wegovy prior authorization criteria
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WebPrior Authorization tools are comprised of objective criteria that are based on sound clinical evidence. Wegovy is covered, starting in 2022, with a PA. You can use the discount card, comes out to $24.99/month for me (Im on 1.7mg). 
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Use of automated approval and re-approval processes varies by program and/or therapeutic class. 0000000016 00000 n
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Initial approval duration is up to 7 months . 0000004056 00000 n
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OZURDEX (dexamethasone intravitreal implant)
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You, your appointed representative or your prescriber can request prior authorization by calling Express Scripts Medicare toll free at 1.844.374.7377, 24 hours a day, 7 days a week. Drug Exception Forms. 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. WebSemaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist. endstream
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ZEPOSIA (ozanimod)
ZERVIATE (cetirizine)
ZORVOLEX (diclofenac)
XELJANZ/XELJANZ XR (tofacitinib)
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CPT only Copyright 2022 American Medical Association. Do not freeze. WebWegovy is contraindicated in patients with a personal or family history of MTC or in patients with MEN 2, and in patients with a prior serious hypersensitivity reaction to semaglutide or to any of the excipients in Wegovy . Learn about reproductive health. 0000002704 00000 n
SLYND (drospirenone)
INQOVI (decitabine and cedazuridine)
Elapegademase-lvlr (Revcovi)
RUBRACA (rucaparib)
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IGALMI (dexmedetomidine film)
REVATIO (sildenafil citrate)
OLUMIANT (baricitinib)
KADCYLA (Ado-trastuzumab emtansine)
The requested drug will be covered with prior authorization when the following criteria are met: The patient is 18 years of age or . BAVENCIO (avelumab)
ALIQOPA (copanlisib)
your Dashboard to submit your PA request. 0000044887 00000 n
ILUVIEN (fluocinolone acetonide)
XIFAXAN (rifaximin)
P
JYNARQUE (tolvaptan)
There should also be a book you can download that will show you the pre-authorization criteria, if that is required. 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. 0000131155 00000 n
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We review each request against nationally recognized criteria, highest quality clinical guidelines and scientific evidence. 0000002567 00000 n
All Rights Reserved. hb```b``mf`c`[ @Q{9
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Criteria (Requires intolerance or treatment failure with a preferred drug unless otherwise noted.) 0000006215 00000 n
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GLEEVEC (imatinib)
PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp)
HEMLIBRA (emicizumab-kxwh)
RADICAVA (edaravone)
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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). Z3mo5&/ ^fHx&,=dtbX,DGjbWo.AT+~D.yVc$o5`Jkxyk+ln
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VONJO (pacritinib)
Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn)
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This page includes important information for MassHealth providers about prior authorizations. 0000043989 00000 n
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. C
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SUPPRELIN LA (histrelin SC implant)
If denied, the provider may choose to prescribe a less costly but equally effective, alternative Fax : 1 (888) 836- 0730. 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. z@vOK.d CP'w7vmY Wx* The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. TEZSPIRE (tezepelumab-ekko)
Has lost at least 5% of baseline (prior to the initiation of Wegovy) body weight (only required once) 4. Fax complete signed and dated forms to CVS/Caremark at 888-836-0730. startxref
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ELYXYB (celecoxib solution)
ORGOVYX (relugolix)
SENSIPAR (cinacalcet)
XIIDRA (lifitegrast)
The AMA is a third party beneficiary to this Agreement. authorization (PA) guidelines* to encompass assessment of drug indications, set guideline SPRAVATO (esketamine)
You are now being directed to the CVS Health site. TAVNEOS (avacopan)
NUCALA (mepolizumab)
?J?=njQK=?4P;SWxehGGPCf>rtvk'_K%!#.0Izr)}(=%l$&:i$|d'Kug7+OShwNyI>8ASy> Specialty pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used to treat complex conditions. 0000043471 00000 n
0000169482 00000 n
Our prior authorization process will see many improvements. endobj
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endobj
Step #2: We review your request against our evidence-based, clinical guidelines.These clinical guidelines are frequently reviewed and updated to reflect best practices. %%EOF
ADCETRIS (brentuximab)
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. ADDYI (flibanserin)
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. Evkeeza (evinacumab-dgnb) Open a PDF. WebWegovy 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 Documentation of initiation of or ongoing reduced calorie diet; OR Documentation of ongoing care of a registered dietitian nutritionist; AND 0000097799 00000 n
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. Drug Prior Authorization Request Forms. Check authorization requirements using an eTool. Our prior authorization process will see many improvements. For pediatric patients 12 years of age, if a patient does not tolerate the maintenance 2.4 mg once weekly dose, the maintenance dose may be reduced to 1.7 mg once weekly. 0000180429 00000 n
MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate)
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XIPERE (triamcinolone acetonide injectable suspension)
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).