000 n
LEMTRADA (alemtuzumab)
NEXLETOL (bempedoic acid)
TEMODAR (temozolomide)
MAYZENT (siponimod)
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.
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. 0000008320 00000 n
ENJAYMO (sutimlimab-jome)
While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits.
manner, please submit all information needed to make a decision.
RUBRACA (rucaparib)
z
AVEED (testosterone undecanoate)
a State mandates may apply. BREXAFEMME (ibrexafungerp)
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.
Pretomanid
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). 2 0 obj
Wegovy has not been studied in patients with a history of pancreatitis ~ -The safety .
XIFAXAN (rifaximin)
Disclaimer of Warranties and Liabilities. 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.
GIVLAARI (givosiran)
VYVGART (efgartigimod alfa-fcab)
Prior Authorization Hotline. 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. endstream
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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. OCREVUS (ocrelizumab)
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BELEODAQ (belinostat)
TRIJARDY XR (empagliflozin, linagliptin, metformin)
TIVDAK (tisotumab vedotin-tftv)
As part of an ongoing effort to increase security, accuracy, and timeliness of PA
BARHEMSYS (amisulpride)
Asenapine (Secuado, Saphris)
s
ZEPATIER (elbasvir-grazoprevir)
Coagulation Factor IX, recombinant human (Ixinity)
TRODELVY (sacituzumab govitecan-hziy)
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KOMBIGLYZE XR (saxagliptin and metformin hydrochloride, extended release)
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.
0000012735 00000 n
Alogliptin (Nesina)
Just enter your mobile number and well text you a link to download the Aetna Health app from the App Store or on Google Play. DELATESTRYL (testosterone cypionate 100mg/ml; 200mg/ml)
389 38
encourage providers to submit PA requests using the ePA process as described 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. New and revised codes are added to the CPBs as they are updated. XEMBIFY (immune globulin subcutaneous, human klhw)
FIRDAPSE (amifampridine)
Any use of CPT outside of Aetna Precertification Code Search Tool should refer to the most Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. VESICARE LS (solifenacin succinate suspension)
Weight Loss - phentermine (all brand products including Adipex-P and Lomaira), benzphetamine, Contrave (naltrexone HCl and bupropion HCl, diethylpropion, Imcivree (setmelanotide), phendimetrazine, orlistat (Xenical), Qsymia (phentermine and topiramate extended-release), Saxenda (liraglutide), and Wegovy (semaglutide) - Prior Authorization .
SUTENT (sunitinib)
0000069611 00000 n
GLEEVEC (imatinib)
The maintenance dose of Wegovy is 2.4 mg injected subcutaneously once weekly. EPCLUSA (sofosbuvir/velpatasvir)
ONPATTRO (patisiran for intravenous infusion)
PENNSAID (diclofenac)
KORSUVA (difelikefalin)
0000055177 00000 n
ZEPZELCA (lurbinectedin)
SYMDEKO (tezacaftor-ivacaftor)
RECARBRIO (imipenem, cilastin and relebactam)
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-5 ENBREL (etanercept)
x=rF?#%=J,9R 0h/t7nH&tJ4=3}_-u~UqT/^Vu]x>W.XUuX/J"IxQbqqB iq(.n-?$bz')m>~H?
INQOVI (decitabine and cedazuridine)
Therapeutic indication. OhV\0045|
FINTEPLA (fenfluramine)
ZIPSOR (diclofenac)
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0000069417 00000 n
All Rights Reserved. ILUMYA (tildrakizumab-asmn)
You can review prior authorization criteria for Releuko for oncology indications, as well as any recent coding updates, on the OncoHealth website. denied. UPNEEQ (oxymetazoline hydrochloride)
Alogliptin and Pioglitazone (Oseni)
Click on "Claims," "CPT/HCPCS Coding Tool," "Clinical Policy Code Search.
NUPLAZID (pimavanserin)
VABYSMO (faricimab)
Capsaicin Patch
AUBAGIO (teriflunomide)
It is .
LUCEMYRA (lofexidine)
0000011005 00000 n
You are now being directed to the CVS Health site.
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. TYSABRI (natalizumab)
MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate)
I was just informed by my insurance (UnitedHealthcare) that the Ozempic Rx that Calibrate ordered for me was denied because I am not diabetic. Elapegademase-lvlr (Revcovi)
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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. TECHNIVIE (ombitasvir, paritaprevir, and ritonavir)
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If this is the case, our team of medical directors is willing to speak with your health care provider for next steps. SPRYCEL (dasatinib)
Navitus believes that effective and efficient communication is the key to ensuring a strong working relationship with our prescribers.
XEPI (ozenoxacin)
TAFINLAR (dabrafenib)
MINOCIN (minocycline tablets)
headache. [Document the weight prior to Wegovy therapy and the weight after Wegovy therapy, including the date the weights were taken:_____] Yes No 3 Does the patient have a body mass index (BMI) greater than or equal to 30 kilogram per .
Please note also that the ABA Medical Necessity Guidemay be updated and are, therefore, subject to change. 0000054934 00000 n
Program Name: BadgerCare Plus and Medicaid: Handbook Area: Pharmacy: 01/15/2023 WHA members have access to a wealth of resources including a
HWn8}7#Y@A I-Zi!8j;)?_i-vyP$9C9*rtTf: p4U9tQM^Mz^71" >({/N$0MI\VUD;,asOd~k&3K+4]+2yY?Da C PROLIA (denosumab)
In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. Step #1: Your health care provider submits a request on your behalf. 0000008945 00000 n
XIAFLEX (collagenase clostridium histolyticum)
0000005681 00000 n
FULYZAQ (crofelemer)
MYALEPT (metreleptin)
BCBSKS _ Commercial _ PS _ Weight Loss Agents Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ . MYRBETRIQ (mirabegron granules)
ORILISSA (elagolix)
0000092598 00000 n
Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. 0000013058 00000 n
How to access the OptumRx PA guidelines: Reference the OptumRx electronic prior authorization ( ePA ) and (fax ) forms.
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0000017217 00000 n
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0000002392 00000 n
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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If you have questions, you can reach out to your health care provider. TRACLEER (bosentan)
VYNDAQEL (tafamidis meglumine)
TYVASO (treprostinil)
0000055600 00000 n
MONJUVI (tafasitamab-cxix)
For language services, please call the number on your member ID card and request an operator.
Once a review is complete, the provider is informed whether the PA request has been approved or DUEXIS (ibuprofen and famotidine)
Wegovy should be stored in refrigerator from 2C to 8C (36F to 46F).
NOURIANZ (istradefylline)
CYRAMZA (ramucirumab)
Drug list prices are set by the manufacturer, whereas cash prices fluctuate based on distribution costs that impact the pharmacies that fill the prescriptions. Wegovy must be kept in the original carton until time of administration. 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 .
AEMCOLO (rifamycin delayed-release)
KADCYLA (Ado-trastuzumab emtansine)
LUXTURNA (voretigene neparvovec-rzyl)
prior authorization (PA), to ensure that they are medically necessary and appropriate for the
Has anyone been able to jump through this type of hoop?
0000013580 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. CIBINQO (abrocitinib)
0000002376 00000 n
MEKINIST (trametinib)
CAMZYOS (mavacamten)
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 . Our prior authorization process will see many improvements. 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. WAKIX (pitolisant)
TREMFYA (guselkumab)
AMEVIVE (alefacept)
CIALIS (tadalafil)
your Dashboard to submit your PA request.
Xenical (orlistat) Capsule Obesity management including weight loss and weight maintenance when used in conjunction with a reduced-calorie diet and to reduce the risk for weight regain after prior weight loss. T
Please log in to your secure account to get what you need.
0000001076 00000 n
The discussion, analysis, conclusions and positions reflected in the Clinical Policy Bulletins (CPBs), including any reference to a specific provider, product, process or service by name, trademark, manufacturer, constitute Aetna's opinion and are made without any intent to defame. So far, all weight loss drugs are 'excluded' from coverage for my specific employer's contracted plan. 0000092359 00000 n
IMCIVREE (setmelanotide)
ZOLGENSMA (onasemnogene abeparvovec-xioi)
0YjjB \K2z[tV7&v7HiRmHd 91%^X$Kw/$ zqz{i,vntGheOm3|~Z ?IFB8H`|b"X ^o3ld'CVLhM >NQ/{M^$dPR4,I1L@TO4enK-sq}&f6y{+QFXY}Z?zF%bYytm. SUSTOL (granisetron)
Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt.
Western Health Advantage.
0000003227 00000 n
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increase WEGOVY to the maintenance 2.4 mg once weekly. RETEVMO (selpercatinib)
VEMLIDY (tenofovir alafenamide)
TWIRLA (levonorgestrel and ethinyl estradiol)
Wegovy This fax machine is located in a secure location as required by HIPAA regulations.
0000013356 00000 n
GILOTRIF (afatini)
VOSEVI (sofosbuvir/velpatasvir/voxilaprevir)
FASENRA (benralizumab)
PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp)
You can take advantage of a wide range of services across a variety of categories, including: CVS HealthHUBservices SENSIPAR (cinacalcet)
Do not freeze. PCSK9-Inhibitors (Repatha, Praluent)
POLIVY (polatuzumab vedotin-piiq)
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yN.oHC Dhx4iE$D;NP&+Xi:!WB>|\_ COSELA (trilaciclib)
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
Interferon beta-1a (Avonex, Rebif/Rebif Rebidose)
ePA is a secure and easy method for submitting,managing, tracking PAs, step ASPARLAS (calaspargase pegol)
VALTOCO (diazepam nasal spray)
0000002571 00000 n
AIMOVIG (erenumab-aooe)
BESPONSA (inotuzumab ozogamicin IV)
Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba)
TEZSPIRE (tezepelumab-ekko)
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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. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. stream
BYLVAY (odevixibat)
ACTHAR (corticotropin)
JUXTAPID (lomitapide)
PALYNZIQ (pegvaliase-pqpz)
SILIQ (brodalumab)
TURALIO (pexidartinib)
NAPRELAN (naproxen)
0000002153 00000 n
reason prescribed before they can be covered. Some subtypes have five tiers of coverage. <>
Cost effective; You may need pre-authorization for your . Semaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist. 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. Loginto your preferred web-based portal account and select New Requestwithin xref
Antihemophilic factor VIII (Eloctate)
In some cases, not enough clinical documentation could result in a denial. ZYNLONTA (loncastuximab tesirine-lpyl). EMPAVELI (pegcetacoplan)
startxref
TRIKAFTA (elexacaftor, tezacaftor, and ivacaftor)
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. LEQVIO (inclisiran)
RITUXAN (rituximab)
Patient Information
This page includes important information for MassHealth providers about prior authorizations.
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. XOSPATA (gilteritinib)
Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider.
AMZEEQ (minocycline)
Sodium oxybate (Xyrem); calcium, magnesium, potassium, and sodium oxybates (Xywav)
LONHALA MAGNAIR (glycopyrrolate)
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. TALTZ (ixekizumab)
The cash price is even higher, averaging $1,988.22 since August 2021 according to GoodRx .
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