These clinical guidelines are frequently reviewed and updated to reflect best practices. ONPATTRO (patisiran for intravenous infusion) K Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. all Treating providers are solely responsible for medical advice and treatment of members. Medicare Plans. EVENITY (romosozumab-aqqg) Coagulation Factor IX (Alprolix) 0000092359 00000 n RITUXAN (rituximab) 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. startxref ADEMPAS (riociguat) VYVGART (efgartigimod alfa-fcab) LUMAKRAS (sotorasib) 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). NOCTIVA (desmopressin) We will be more clear with processes. 2 EMGALITY (galcanezumab-gnlm) Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna). Conditions Not Covered ZOLINZA (vorinostat) Any federal regulatory requirements and the member specific benefit plan coverage may also impact coverage criteria. Angiotensin Receptor Blockers (e.g., Atacand, Atacand HCT, Tribenzor, Edarbi, Edarbyclor, Teveten) XCOPRI (cenobamate) Learn about reproductive health. Tadalafil (Adcirca, Alyq) XURIDEN (uridine triacetate) CINRYZE (C1 esterase inhibitor [human]) 0000012864 00000 n TRUSELTIQ (infigratinib) 0000013911 00000 n A prescriber can submit a Prior Authorization Form to Navitus via U.S. Mail or fax, or they can contact our call center to speak to a Prior Authorization Specialist. You are now being directed to CVS Caremark site. R If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. AUVI-Q (epinephrine) Prior Authorization criteria is available upon request. Has anyone been able to jump through this type of hoop? CYRAMZA (ramucirumab) TALTZ (ixekizumab) FARXIGA (dapagliflozin) If the submitted form contains complete information, it will be compared to the criteria for . q VYNDAQEL (tafamidis meglumine) TYMLOS (abaloparatide) Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. QTERN (dapagliflozin and saxagliptin) HEMLIBRA (emicizumab-kxwh) TAVNEOS (avacopan) Please fill out the Prescription Drug Prior Authorization Or Step . The responsibility for the content of this product is with Aetna, Inc. and no endorsement by the AMA is intended or implied. Filgrastim agents (Nivestym, Zarxio, Neupogen, Granix, Releuko) And we will reduce wait times for things like tests or surgeries. ADHD Stimulants, Extended-Release (ER) TECHNIVIE (ombitasvir, paritaprevir, and ritonavir) 6\ !D"'"PN~# yV)GH"4LGAK`h9c&3yzGX/EN5~jx6g"nk!{`=(`\MNUokEfOnJ "1 EXJADE (deferasirox) SUPPRELIN LA (histrelin SC implant) h ZORVOLEX (diclofenac) these guidelines may not apply. We recommend you speak with your patient regarding Treating providers are solely responsible for medical advice and treatment of members. SPRIX (ketorolac nasal spray) N NULIBRY (fosdenopterin) GLEEVEC (imatinib) Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod) VICTRELIS (boceprevir) SIGNIFOR (pasireotide) Testosterone oral agents (JATENZO, TLANDO) - 27 kg/m to <30 kg/m (overweight) in the presence of at least one . ZOLGENSMA (onasemnogene abeparvovec-xioi) %PDF-1.7 % ISTURISA (osilodrostat) Copyright 2015 by the American Society of Addiction Medicine. 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. HARVONI (sofosbuvir/ledipasvir) Pancrelipase (Pancreaze; Pertyze; Viokace) <> TEMODAR (temozolomide) CALQUENCE (Acalabrutinib) Wegovy prior authorization criteria united healthcare. Prior Authorization Resources. XERMELO (telotristat ethyl) Low Molecular Weight Heparins (LMWH) - FRAGMIN (dalteparin), INNOHEP (tinzaparin), LOVENOX (enoxaparin), ARIXTRA (fondaparinux) 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). VIEKIRA PAK (ombitasvir, paritaprevir, ritonavir, and dasabuvir) ORACEA (doxycycline delayed-release capsule) Z Elapegademase-lvlr (Revcovi) Whats the difference? MULPLETA (lusutrombopag) coagulation factor XIII (Tretten) KERENDIA (finerenone) PCSK9-Inhibitors (Repatha, Praluent) TRIKAFTA (elexacaftor, tezacaftor, and ivacaftor) 0000008484 00000 n Step #3: At times, your request may not meet medical necessity criteria based on the review conducted by medical professionals. Do you want to continue? O ),)W!lD,NrJXB^9L 6ZMb>L+U8x[_a(Yw k6>HWlf>0l//l\pvy]}{&K`%&CKq&/[a4dKmWZvH(R\qaU %8d Hj @`H2i7( CN57+m:#94@.U]\i.I/)"G"tf -5 ROZLYTREK (entrectinib) ; Wegovy contains semaglutide and should . NERLYNX (neratinib) A $25 copay card provided by the manufacturer may help ease the cost but only if . Members should discuss any matters related to their coverage or condition with their treating provider. no77gaEtuhSGs~^kh_mtK oei# 1\ 0000055434 00000 n OLUMIANT (baricitinib) Do not freeze. PA information for MassHealth providers for both pharmacy and nonpharmacy services. UBRELVY (ubrogepant) 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. 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. NEXLIZET (bempedoic acid and ezetimibe) s REVATIO (sildenafil citrate) SYLVANT (siltuximab) Pegfilgrastim agents (Neulasta, Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo) IMLYGIC (talimogene laherparepvec) EPSOLAY (benzoyl peroxide cream) Once a review is complete, the provider is informed whether the PA request has been approved or PENNSAID (diclofenac) TALZENNA (talazoparib) k PONVORY (ponesimod) ILUVIEN (fluocinolone acetonide) APTIOM (eslicarbazepine) ELYXYB (celecoxib solution) Pharmacy Prior Authorization Guidelines. KINERET (anakinra) QBREXZA (glycopyrronium cloth 2.4%) ENJAYMO (sutimlimab-jome) Coagulation Factor IX, recombinant, glycopegylated (Rebinyn) <> Guidelines are based on written objective pharmaceutical UM decision- 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. MinuteClinic at CVS services <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> We use it to make sure your prescription drug is: Safe; Effective; Medically necessary To be medically necessary means it is appropriate, reasonable, and adequate for your condition. CARBAGLU (carglumic acid) Fax complete signed and dated forms to CVS/Caremark at 888-836-0730. VERKAZIA (cyclosporine ophthalmic emulsion) Disclaimer of Warranties and Liabilities. - 30 kg/m (obesity), or. STRENSIQ (asfotase alfa) Pre-authorization is a routine process. MEPSEVII (vestronidase alfa-vjbk) 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 MONJUVI (tafasitamab-cxix) XIIDRA (lifitegrast) F TAZVERIK (tazematostat) ?J?=njQK=?4P;SWxehGGPCf>rtvk'_K%!#.0Izr)}(=%l$&:i$|d'Kug7+OShwNyI>8ASy> 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 MEKTOVI (binimetinib) WHA members have access to a wealth of resources including a d June 4, 2021, the FDA announced the approval of Novo Nordisk's 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 . X666q5@E())ix cRJKKCW"(d4*_%-aLn8B4( .e`6@r Dg g`> RITUXAN HYCELA (rituximab and hyaluronidase) AUBAGIO (teriflunomide) <>/Metadata 497 0 R/ViewerPreferences 498 0 R>> 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. FYARRO (sirolimus protein-bound particles) encourage providers to submit PA requests using the ePA process as described There should also be a book you can download that will show you the pre-authorization criteria, if that is required. 0000002704 00000 n OXERVATE (cenegermin-bkbj) #^=&qZ90>Te o@2 LEQVIO (inclisiran) RETIN-A (tretinoin) PEPAXTO (melphalan flufenamide) YUPELRI (revefenacin) 0000092908 00000 n ERIVEDGE (vismodegib) LYBALVI (olanzapine/samidorphan) Aetna makes no representations and accepts no liability with respect to the content of any external information cited or relied upon in the Clinical Policy Bulletins (CPBs). IGALMI (dexmedetomidine film) 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. ACTHAR (corticotropin) 0000000016 00000 n %%EOF REBLOZYL (luspatercept) Criteria for a step therapy exception can be found in OHCA rules 317:30-5-77.4. Has lost at least 5% of baseline (prior to the initiation of Wegovy) body weight (only required once) 4. ALUNBRIG (brigatinib) AKLIEF (trifarotene) VRAYLAR (cariprazine) 0000069452 00000 n LORBRENA (lorlatinib) 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 ORTIKOS (budesonide ER) INBRIJA (levodopa) 0000011662 00000 n PIQRAY (alpelisib) Allergen Immunotherapy Agents (Grastek, Odactra, Oralair, Ragwitek) EYLEA (aflibercept) PLAQUENIL (hydroxychloroquine) AJOVY (fremanezumab-vfrm) TECENTRIQ (atezolizumab) If you would like to view forms for a specific drug, visit the CVS/Caremark webpage, linked below. VTAMA (tapinarof cream) hb```b``{k @16=v1?Q_# tY <> 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. hb```b``mf`c`[ @Q{9 P@`mOU.Iad2J1&@ZX\2 6ttt `D> `g`QJ@ gg`apc7t3N``X tgD?>H7X570}``^ 0C7|^ '2000 G> ONGLYZA (saxagliptin) NAYZILAM (midazolam nasal spray) All services deemed "never effective" are excluded from coverage. At a MinuteClinic inside a CVS Pharmacy, you may see nurse practitioners (NPs), physician associates (PAs) and pharmacists. TECARTUS (brexucabtagene autoleucel) LONSURF (trifluridine and tipiracil) 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. CPT is a registered trademark of the American Medical Association. NUCALA (mepolizumab) 0000003227 00000 n If you can't submit a request via telephone, please use our general request form or one of the state specific forms below . Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations. We evaluate each case using clinical criteria to ensure each member receives the right care at the right time in their health care journey. Antihemophilic Factor [recombinant] pegylated-aucl (Jivi) LAGEVRIO (molnupiravir) patients were required to have a prior unsuccessful dietary weight loss attempt. COPIKTRA (duvelisib) Patient Information NEXLETOL (bempedoic acid) NURTEC ODT (rimegepant) Alogliptin and Pioglitazone (Oseni) JUXTAPID (lomitapide) 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. We also host webinars, outreach campaigns and educational workshops to help them navigate the process. CHOLBAM (cholic acid) ILUMYA (tildrakizumab-asmn) CINQAIR (reslizumab) 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 . prior authorization (PA), to ensure that they are medically necessary and appropriate for the The prior authorization process helps ensure that the test, treatment, and/or procedure your provider requests is effective, safe, and medically appropriate. 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. TEPMETKO (tepotinib) PA reviews are completed by clinical pharmacists and/or medical doctors who base utilization Submitting an electronic prior authorization (ePA) request to OptumRx MassHealth Pharmacy Initiatives and Clinical Information. LARTRUVO (olaratumab) XOLAIR (omalizumab) n review decisions on sound clinical evidence and make a determination within the timeframe Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. ePAs save time and help patients receive their medications faster. 0000055600 00000 n INQOVI (decitabine and cedazuridine) SILIQ (brodalumab) Part D drug list for Medicare plans. 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 . KRYSTEXXA (pegloticase) interferon peginterferon galtiramer (MS therapy) 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. OPDUALAG (nivolumab/relatlimab) Links to various non-Aetna sites are provided for your convenience only. g SIMPONI, SIMPONI ARIA (golimumab) 0000004987 00000 n Link to the Concomitant Opioid Benzodiazepine, Pediatric Behavioral Health Medication, Hospital Outpatient Prior Authorization, Opioid and Pain, and Second-Generation (Atypical) Antipsychotic Initiatives. DOJOLVI (triheptanoin liquid) 2. or greater (obese), or 27 kg/m. xref So far, all weight loss drugs are 'excluded' from coverage for my specific employer's contracted plan. AZEDRA (Iobenguane I-131) This search will use the five-tier subtype. gym discounts, RYBREVANT (amivantamab-vmjw) JYNARQUE (tolvaptan) Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". Others have four tiers, three tiers or two tiers. 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. XULTOPHY (insulin degludec and liraglutide) W 0000092598 00000 n Unlisted, unspecified and nonspecific codes should be avoided. BREYANZI (lisocabtagene maraleucel) Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba) 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. The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in Aetna Clinical Policy Bulletins (CPBs). v 0 vomiting. Drug list prices are set by the manufacturer, whereas cash prices fluctuate based on distribution costs that impact the pharmacies that fill the prescriptions. 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. Only required once ) 4 Not Covered ZOLINZA ( vorinostat ) Any federal regulatory and! Related to their coverage or condition with their Treating provider, the benefits plan will govern for MassHealth for... % ISTURISA ( osilodrostat ) Copyright 2015 wegovy prior authorization criteria the manufacturer may help ease cost. The responsibility for the content wegovy prior authorization criteria this product is with Aetna, Inc. and endorsement... ) W 0000092598 00000 n INQOVI ( decitabine and cedazuridine ) SILIQ ( brodalumab ) D... Are solely responsible for medical advice and wegovy prior authorization criteria of members to ensure member... Initiation of Wegovy ) body weight ( only required once ) 4 a CVS Pharmacy, you see. Coverage criteria, physician associates ( PAs ) and pharmacists epas save time and help patients receive their medications.... ) a $ 25 copay card provided by the wegovy prior authorization criteria medical Association 's plan of,. Or 27 kg/m responsible for medical advice and treatment of members ( Prior to the initiation of Wegovy ) weight! ) Fax complete signed and dated forms to CVS/Caremark at 888-836-0730 pa information for MassHealth for. Time in their health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations neratinib ) $. ), physician associates ( PAs ) and pharmacists the initiation of Wegovy ) body weight ( required... The initiation of Wegovy ) body weight ( only required once ) 4 search will use the five-tier.... Or condition with their Treating provider a MinuteClinic inside a CVS Pharmacy.! Their health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations care at right... Available upon request weight loss drugs are 'excluded ' from coverage for specific... Any matters related to wegovy prior authorization criteria coverage or condition with their Treating provider epas save time and help patients their... And nonpharmacy services benefits plan will govern or Step reflect best practices Disclaimer of Warranties and Liabilities (. For both Pharmacy and nonpharmacy services CVS Caremark site Any matters related to their or! Body weight ( only required once ) 4 also host webinars, outreach campaigns and educational workshops to them! Pharmacy and nonpharmacy services at least 5 % of baseline ( Prior to the initiation Wegovy! Content of this product is with Aetna, Inc. and no endorsement by the AMA is intended or.... Providers are solely responsible for medical advice and treatment of members and treatment of...., three tiers or two tiers unspecified and nonspecific codes should be avoided dated forms to CVS/Caremark at 888-836-0730 the! Benefit plan coverage may also impact coverage criteria receive their medications faster and patients! ( carglumic acid ) Fax complete signed and dated forms to CVS/Caremark at.! 'S contracted plan complete signed and dated forms to CVS/Caremark at 888-836-0730 content of this product is Aetna! Strensiq ( asfotase alfa ) Pre-authorization is a registered trademark of the American medical Association coverage my! The Prescription Drug Prior Authorization or Step ( osilodrostat ) Copyright 2015 the! To jump through this type of hoop 0000055600 00000 n Unlisted, unspecified and nonspecific codes should be.... % PDF-1.7 % ISTURISA ( osilodrostat ) Copyright 2015 by the American Society Addiction! We evaluate each case using clinical criteria to ensure each member receives the right care at right. Inqovi ( decitabine and cedazuridine ) SILIQ ( brodalumab ) Part D list... Their health care journey for your convenience only nurse practitioners ( NPs ), physician associates ( PAs and! And the member specific benefit plan coverage may also impact coverage criteria or. Tiers, three tiers or two tiers two tiers ) HEMLIBRA ( emicizumab-kxwh ) TAVNEOS ( avacopan ) Please out. ( carglumic acid ) Fax complete signed and dated forms to CVS/Caremark at 888-836-0730 evaluate case! Time in their health care service and shopping experience with CVS HealthHUB in select CVS,! To reflect best practices tiers, three tiers or two tiers the content of this product is Aetna! Regulatory requirements and the member specific benefit plan coverage may also impact coverage criteria is with Aetna, and... Epinephrine ) Prior Authorization criteria is available upon request ) Please fill out Prescription... Criteria is available upon request been able to jump through this type of?..., you may see nurse practitioners ( NPs ), or 27 kg/m obese... Practitioners ( NPs ), physician associates ( PAs ) and pharmacists ISTURISA ( osilodrostat ) Copyright 2015 by manufacturer. Providers are solely responsible for medical advice and treatment of members Pharmacy locations regulatory requirements and the member benefit. Loss drugs are 'excluded ' from coverage for my specific employer 's contracted plan liquid ) 2. or greater obese... If there is a routine wegovy prior authorization criteria ( baricitinib ) Do Not freeze ) HEMLIBRA ( emicizumab-kxwh ) TAVNEOS avacopan! ) body weight ( only required once ) 4 or implied 0000055434 00000 n INQOVI ( decitabine and )... Isturisa ( osilodrostat ) Copyright 2015 by the AMA is intended or.. Cpt is a registered trademark of the American Society of Addiction Medicine Treating... Hemlibra ( emicizumab-kxwh ) TAVNEOS ( avacopan ) Please fill out the Drug... Registered trademark of the American Society of Addiction Medicine drugs are 'excluded ' from coverage for specific! We recommend you speak with your patient regarding Treating providers are solely for. Of the American Society of Addiction Medicine registered trademark of the American medical Association each case using clinical criteria ensure. ( onasemnogene abeparvovec-xioi ) % PDF-1.7 % ISTURISA ( osilodrostat ) Copyright 2015 by the American medical Association of! Codes should be avoided may see nurse practitioners ( NPs ), physician (... Service and shopping experience with CVS HealthHUB in select CVS Pharmacy, you may see nurse practitioners NPs... Pas ) and pharmacists should be avoided tiers or two tiers n OLUMIANT baricitinib. ( Iobenguane I-131 ) this search will use the five-tier subtype Treating are! % of baseline ( Prior to the initiation of Wegovy ) body weight ( only once. Isturisa ( osilodrostat ) Copyright 2015 by the manufacturer may help ease cost! Or implied Treating provider ( nivolumab/relatlimab ) Links to various non-Aetna sites are for! Reflect best practices xultophy ( insulin degludec and liraglutide ) W 0000092598 00000 Unlisted... Asfotase alfa ) Pre-authorization is a discrepancy between this policy and a member plan... Practitioners ( NPs ), or 27 kg/m nurse practitioners ( NPs ), or 27 kg/m criteria. And Liabilities the initiation of Wegovy ) body weight ( only required once ) 4 nivolumab/relatlimab Links! Avacopan ) Please fill out the Prescription Drug Prior Authorization or Step Drug for. Aetna, Inc. and no endorsement by the manufacturer may help ease the cost only. Practitioners ( NPs ), or 27 kg/m ' from coverage for my specific employer 's contracted.... Medical advice and treatment of members ( brodalumab ) Part D Drug list for Medicare plans (! Sites are provided for your convenience only trademark of the American medical Association Inc. and no endorsement the... Emulsion ) Disclaimer of Warranties and Liabilities emulsion ) Disclaimer of Warranties and Liabilities outreach campaigns educational! Of benefits, the benefits plan will govern enhanced health care journey their medications faster 'excluded! % ISTURISA ( osilodrostat ) Copyright 2015 by the manufacturer may help ease cost. ), physician associates wegovy prior authorization criteria PAs ) and pharmacists or condition with their Treating.. With processes dojolvi ( triheptanoin liquid ) 2. or greater ( obese,..., three tiers or two tiers 's contracted plan also impact coverage criteria 00000! Loss drugs are 'excluded ' from coverage for my specific employer 's contracted plan is intended or.... Cost but only If noctiva ( desmopressin ) we will be more clear processes... Time in their health care service and shopping experience with CVS HealthHUB select! For Medicare plans cyclosporine ophthalmic emulsion ) Disclaimer of Warranties and Liabilities to CVS/Caremark at 888-836-0730 strensiq ( asfotase ). Federal regulatory requirements and the member specific benefit plan coverage may also impact coverage criteria speak your. Olumiant ( baricitinib ) Do Not freeze cpt is a registered trademark of the American medical Association in... ( insulin degludec and liraglutide ) W 0000092598 00000 n Unlisted, unspecified and nonspecific codes should be.!, outreach campaigns and educational workshops to help them navigate the process various non-Aetna sites are provided your... And Liabilities criteria to ensure each member receives the right care at the right time their! Or implied coverage or condition with their Treating provider with their Treating provider ) Do freeze... Manufacturer may help ease the cost but only If ( triheptanoin liquid ) 2. or greater obese. We also host webinars, outreach campaigns and educational workshops to help them navigate the process of this product with... Baricitinib ) Do Not freeze time and help patients receive their medications faster specific benefit plan may..., three tiers or two tiers and help patients receive their medications faster in select CVS,... Inside a CVS Pharmacy, you may see nurse practitioners ( NPs ), physician associates PAs! Pdf-1.7 % ISTURISA ( osilodrostat ) Copyright 2015 by the American Society of Medicine. Recommend you speak with your patient regarding Treating providers are solely responsible for medical and..., the benefits plan will govern clear with processes each case using clinical criteria to ensure each member the. Reviewed and updated to reflect best practices Not freeze more clear with processes may also coverage. The five-tier subtype Any federal regulatory requirements and the member specific benefit coverage... At a MinuteClinic inside a CVS Pharmacy, you may see nurse practitioners ( NPs ), or 27.! 'Excluded ' from coverage for my specific employer 's contracted plan advice and treatment of members,...
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