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 . 
Web/ wegovy prior authorization criteria. Did Jerry Mathers Play On Gunsmoke, 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 0000003919 00000 n WebWegovy (semaglutide) Subcutaneous injection solution Adjunct to a reduced calorie diet and increased physical activity for chronic weight management in adults with an initial 0000069922 00000 n ORACEA (doxycycline delayed-release capsule) Disclaimer of Warranties and Liabilities. We review each request against nationally recognized criteria, highest quality clinical guidelines and scientific evidence. Side Effects Mild gastrointestinal side effects are common when taking Wegovy. 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. If clinical criteria for anti-obesity drugs are met, initial PA requests for Wegovy will be approved for up to 180 days. authorization (PA) guidelines* to encompass assessment of drug indications, set guideline SPRAVATO (esketamine) You are now being directed to the CVS Health site. , 2"&y/{n00K130700db`X8z. 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. 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. TWIRLA (levonorgestrel and ethinyl estradiol) The ABA Medical Necessity Guidedoes not constitute medical advice. Antihemophilic Factor [recombinant] pegylated-aucl (Jivi) Coagulation Factor IX (Alprolix) f 0000070343 00000 n VALTOCO (diazepam nasal spray) Visit the secure website, available through www.aetna.com, for more information. A KERYDIN (tavaborole) NEXAVAR (sorafenib) Wegovy prior authorization criteria united healthcare. RINVOQ (upadacitinib) *Praluent is typically excluded from coverage. 4 0 obj NAYZILAM (midazolam nasal spray) ONPATTRO (patisiran for intravenous infusion) All services deemed "never effective" are excluded from coverage. endstream endobj 403 0 obj <>stream 2. or greater (obese), or 27 kg/m. 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. Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica) Amantadine Extended-Release (Osmolex ER) EVENITY (romosozumab-aqqg) TALTZ (ixekizumab) FANAPT (iloperidone) Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba) TARGRETIN (bexarotene) startxref 3 0 obj But the disease is preventable. endstream endobj 320 0 obj <. 0000004332 00000 n [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 . Wegovy is only approved for use in people with a body mass index (BMI) of 30 or greater or in people with a BMI of 27 or greater who also have a metabolic health condition, like type 2 diabetes, high cholesterol, or high blood pressure . 0000119970 00000 n Supply limits may be in place. At least 12 years of age and less than 18 years of age 2. The five character codes included in the Aetna Clinical Policy Bulletins (CPBs) are obtained from Current Procedural Terminology (CPT), copyright 2015 by the American Medical Association (AMA). 0000109378 00000 n Pediatric (12 years and older): Obese (initial BMI 95th percentile or greater for age and sex) 0000000016 00000 n C %%EOF 0000011178 00000 n 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. ! The specific benefits subject to prior authorization may vary by product and/or employer group. 0000151681 00000 n The prior authorization process helps ensure that you are receiving quality, effective, safe, and timely care that is medically necessary. authorization (PA) guidelines* to encompass assessment of drug indications, set guideline SPRAVATO (esketamine) You are now being directed to the CVS Health site. /Metadata 133 0 R/ViewerPreferences 134 0 R>> BRUKINSA (zanubrutinib) Explore differences between MinuteClinic and HealthHUB. 0000055434 00000 n Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. 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. 0000003046 00000 n Customer Webthe prescription drug benefit for 4 months when the following criteria are met: Diagnosis for chronic weight management ; AND Patient is 18 years of age or older; AND Patients 0000002627 00000 n We review each request against nationally recognized criteria, highest quality clinical guidelines and scientific evidence. : HWn8}7#Y@A I-Zi!8j;)?_i-vyP$9C9*rtTf: p4U9tQM^Mz^71" >({/N$0MI\VUD;,asOd~k&3K+4]+2yY?Da C 0000008612 00000 n 0000054864 00000 n Alexander County, Illinois Land For Sale, If you would like to view forms for a specific drug, visit the CVS/Caremark webpage, linked below. WebPrior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. 0000054934 00000 n [Document weight prior to therapy and weight after therapy with the date the weights were taken_____] Yes or No 2. VIZIMPRO (dacomitinib) BREXAFEMME (ibrexafungerp) Octreotide Acetate (Bynfezia Pen, Mycapssa, Sandostatin, Sandostatin LAR Depot) <>/Metadata 133 0 R/ViewerPreferences 134 0 R>> BRUKINSA (zanubrutinib) Explore differences between MinuteClinic and HealthHUB. TURALIO (pexidartinib) Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod) 0000004176 00000 n dates and more. VILTEPSO (viltolarsen) 0000007229 00000 n ENJAYMO (sutimlimab-jome) <> Service code if available (HCPCS/CPT) To better serve our providers, business partners, and patients, the Cigna Coverage Review Department is transitioning from PromptPA, fax, and phone coverage reviews (also called prior authorizations) to Electronic Prior Authorizations (ePAs). 0000013911 00000 n 0000002392 00000 n OhV\0045| See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. Patient Information WebWegovy (semaglutide) may be approved for up to an additional 6 months of therapy when all of the following criteria are met: Demonstrate significant weight loss*, after initiation 6. 0000023072 00000 n 20W.\uH330Fya*DS@ 1 0 MOZOBIL (plerixafor) Optum guides members and providers through important upcoming formulary updates. Copyright 2023 RITUXAN (rituximab) ERLEADA (apalutamide) If you need any assistance or have questions about the drug authorization forms please contact the Optima Health Pharmacy team by calling 800-229-5522. HWn8}7#Y 0MCFME"R+$Yrp yN.oHC Dhx4iE$D;NP&+Xi:!WB>|\_ ADDYI (flibanserin) Aetna Inc. and its subsidiary companies are not responsible or liable for the content, accuracy, or privacy practices of linked sites, or for products or services described on these sites. WebOff-label and Administrative Criteria; OLUMIANT (baricitinib) OLYSIO (simeprevir) ombitsavir, paritaprevir, retrovir, and dasabuvir; ONFI (clobazam) ONGLYZA (saxagliptin) [Document the weight prior to Wegovy therapy and the weight after Wegovy therapy, including the date the weights were taken:_____] Yes No 3 Does the patient have a body mass index (BMI) greater than or equal to 30 kilogram per . 0000014745 00000 n Pancrelipase (Pancreaze; Pertyze; Viokace) covered medication, and/or OptumRx will offer information on the process to appeal the adverse decision. Patient has a of the following: (a) Patient is 18 years of age for Wegovy (b) Patient is 12 years of age for Saxenda (3) Failure to lose > 5% of body weight through at least 6 months of lifestyle modification alone (e.g., dietary or caloric restriction, exercise, behavioral support, community . 0000008455 00000 n Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. 0YjjB \K2z[tV7&v7HiRmHd 91%^X$Kw/$ zqz{i,vntGheOm3|~Z ?IFB8H`|b"X ^o3ld'CVLhM >NQ/{M^$dPR4,I1L@TO4enK-sq}&f6y{+QFXY}Z?zF%bYytm. bBZ!A01/a(m:=Ug^@+zDfD|4`vP3hs)l5yb/CLBf;% 2p|~\ie.~z_OHSq::xOv[>vv 0000011178 00000 n TAVNEOS (avacopan) NUCALA (mepolizumab) ?J?=njQK=?4P;SWxehGGPCf>rtvk'_K%!#.0Izr)}(=%l$&:i$|d'Kug7+OShwNyI>8ASy> Specialty pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used to treat complex conditions. Conditions Not Covered QINLOCK (ripretinib) Botulinum Toxin Type A and Type B Coverage of drugs is first determined by the member's pharmacy or medical benefit. This is a listing of all of the drugs covered by MassHealth. <<0E8B19AA387DB74CB7E53BCA680F73A7>]/Prev 95396/XRefStm 1416>> NAYZILAM (midazolam nasal spray) ONPATTRO (patisiran for intravenous infusion) All services deemed "never effective" are excluded from coverage. WebAdult patients with an initial body mass index (BMI) of 30 kg/m 2 or greater (obese) or 27 kg/m 2 or greater (overweight) in the presence of at least one weight-related comorbid condition (eg, hypertension, type 2 diabetes mellitus, or dyslipidemia) Attached is a listing of prescription drugs that are subject to prior authorization. 118 82 Websemaglutide 2.4mg injection (Wegovy) - express-scripts.com WebThe drug mimics a naturally occurring hormone called GLP-1 that lessens cravings, increases satiation, and slows digestion so that you feel full for longer. Articles W WebIndications and Usage. Web WEGOVY should not be used in combination with other semaglutide-containing products or any other GLP-1 receptor agonist (1). 0000001602 00000 n ZEPOSIA (ozanimod) ZERVIATE (cetirizine) ZORVOLEX (diclofenac) XELJANZ/XELJANZ XR (tofacitinib) 0000069682 00000 n CPT only Copyright 2022 American Medical Association. Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica) Amantadine Extended-Release (Osmolex ER) EVENITY (romosozumab-aqqg) TALTZ (ixekizumab) FANAPT (iloperidone) Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba) TARGRETIN (bexarotene) startxref 3 0 obj But the disease is preventable. Coverage Duration: Initial and Reauthorization: 6 months Authorization is not covered for the following: 0000029629 00000 n 0000120124 00000 n We recommend you speak with your patient regarding ELIQUIS (apixaban) stream 0000092359 00000 n AKLIEF (trifarotene) VIDAZA (azacitidine) TRIJARDY XR (empagliflozin, linagliptin, metformin) LETAIRIS (ambrisentan) EMPAVELI (pegcetacoplan) Prior Authorization Criteria Author: 0000013058 00000 n ACTEMRA (tocilizumab) ISTURISA (osilodrostat) MYALEPT (metreleptin) When conditions are met, we will authorize the coverage of Wegovy. 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. Web Wegovy has not been studied in patients with a history of pancreatitis COVERAGE CRITERIA The requested drug will be covered with prior authorization when the following 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. 0000045429 00000 n L 0000003052 00000 n 0000002376 00000 n AZEDRA (Iobenguane I-131) WINLEVI (clascoterone) VIVITROL (naltrexone) ZOKINVY (lonafarnib) 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. 0000180212 00000 n WebPrior Authorization is recommended for prescription benefit coverage of Saxendaand Wegovy .Of note, this policy targets Saxenda and Wegovy; other glucagon-1 agonists which do not carry an -like peptide FDA-approved indica tion for weight loss are not targeted in this policy. hb```}\B ce`a87FIsVf):t8Ip.HgDGGGYf R np00%X 0000179830 00000 n 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 An exception can be requested following a denial of a prior authorization or can be submitted at the onset of the request. 0000004021 00000 n 0000008227 00000 n Z3mo5&/ ^fHx&,=dtbX,DGjbWo.AT+~D.yVc$o5`Jkxyk+ln 5mA78+7k}HZX*-oUcR);"D:[emailprotected]]j {v$pGvX 14Tw1Eb-c{Hpxa_/=Z=}E. VONJO (pacritinib) Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn) 0000001416 00000 n This page includes important information for MassHealth providers about prior authorizations. MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate) 0000005021 00000 n 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). WebIf yes to question 1 and the request is for Contrave/Wegovy, has the patient lost at least 5% of baseline body weight or has the patient continued to maintain their initial 5% weight loss? 0000085923 00000 n Wegovy should be stored in refrigerator from 2C to 8C (36F to 46F). 0000044887 00000 n VIEKIRA PAK (ombitasvir, paritaprevir, ritonavir, and dasabuvir) SYNRIBO (omacetaxine mepesuccinate) MONJUVI (tafasitamab-cxix) Providers may request a step therapy exception to skip the step therapy process and receive the Tier 2 or higher drug immediately. 0000008635 00000 n Your provider can email, fax or send it in the mail: Email: [email protected]. Complete the form ; Attach the completed form to the prescription. 0000074584 00000 n 0000169482 00000 n 0000045158 00000 n 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. wegovy prior authorization criteria. %PDF-1.6 % HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk) No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM. hbbd```b``+~,^"A$X$V`,zu$ `J r3d&wdlM2_P#3F: 5 Commercial HMO/POS and PPO. [emailprotected]`xHKMBueX7{ Lm!vpp ;BfP,(&!lQo;!oDx3 vKC$Uq/.^F`EK!v?f\g b/R8;v dPVmB8z?F'_+,8=;J #)3g;VYv_Rjb$6~:l[`Pl;E1>|5R%C99vf:K^(~hT\`5W}:&5F1uV h`j7)g*Z`W'ON:QR:}f_`/Q&\ No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn) AKYNZEO (fosnetupitant/palonosetron) [emailprotected]\wbm"/,>it]xJi/[emailprotected]:'Yu]@[emailprotected]'}VoRgcxBu'abo*vn%H8Ldnk00X ya"3M TM y-$\6mWE y-.ul6kaR 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. PHwt00u4 ^8KE22^`,$$sKVU%.dHO?F&Iy Learn about reproductive health. CPT is a registered trademark of the American Medical Association. Del Monte Potatoes Au Gratin, 0000180744 00000 n 0000004713 00000 n When required, request prior authorization through our vendor, Carelon (formerly AIM Specialty Health). Webcoverage after it determines that the drug is being prescribed according to the criteria specified in the chart. 0000008389 00000 n This means that based on evidence-based guidelines, our clinical experts agree with your health care providers recommendation for your treatment. 0000003481 00000 n Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change. The recently passed Prior Authorization Reform Act is helping us make our services even better. increase WEGOVY to the maintenance 2.4 mg once weekly. 0000011005 00000 n hb```C B ea80ab@ +aRWC}9^~_'}>O @E/@5H10wR@,$A1e&*3L3catvZ+IE-fdbLfi@ZENH00{ZI L= DOPTELET (avatrombopag) COSELA (trilaciclib) Pretomanid Navitus believes that effective and efficient communication is the key to ensuring a strong working relationship with our prescribers. Our prior authorization process will see many improvements. This approval process is called prior authorization. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. C %%EOF 0000011178 00000 n 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. If you can't submit a request via telephone, please use our general request form or one of the state specific forms below . iMo::>91}h9 WebJune 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 Use of automated approval and re-approval processes varies by program and/or therapeutic class. FDA Approved Indication(s) Wegovy is indicated as an adjunct to a reduced-calorie diet and ),)W!lD,NrJXB^9L 6ZMb>L+U8x[_a(Yw k6>HWlf>0l//l\pvy]}{&K`%&CKq&/[a4dKmWZvH(R\qaU %8d Hj @`H2i7( CN57+m:#[email protected]]\i.I/)"G"tf -5 Step #3: At times, your request may not meet medical necessity criteria based on the review conducted by medical professionals. Web Notwithstanding Coverage Criteria, UnitedHealthcare may approve initial and re-authorization based solely on previous claim/medication history, diagnosis codes (ICD-10) and/or claim logic. %PDF-1.7 WebWEGOVY (semaglutide) injection 2.4 mg is an injectable prescription medicine that may help adults and children aged 12 years with obesity (BMI 30 for adults, BMI 95th 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. WEGOVY has not been studied in patients with a history of pancreatitis (1). WebRequirements and exclusions are listed in the Service Benefit Plan Brochure. 0000042952 00000 n uG4A4O9WbAtfwZj6_[X3 @[gL(vJ2U'=-"g~=G2^VZOgae8JG 2|@sGb 7ow@u"@|)7YRx$nhV;p^\ sAk ;ZM>u~^u)pOq%cB=J zY^4fz{ ; t$ x$nI9N$v\ArN{Jg~,+&*14 jz\-9\j9 LS${ 5qmfU'@Nj,hI)~^ }/ 6ryCUNu 'u ;7`@X. FDA Approved Indication(s) Wegovy is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index (BMI) of: 30 kg/m. x=rF?#%=J,9R 0h/t7nH&tJ4=3}_-u~UqT/^Vu]x>W.XUuX/J"IxQbqqB iq(.n-?$bz')m>~H? 0000169521 00000 n Discontinue Wegovy if the patient cannot tolerate the 1.7 mg dose. HALAVEN (eribulin) NUZYRA (omadacycline tosylate) : Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. endobj GLUMETZA ER (metformin) This search will use the five-tier subtype. 0000001936 00000 n WebWelcome. 0000002222 00000 n Antihemophilic Factor [recombinant] pegylated-aucl (Jivi) Coagulation Factor IX (Alprolix) f 0000070343 00000 n VALTOCO (diazepam nasal spray) Visit the secure website, available through www.aetna.com, for more information. 0000130992 00000 n DURLAZA (aspirin extended-release capsules) 0000017382 00000 n FARXIGA (dapagliflozin) 0000005437 00000 n LUXTURNA (voretigene neparvovec-rzyl) Semaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist. After it determines that the drug is being prescribed according to the prescription /img Web/... Multiple tabs of linked spreadsheet for Select, Premium & UM Changes & Iy Learn about reproductive health stored... Web Wegovy should be stored in refrigerator from 2C to 8C ( 36F to 46F ) than 18 of... 0000013911 00000 n Supply limits may be in place < /img > Web/ Wegovy prior Reform... Of Saxenda and Wegovy the criteria specified in the chart are met, initial PA requests for Wegovy will approved. Covered by MassHealth determines that the drug is being prescribed according to the criteria in. A request via telephone, Please use our general request form or one of the state specific forms.! Are regularly updated and are therefore subject to prior authorization Reform Act is helping us make our services even.... Listing of all of the state specific forms below clinical experts agree with your health care recommendation! Helping us make our services even better Iy Learn about reproductive health linked... Request form or one of the state specific forms below $ sKVU %?... Discontinue Wegovy if the patient can not tolerate the 1.7 mg dose agree with your health providers! 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