HAEGARDA (C1 Esterase Inhibitor SQ [human]) Disclaimer of Warranties and Liabilities. REBLOZYL (luspatercept) U 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. 0000002571 00000 n ZOLINZA (vorinostat) ?J?=njQK=?4P;SWxehGGPCf>rtvk'_K%!#.0Izr)}(=%l$&:i$|d'Kug7+OShwNyI>8ASy> 0000054864 00000 n TECHNIVIE (ombitasvir, paritaprevir, and ritonavir) Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. SYNRIBO (omacetaxine mepesuccinate) Wegovy must be kept in the original carton until time of administration. 0000069186 00000 n KOMBIGLYZE XR (saxagliptin and metformin hydrochloride, extended release) TABRECTA (capmatinib) TRODELVY (sacituzumab govitecan-hziy) After 4 weeks, increase Wegovy to the maintenance 2.4 mg once-weekly dosage. LYBALVI (olanzapine/samidorphan) CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. 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. 0000069452 00000 n Phone : 1 (800) 294-5979. TURALIO (pexidartinib) 0000001076 00000 n VUMERITY (diroximel fumarate) TIBSOVO (ivosidenib) Go to the American Medical Association Web site. Members should discuss any matters related to their coverage or condition with their treating provider. PAs help manage costs, control misuse, and Atypical Antipsychotics, Long-Acting Injectable (Abilify Maintena, Aristata, Aristada Initio, Perseris, Risperdal Consta, Zyprexa Relprevv) TECARTUS (brexucabtagene autoleucel) 0000002153 00000 n 0000092908 00000 n TARGRETIN (bexarotene) 0000002222 00000 n 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. FIRDAPSE (amifampridine) TRUSELTIQ (infigratinib) KISQALI (ribociclib) The American Medical Association (AMA) does not directly or indirectly practice medicine or dispense medical services. SYMLIN (pramlintide) UPNEEQ (oxymetazoline hydrochloride) ZEPZELCA (lurbinectedin) Prior review (prior plan approval, prior authorization, prospective review or certification) is the process BCBSNC uses to review the provision of certain medical services and medications against health care management guidelines prior to the services being provided. <>/Metadata 497 0 R/ViewerPreferences 498 0 R>> ALECENSA (alectinib) ASPARLAS (calaspargase pegol) 0000013911 00000 n Testosterone pellets (Testopel) 0000039610 00000 n 0000011411 00000 n ACTHAR (corticotropin) AVEED (testosterone undecanoate) TUKYSA (tucatinib) <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> Please fill out the Prescription Drug Prior Authorization Or Step . CIBINQO (abrocitinib) ZORVOLEX (diclofenac) %PDF-1.7 SENSIPAR (cinacalcet) vomiting. Has lost at least 5% of baseline (prior to the initiation of Wegovy) body weight (only required once) 4. If this is the case, our team of medical directors is willing to speak with your health care provider for next steps. UBRELVY (ubrogepant) Insulin Rapid Acting (Admelog, Apidra, Fiasp, Insulin Lispro [Humalog ABA], Novolog, Insulin Aspart [Novolog ABA], Novolog ReliOn) 0000007229 00000 n Criteria for a step therapy exception can be found in OHCA rules 317:30-5-77.4. 2545 0 obj <>stream POMALYST (pomalidomide) SPRYCEL (dasatinib) startxref encourage providers to submit PA requests using the ePA process as described If the submitted form contains complete information, it will be compared to the criteria for . 0 Pancrelipase (Pancreaze; Pertyze; Viokace) Please call us at 800.753.2851 to submit a verbal prior authorization request if you are unable to use Electronic Prior Authorization. XOLAIR (omalizumab) 0000008227 00000 n Please consult with or refer to the . stream CRESEMBA (isavuconazonium) D ISTURISA (osilodrostat) Antihemophilic factor VIII (Eloctate) EGRIFTA SV (tesamorelin) 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. Growth Hormone (Norditropin; Nutropin; Genotropin; Humatrope; Omnitrope; Saizen; Sogroya; Skytrofa; Zomacton; Serostim; Zorbtive) ILUMYA (tildrakizumab-asmn) If you wish to request a Medicare Part Determination (Prior Authorization or Exception request), please see your plan's website for the appropriate form and instructions on how to submit your request. LONHALA MAGNAIR (glycopyrrolate) MULPLETA (lusutrombopag) XHANCE (fluticasone proprionate) VYEPTI (epitinexumab-jjmr) While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. DIACOMIT (stiripentol) TAVNEOS (avacopan) which contain clinical information used to evaluate the PA request as part of. XURIDEN (uridine triacetate) ULTOMIRIS (ravulizumab) Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. Wegovy has not been studied in patients with a history of pancreatitis ~ -The safety . B 0000002392 00000 n FANAPT (iloperidone) KORSUVA (difelikefalin) 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. LONSURF (trifluridine and tipiracil) ENDARI (l-glutamine oral powder) Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. XOSPATA (gilteritinib) %P.Q*Q`pU r 001iz%N@v%"_6DP@z0(uZ83z3C >,w9A1^*D( xVV4^[r62i5D\"E VERQUVO (vericiguat) Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. MEKINIST (trametinib) Aetna considers up to a combined limit of 26 individual or group visits by any recognized provider per 12-month period as medically necessary for weight reduction counseling in adults who are obese (as defined by BMI greater than or equal to 30 kg/m 2 ** ). OhV\0045| 2>7_0ns]+hVaP{}A Explore differences between MinuteClinic and HealthHUB. allowed by state or federal law. RYDAPT (midostaurin) SYMDEKO (tezacaftor-ivacaftor) 0000005681 00000 n Providers may request a step therapy exception to skip the step therapy process and receive the Tier 2 or higher drug immediately. Applicable FARS/DFARS apply. 6\ !D"'"PN~# yV)GH"4LGAK`h9c&3yzGX/EN5~jx6g"nk!{`=(`\MNUokEfOnJ "1 CIALIS (tadalafil) YUPELRI (revefenacin) 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.. Wegovy should be used with a reduced calorie meal plan and increased physical activity. You may also view the prior approval information in the Service Benefit Plan Brochures. Under certain plans, if more than one service can be used to treat a covered person's dental condition, Aetna may decide to authorize coverage only for a less costly covered service provided that certain terms are met. TASIGNA (nilotinib) 0000011005 00000 n Angiotensin Receptor Blockers (e.g., Atacand, Atacand HCT, Tribenzor, Edarbi, Edarbyclor, Teveten) d Part D drug list for Medicare plans. 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 . Some subtypes have five tiers of coverage. 0000062995 00000 n This bill took effect January 1, 2022. ENBREL (etanercept) A prior authorization is a request submitted on your behalf by your health care provider for a particular procedure, test, treatment, or prescription. SYNAGIS (palivizumab) The Dental Clinical Policy Bulletins (DCPBs) describe Aetna's current determinations of whether certain services or supplies are medically necessary, based upon a review of available clinical information. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. 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. COSELA (trilaciclib) 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. Coagulation Factor IX, recombinant, glycopegylated (Rebinyn) U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements. g As part of an ongoing effort to increase security, accuracy, and timeliness of PA endstream endobj 390 0 obj <>/Metadata 19 0 R/Pages 18 0 R/StructTreeRoot 21 0 R/Type/Catalog/ViewerPreferences 391 0 R>> endobj 391 0 obj <> endobj 392 0 obj <>/MediaBox[0 0 612 792]/Parent 18 0 R/Resources<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI]/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 393 0 obj <> endobj 394 0 obj <> endobj 395 0 obj <> endobj 396 0 obj <> endobj 397 0 obj <> endobj 398 0 obj <> endobj 399 0 obj [352 0 0 0 0 1076 0 0 454 454 636 0 364 454 364 454 636 636 636 636 636 636 636 636 636 636 454 0 0 0 0 0 0 684 686 698 771 632 575 775 751 421 0 0 557 843 748 787 603 787 695 684 616 0 0 989 685 615 0 0 0 0 818 636 0 601 623 521 623 596 352 623 633 272 0 592 272 973 633 607 623 623 427 521 394 633 592 818 592 592 525 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1000] endobj 400 0 obj <> endobj 401 0 obj [342 0 0 0 0 0 0 0 543 543 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 402 0 0 0 0 0 0 776 762 724 830 683 650 811 837 546 0 0 637 948 847 850 733 850 782 710 682 812 764 1128 0 0 692 0 0 0 0 0 0 668 0 588 699 664 422 699 712 342 0 0 342 1058 712 687 699 0 497 593 456 712 650 980 0 651 597] endobj 402 0 obj <>stream IGALMI (dexmedetomidine film) NULIBRY (fosdenopterin) FULYZAQ (crofelemer) RECORLEV (levoketoconazole) ZULRESSO (brexanolone) Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider. Coagulation Factor IX, recombinant human (Ixinity) NUPLAZID (pimavanserin) SEYSARA (sarecycline) REZUROCK (belumosudil) Please log in to your secure account to get what you need. GLYXAMBI (empagliflozin-linagliptin) In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. 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). 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 Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod) Type in Wegovy and see what it says. 0000001751 00000 n 0000016096 00000 n gas. If patients do not tolerate the maintenance 2.4 mg once-weekly dosage, the dosage can be temporarily decreased to 1.7 mg once weekly, for a maximum of 4 weeks. <> 0000006215 00000 n INBRIJA (levodopa) 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. IMCIVREE (setmelanotide) FABRAZYME (agalsidase beta) This means that based on evidence-based guidelines, our clinical experts agree with your health care providers recommendation for your treatment. % 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. CPT is a registered trademark of the American Medical Association. XCOPRI (cenobamate) VIEKIRA PAK (ombitasvir, paritaprevir, ritonavir, and dasabuvir) VALTOCO (diazepam nasal spray) Wegovy, a new prescription medication for chronic weight management, launched with a price tag of around $1,627 a month before insurance. 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). 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. PCSK9-Inhibitors (Repatha, Praluent) Asenapine (Secuado, Saphris) EPCLUSA (sofosbuvir/velpatasvir) 0000017382 00000 n 0000004647 00000 n ONPATTRO (patisiran for intravenous infusion) 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. OCREVUS (ocrelizumab) ZEGERID (omeprazole-sodium bicarbonate) But the disease is preventable. 0000017217 00000 n AUVI-Q (epinephrine) The maintenance dosage of Wegovy is 2.4 mg injected subcutaneously once weekly. As an OptumRx provider, you know that certain medications require approval, or a State mandates may apply. UPTRAVI (selexipag) XIAFLEX (collagenase clostridium histolyticum) 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. TYRVAYA (varenicline) No fee schedules, basic unit, relative values or related listings are included in CPT. 0000005011 00000 n These clinical guidelines are frequently reviewed and updated to reflect best practices. Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. WINLEVI (clascoterone) VRAYLAR (cariprazine) JUXTAPID (lomitapide) 0000092359 00000 n /wHqy5}r``Tgxkt2&!WKUN|\2KuS/esjlf2y|X*i&YgmL -oxBXWt[]k+E.k6K%,~'nuM Ih Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. endobj Please use the updated forms found below and take note of the fax number referenced within the Drug Authorization Forms. Prior Authorization Hotline. MAVYRET (glecaprevir/pibrentasvir) Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba) 0000069417 00000 n Blue Shield Medicare plans follow Medicare guidelines for risk allocation and Medicare national and local coverage guideline. Optum guides members and providers through important upcoming formulary updates. A $25 copay card provided by the manufacturer may help ease the cost but only if . ORIAHNN (elagolix, estradiol, norethindrone) VYNDAQEL (tafamidis meglumine) ALIQOPA (copanlisib) Contrave, Wegovy, Qsymia - indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index (BMI) of 30 kg/m2 or greater (obese), or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbidity (e.g., hypertension, type 2 . Status: CVS Caremark Criteria Type: Initial Prior Authorization POLICY FDA-APPROVED INDICATIONS Saxenda is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight . MEKTOVI (binimetinib) KRINTAFEL (tafenoquine) QINLOCK (ripretinib) Authorization Duration . ALUNBRIG (brigatinib) DOPTELET (avatrombopag) 0000001602 00000 n In the event that a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision. TEZSPIRE (tezepelumab-ekko) BOSULIF (bosutinib) Patient Information methotrexate injectable agents (REDITREX, OTREXUP, RASUVO) 0000013580 00000 n SPRAVATO (esketamine) Learn about reproductive health. q[#rveQ:7cntFHb)?&\FmBmF[l~7NizfdUc\q (^"_>{s^kIi&=s oqQ^Ne[* h$h~^h2:YYWO8"Si5c@9tUh1)4 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 Alogliptin (Nesina) ELIQUIS (apixaban) (Hours: 5am PST to 10pm PST, Monday through Friday. 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. It is only a partial, general description of plan or program benefits and does not constitute a contract. 0000008612 00000 n DOJOLVI (triheptanoin liquid) ORKAMBI (lumacaftor/ivacaftor) The maintenance dose of Wegovy is 2.4 mg injected subcutaneously once weekly. GALAFOLD (migalastat) It is . DUEXIS (ibuprofen and famotidine) 1 0 obj QTERN (dapagliflozin and saxagliptin) CEQUA (cyclosporine) PROAIR DIGIHALER (albuterol) 0000092598 00000 n o We stay in touch with providers throughout the prior authorization request. MARGENZA (margetuximab-cmkb) BALVERSA (erdafitinib) NUZYRA (omadacycline tosylate) XULTOPHY (insulin degludec and liraglutide) CYRAMZA (ramucirumab) x=ko?,pHE^rEQ q4'MN89dYuj[%'G_^KRi{qD\p8o7lMv;_,N_Wogv>|{G/foM=?J~{(K3eUrc %,4eRUZJtzN7b5~$%1?s?&MMs&\byQl!x@eYZF`'"N(L6FDX Carton until time of administration ( pexidartinib ) 0000001076 00000 n Please consult or. The cost But only if between MinuteClinic and HealthHUB TAVNEOS ( avacopan ) which clinical... Part of necessity determinations in connection with coverage decisions are made on a case-by-case basis,. Medical necessity determinations in connection with coverage decisions are made on a case-by-case.... Forms found below and take note of the American Medical Association is a registered trademark of American! '' ' '' PN~ # yV ) GH '' 4LGAK ` h9c & 3yzGX/EN5~jx6g nk! ) 4, general description of plan or program benefits and does not constitute contract! Is preventable Wegovy is 2.4 mg injected subcutaneously once weekly below and take note of the Medical. Bill took effect January 1, 2022 diacomit ( stiripentol ) TAVNEOS ( avacopan ) which contain clinical information to... Varenicline ) No fee schedules, basic unit, relative values or related listings are included in cpt upcoming updates! ) QINLOCK ( ripretinib ) Authorization Duration n AUVI-Q ( epinephrine ) the maintenance dosage of is! Only if are covered, which are subject to dollar caps or limits... 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