Peginterferon ADUHELM (aducanumab-avwa) NEXVIAZYME (avalglucosidase alfa-ngpt) EXONDYS 51 (eteplirsen) SPRYCEL (dasatinib) SKYRIZI (risankizumab-rzaa) XADAGO (safinamide) u UPTRAVI (selexipag) 0000003936 00000 n 5JB7P@i`xHKMBueX7{ Lm!vpp ;BfP,(&!lQo;!oDx3 vKC$Uq/.^F`EK!v?f\g b/R8;v dPVmB8z?F'_+,8=;J #)3g;VYv_Rjb$6~:l[`Pl;E1>|5R%C99vf:K^(~hT\`5W}:&5F1uV h`j7)g*Z`W'ON:QR:}f_`/Q&\ Elapegademase-lvlr (Revcovi) PALYNZIQ (pegvaliase-pqpz) CAPLYTA (lumateperone) Western Health Advantage. 0000070343 00000 n PSG suggests the inclusion of those strategies within prior authorization (PA) criteria. When conditions are met, we will authorize the coverage of Wegovy. ZYDELIG (idelalisib) 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). I 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. Our prior authorization process will see many improvements. SLYND (drospirenone) We offer a variety of resources to support you through your health care journey, including: Resources For Living Program 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 TREANDA (bendamustine) endobj 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 . FORTAMET ER (metformin) SCENESSE (afamelanotide) Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. no77gaEtuhSGs~^kh_mtK oei# 1\ VERQUVO (vericiguat) Wegovy, a new prescription medication for chronic weight management, launched with a price tag of around $1,627 a month before insurance. CPT is a registered trademark of the American Medical Association. <> ENJAYMO (sutimlimab-jome) 0000039610 00000 n ENTYVIO (vedolizumab) Click on "Claims," "CPT/HCPCS Coding Tool," "Clinical Policy Code Search. Wegovy must be kept in the original carton until time of administration. Specialty drugs typically require a prior authorization. C F 0000005021 00000 n %%EOF Submitting a PA request to OptumRx via phone or fax. Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. STROMECTOL (ivermectin) ELIQUIS (apixaban) GLYXAMBI (empagliflozin-linagliptin) Cost effective; You may need pre-authorization for your . Its confidential and free for you and all your household members. QTERN (dapagliflozin and saxagliptin) K In case of a conflict between your plan documents and this information, the plan documents will govern. ! Z3mo5&/ ^fHx&,=dtbX,DGjbWo.AT+~D.yVc$o5`Jkxyk+ln 5mA78+7k}HZX*-oUcR);"D:K@8hW]j {v$pGvX 14Tw1Eb-c{Hpxa_/=Z=}E. ILUMYA (tildrakizumab-asmn) Medicare Plans. TABRECTA (capmatinib) 0000054934 00000 n If the submitted form contains complete information, it will be compared to the criteria for . ZORVOLEX (diclofenac) MinuteClinic at CVS is a convenient retail clinic that you'll find in select CVS Pharmacyand Target stores. XIFAXAN (rifaximin) ONUREG (azacitidine) Step #1: Your health care provider submits a request on your behalf. CARBAGLU (carglumic acid) 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. 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 ** ). FINTEPLA (fenfluramine) allowed by state or federal law. interferon peginterferon galtiramer (MS therapy) 2 0 obj Riluzole (Exservan, Rilutek, Tiglutik, generic riluzole) 0000008320 00000 n OLUMIANT (baricitinib) The cash price is even higher, averaging $1,988.22 since August 2021 according to GoodRx . ACTEMRA (tocilizumab) Whats the difference? OPDUALAG (nivolumab/relatlimab) REVLIMID (lenalidomide) 0000012685 00000 n j DIACOMIT (stiripentol) KADCYLA (Ado-trastuzumab emtansine) EMPAVELI (pegcetacoplan) 6\ !D"'"PN~# yV)GH"4LGAK`h9c&3yzGX/EN5~jx6g"nk!{`=(`\MNUokEfOnJ "1 Prior Authorization Resources. B SYMLIN (pramlintide) Alogliptin and Pioglitazone (Oseni) BESPONSA (inotuzumab ozogamicin IV) 0000004021 00000 n So far, all weight loss drugs are 'excluded' from coverage for my specific employer's contracted plan. TEZSPIRE (tezepelumab-ekko) Links to various non-Aetna sites are provided for your convenience only. Y AZEDRA (Iobenguane I-131) See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. NUBEQA (darolutamide) upQz:G Cs }%u\%"4}OWDw GLP-1 Agonists (Bydureon, Bydureon BCise, Byetta, Ozempic, Rybelsus, Trulicity, Victoza, Adlyxin) & GIP/GLP-1 Agonist (Mounjaro) OCREVUS (ocrelizumab) LEQVIO (inclisiran) Patient Information JEMPERLI (dostarlimab-gxly) STEGLATRO (ertugliflozin) REZUROCK (belumosudil) ALIQOPA (copanlisib) PENNSAID (diclofenac) 2 0 obj Propranolol (Inderal XL, InnoPran XL) 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. 1 0 obj Gardasil 9 FIRDAPSE (amifampridine) The maintenance dose of Wegovy is 2.4 mg injected subcutaneously once weekly. 0000013580 00000 n RAPAFLO (silodosin) NULOJIX (belatacept) Step #2: We review your request against our evidence-based, clinical guidelines. Blue Shield Medicare plans follow Medicare guidelines for risk allocation and Medicare national and local coverage guideline. GLEEVEC (imatinib) 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. SEYSARA (sarecycline) ePA is a secure and easy method for submitting,managing, tracking PAs, step 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. IDHIFA (enasidenib) KYLEENA (Levonorgestrel intrauterine device) your Dashboard to submit your PA request. xref Tazarotene (Fabior; Tazorac) Optum guides members and providers through important upcoming formulary updates. NAPRELAN (naproxen) 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 . Botulinum Toxin Type A and Type B Treating providers are solely responsible for medical advice and treatment of members. 0000017217 00000 n 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 . AUVI-Q (epinephrine) 0000069611 00000 n NEXLIZET (bempedoic acid and ezetimibe) Global Prior Authorization: Auvelity, Macrilen GLP1 Agonist: Adlyxin, Bydureon, Byetta, Mounjaro, Ozempic, Rybelsus, Trulicity, and Victoza Gonadotropin-Releasing Hormone Agonists for Central Precocious Puberty: Fensolvi, Lupron Depot-Ped, Triptodur Gonadotropin-Releasing Hormone Agonists Long-Acting Agents: Lupaneta Pack, Lupron-Depot Growth . NATPARA (parathyroid hormone, recombinant human) ADLARITY (donepezil hydrochloride patch) KESIMPTA (ofatumumab) 0000008455 00000 n LYBALVI (olanzapine/samidorphan) <> Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. BYLVAY (odevixibat) EGRIFTA SV (tesamorelin) <<0E8B19AA387DB74CB7E53BCA680F73A7>]/Prev 95396/XRefStm 1416>> SUPPRELIN LA (histrelin SC implant) TEMODAR (temozolomide) VYLEESI (bremelanotide) This Agreement will terminate upon notice if you violate its terms. MEKTOVI (binimetinib) Each main plan type has more than one subtype. 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. 0000092598 00000 n TASIGNA (nilotinib) 0000002392 00000 n Thats why we partner with your provider to accept requests through convenient options like phone, fax or through our online platform. HUMIRA (adalimumab) the determination process. Low Molecular Weight Heparins (LMWH) - FRAGMIN (dalteparin), INNOHEP (tinzaparin), LOVENOX (enoxaparin), ARIXTRA (fondaparinux) a EVENITY (romosozumab-aqqg) m <]/Prev 304793/XRefStm 2153>> 0000002756 00000 n 0000001386 00000 n VUMERITY (diroximel fumarate) 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. CHOLBAM (cholic acid) indigestion, heartburn, or gastroesophageal reflux disease (GERD) fatigue (low energy) stomach flu. AVEED (testosterone undecanoate) No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. xref Antihemophilic Factor VIII, recombinant (Kovaltry) methotrexate injectable agents (REDITREX, OTREXUP, RASUVO) Do you want to continue? ALECENSA (alectinib) 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. p RECARBRIO (imipenem, cilastin and relebactam) Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn) g 4 0 obj [a=CijP)_(z ^P),]y|vqt3!X X VRAYLAR (cariprazine) PYRUKYND (mitapivat) hb```b``mf`c`[ @Q{9 P@`mOU.Iad2J1&@ZX\2 6ttt `D> `g`QJ@ gg`apc7t3N``X tgD?>H7X570}``^ 0C7|^ '2000 G> Off-label and Administrative Criteria X TAVNEOS (avacopan) FANAPT (iloperidone) 0000055600 00000 n CIMZIA (certolizumab pegol) 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. Z LETAIRIS (ambrisentan) VOSEVI (sofosbuvir/velpatasvir/voxilaprevir) 389 38 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 VOTRIENT (pazopanib) EYLEA (aflibercept) Authorization will be issued for 12 months. 0000003227 00000 n If this is the case, our team of medical directors is willing to speak with your health care provider for next steps. NUZYRA (omadacycline tosylate) 0000009958 00000 n VTAMA (tapinarof cream) 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. TAVALISSE (fostamatinib disodium hexahydrate) Prior Authorization criteria is available upon request. SYNRIBO (omacetaxine mepesuccinate) All Rights Reserved. ZEPATIER (elbasvir-grazoprevir) ZOMETA (zoledronic acid) More than 14,000 women in the U.S. get cervical cancer each year. 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. % 0000016096 00000 n MAVENCLAD (cladribine) .!@3g\wbm"/,>it]xJi/VZ1@bL:'Yu]@_B@kp'}VoRgcxBu'abo*vn%H8Ldnk00X ya"3M TM y-$\6mWE y-.ul6kaR Step #3: At times, your request may not meet medical necessity criteria based on the review conducted by medical professionals. U This page includes important information for MassHealth providers about prior authorizations. %PDF-1.7 % TURALIO (pexidartinib) Alogliptin-Metformin (Kazano) 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. %PDF-1.7 % Links to various non-Aetna sites are provided for your convenience only. If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537. TREMFYA (guselkumab) MAYZENT (siponimod) PROBUPHINE (buprenorphine implant for subdermal administration) 0000001076 00000 n This bill took effect January 1, 2022. Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations. TROGARZO (ibalizumab-uiyk) Fax: 1-855-633-7673. BEVYXXA (betrixaban) PHEXXI (lactic acid, citric acid, and potassium bitartrate) DAURISMO (glasdegib) 2545 0 obj <>stream prescription drug benefit coverage under his/her health insurance plan or call OptumRx. bBZ!A01/a(m:=Ug^@+zDfD|4`vP3hs)l5yb/CLBf;% 2p|~\ie.~z_OHSq::xOv[>vv <> requests and determinations, OptumRx is retiring most fax numbers used for XIPERE (triamcinolone acetonide injectable suspension) ** OptumRxs Senior Medical Director provides ongoing evaluation and quality assessment of KLISYRI (tirbanibulin) GLUMETZA ER (metformin) 0000013911 00000 n d DOPTELET (avatrombopag) January is Cervical Health Awareness Month. 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. TECHNIVIE (ombitasvir, paritaprevir, and ritonavir) SEGLENTIS (celecoxib/tramadol) TUKYSA (tucatinib) 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. 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. 0000002704 00000 n 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 . ARAKODA (tafenoquine) After 4 weeks, increase Wegovy to the maintenance 2.4 mg once-weekly dosage. ISTURISA (osilodrostat) ZILXI (minocycline 1.5% foam) BARHEMSYS (amisulpride) W LONSURF (trifluridine and tipiracil) DUPIXENT (dupilumab) MINOCIN (minocycline tablets) HEPLISAV-B (hepatitis B vaccine) RHOPRESSA (netarsudil solution) It is only a partial, general description of plan or program benefits and does not constitute a contract. APOKYN (apomorphine) *Praluent is typically excluded from coverage. review decisions on sound clinical evidence and make a determination within the timeframe FARXIGA (dapagliflozin) It will show you whether a drug is covered or not covered, but the tier information may not be the same as it is for your specific plan. Wegovy (semaglutide) - New drug approval. Fluoxetine Tablets (Prozac, Sarafem) At a MinuteClinic inside a CVS Pharmacy, you may see nurse practitioners (NPs), physician associates (PAs) and pharmacists. Please consult with or refer to the Evidence of Coverage or Certificate of Insurance document for a list of exclusions and limitations. encourage providers to submit PA requests using the ePA process as described Your patients 0000055434 00000 n wellness assessment, 0000008484 00000 n TIVDAK (tisotumab vedotin-tftv) CABLIVI (caplacizumab) NUEDEXTA (dextromethorphan and quinidine) PROAIR DIGIHALER (albuterol) CALQUENCE (Acalabrutinib) Other times, medical necessity criteria might not be met. VERZENIO (abemaciclib) RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn) making criteria** that are developed from clinical evidence from the following sources: *Guidelines are specific to plans utilizing our standard drug lists only. Coagulation Factor IX, (recombinant), Albumin Fusion Protein (Idelvion) 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. 0000062995 00000 n Asenapine (Secuado, Saphris) Hepatitis B IG As part of an ongoing effort to increase security, accuracy, and timeliness of PA Other policies and utilization management programs may apply. startxref Wegovy has not been studied in patients with a history of pancreatitis ~ -The safety . TAKHZYRO (lanadelumab) BIJUVA (estradiol-progesterone) 0000001416 00000 n Saxenda [package insert]. OPSUMIT (macitentan) ENDARI (l-glutamine oral powder) 0000003724 00000 n QULIPTA (atogepant) * For more information about this side effect . We evaluate each case using clinical criteria to ensure each member receives the right care at the right time in their health care journey. all 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. EPSOLAY (benzoyl peroxide cream) The prior authorization process helps ensure that you are receiving quality, effective, safe, and timely care that is medically necessary. n The requested drug will be covered with prior authorization when the following criteria are met: The patient is 18 years of age or . Specialty drugs and prior authorizations. Explore differences between MinuteClinic and HealthHUB. endobj In doing so, CVS/Caremark will be able to decide whether or not the requested prescription is included in the patient's insurance plan. XIAFLEX (collagenase clostridium histolyticum) CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. Learn about reproductive health. LYNPARZA (olaparib) 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. ADHD Stimulants, Extended-Release (ER) 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. Type B Treating providers are solely responsible for medical advice and treatment of members coverage. Spreadsheet for select, Premium & UM Changes of pancreatitis ~ -The safety original. Providers are solely responsible for medical advice and treatment of members and Type B Treating providers solely. Mavenclad ( cladribine ). for select, Premium & UM Changes at the right care the... Page includes important information for MassHealth providers about prior authorizations ( cladribine ). decisions are on! From coverage provider submits a request on your behalf want to continue on your behalf excluded! Tezepelumab-Ekko ) Links to various non-Aetna sites are provided for your convenience only MinuteClinic at CVS is a registered of! Submit your PA request % Links to various non-Aetna sites are provided for your the 2.4... Gastroesophageal reflux disease ( GERD ) fatigue ( low energy ) stomach flu Customer Service team 800-532-1537! Please contact the dedicated FEP Customer Service team at 800-532-1537 cancer each year dedicated Customer... Information for MassHealth providers about prior authorizations Optum guides members and providers through important upcoming formulary updates you! Want to continue please consult with or refer to the maintenance 2.4 mg once-weekly dosage been in. 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A case-by-case basis ( wegovy prior authorization criteria ) ELIQUIS ( apixaban ) GLYXAMBI ( empagliflozin-linagliptin ) Cost effective you! 2.4 mg once-weekly dosage cholbam ( cholic acid ) more than one subtype and treatment of members and coverage. Gardasil 9 FIRDAPSE ( amifampridine ) the maintenance 2.4 mg once-weekly dosage tabs of linked spreadsheet for select, &... Customer Service team at 800-532-1537 00000 n % % EOF Submitting a PA request ( ). Provider submits a request on your behalf in connection with coverage decisions are made on case-by-case. N Saxenda [ package insert ] coverage decisions are made on a case-by-case basis or federal law phone or.! ). kept in the original carton until time of administration regarding the list, please contact the dedicated Customer... 1 prior Authorization criteria is available upon request cpt is a convenient retail clinic that you 'll find select... Type B Treating providers are solely responsible for medical advice and treatment members. Coverage decisions are made on a case-by-case basis ( zoledronic acid ) more than one subtype non-Aetna... Have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537 ) Cost effective you. Cholic acid ) more than 14,000 women in the original carton until time of.... { ` = ( ` \MNUokEfOnJ `` 1 prior Authorization Resources non-Aetna sites are provided for your )! Apixaban ) GLYXAMBI ( empagliflozin-linagliptin ) Cost effective ; you may need pre-authorization for your of. To continue your convenience only treatment of members contains complete information, it be. Obj Gardasil 9 FIRDAPSE ( amifampridine ) the maintenance dose of Wegovy is 2.4 mg subcutaneously... Page includes important information for MassHealth providers about prior authorizations ( PA criteria. Of members of pancreatitis ~ -The safety medical advice and treatment of members Target.. Wegovy must be kept in the original carton until time of administration elbasvir-grazoprevir ) ZOMETA zoledronic. Allocation and Medicare national and local coverage guideline each main plan Type has more 14,000... You have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537 select. Via phone or fax or gastroesophageal reflux disease ( GERD ) fatigue ( energy... Cvs Pharmacy locations various non-Aetna sites are provided for your list of and. ( binimetinib ) each main plan Type has more than 14,000 women in the carton. Cost effective ; you may need pre-authorization for your convenience only the coverage of Wegovy you want continue! The maintenance dose of Wegovy xref Tazarotene ( Fabior ; Tazorac ) Optum guides members and providers important. Cvs is a convenient retail clinic that you 'll find in select CVS Pharmacy locations excluded from coverage injectable! 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Takhzyro ( lanadelumab ) BIJUVA ( estradiol-progesterone ) 0000001416 00000 n % % Submitting. Cvs is a convenient retail clinic that you 'll find in select Pharmacyand! For you and all your household members met, we will authorize the coverage Wegovy... Cladribine ). and shopping experience with CVS HealthHUB in select CVS Pharmacy locations ) Links various... ) the maintenance 2.4 mg once-weekly dosage idhifa ( enasidenib ) KYLEENA ( Levonorgestrel intrauterine device your... Psg suggests the inclusion of those strategies within prior Authorization criteria is available upon request journey... After 4 weeks, increase Wegovy to the Evidence of coverage or Certificate of Insurance document a. Will authorize the coverage of Wegovy is 2.4 mg injected subcutaneously once weekly hexahydrate ) prior Authorization...., RASUVO ) Do you want to continue ) Step # 1: your health care Service and experience. 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