DIACOMIT (stiripentol) 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. Step #3: At times, your request may not meet medical necessity criteria based on the review conducted by medical professionals. Pegfilgrastim agents (Neulasta, Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo) GLUMETZA ER (metformin) c PROBUPHINE (buprenorphine implant for subdermal administration) ", The five character codes included in the Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology (CPT. 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). AIMOVIG (erenumab-aooe) XIPERE (triamcinolone acetonide injectable suspension) Link to the Concomitant Opioid Benzodiazepine, Pediatric Behavioral Health Medication, Hospital Outpatient Prior Authorization, Opioid and Pain, and Second-Generation (Atypical) Antipsychotic Initiatives. Please call us at 800.753.2851 to submit a verbal prior authorization request if you are unable to use Electronic Prior Authorization. ICLUSIG (ponatinib) 0000055963 00000 n Hepatitis C RHOFADE (oxymetazoline) Coverage of drugs is first determined by the member's pharmacy or medical benefit. ONUREG (azacitidine) Go to the American Medical Association Web site. 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). 0000002222 00000 n VRAYLAR (cariprazine) If the submitted form contains complete information, it will be compared to the criteria for . GAVRETO (pralsetinib) 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. *Praluent is typically excluded from coverage. Filgrastim agents (Nivestym, Zarxio, Neupogen, Granix, Releuko) Testosterone pellets (Testopel) Clinician Supervised Weight Reduction Programs. CIMZIA (certolizumab pegol) ERIVEDGE (vismodegib) 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. Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. Fluoxetine Tablets (Prozac, Sarafem) INQOVI (decitabine and cedazuridine) TUKYSA (tucatinib) g FARXIGA (dapagliflozin) January is Cervical Health Awareness Month. ILUVIEN (fluocinolone acetonide) DURLAZA (aspirin extended-release capsules) FLECTOR (diclofenac) <>/Metadata 133 0 R/ViewerPreferences 134 0 R>> I Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. NERLYNX (neratinib) LUXTURNA (voretigene neparvovec-rzyl) Criteria for a step therapy exception can be found in OHCA rules 317:30-5-77.4. Explore differences between MinuteClinic and HealthHUB. ULTOMIRIS (ravulizumab) TAFINLAR (dabrafenib) RETIN-A (tretinoin) 0000003052 00000 n z@vOK.d CP'w7vmY Wx* TAKHZYRO (lanadelumab) DUEXIS (ibuprofen and famotidine) Specialty drugs and prior authorizations. endobj EYLEA (aflibercept) Per AACE/ACE obesity guidelines (2016), pharmacotherapy for . requests and determinations, OptumRx is retiring most fax numbers used for WINLEVI (clascoterone) NATPARA (parathyroid hormone, recombinant human) 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&\ 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). VESICARE LS (solifenacin succinate suspension) VITRAKVI (larotrectinib) ALIQOPA (copanlisib) RYPLAZIM (plasminogen, human-tvmh) Authorization Duration . Coagulation Factor IX, (recombinant), Albumin Fusion Protein (Idelvion) 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 . ELZONRIS (tagraxofusp) TEGSEDI (inotersen) 0000005011 00000 n Viewand print a PA request form, For urgent requests, please call us at 1-800-711-4555. LONHALA MAGNAIR (glycopyrrolate) LUCEMYRA (lofexidine) XEPI (ozenoxacin) POLIVY (polatuzumab vedotin-piiq) SOLOSEC (secnidazole) KISQALI (ribociclib) m We stay in touch with providers throughout the prior authorization request. 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. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp) 0000012864 00000 n If you would like to view forms for a specific drug, visit the CVS/Caremark webpage, linked below. 0000000016 00000 n XGEVA (denosumab) % COTELLIC (cobimetinib) AUSTEDO (deutetrabenazine) hA 04Fv\GczC. MYALEPT (metreleptin) HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk) endobj An exception can be requested following a denial of a prior authorization or can be submitted at the onset of the request. PADCEV (enfortumab vendotin-ejfv) If your prior authorization request is denied, the following options are available to you: We want to make sure you receive the safest, timely, and most medically appropriate treatment. GLP-1 Agonists (Bydureon, Bydureon BCise, Byetta, Ozempic, Rybelsus, Trulicity, Victoza, Adlyxin) & GIP/GLP-1 Agonist (Mounjaro) Pharmacy Prior Authorization Guidelines Coverage of drugs is first determined by the member's pharmacy or medical benefit. TECFIDERA (dimethyl fumarate) 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. No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM. EPIDIOLEX (cannabidiol) Discard the Wegovy pen after use. Step #2: We review your request against our evidence-based, clinical guidelines.These clinical guidelines are frequently reviewed and updated to reflect best practices. TEZSPIRE (tezepelumab-ekko) endobj Authorization will be issued for 12 months. coverage determinations for most PA types and reasons. Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. There should also be a book you can download that will show you the pre-authorization criteria, if that is required. Alogliptin (Nesina) %P.Q*Q`pU r 001iz%N@v%"_6DP@z0(uZ83z3C >,w9A1^*D( xVV4^[r62i5D\"E VTAMA (tapinarof cream) All Rights Reserved. Links to various non-Aetna sites are provided for your convenience only. 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. MEKTOVI (binimetinib) 1 0 obj q B"_?jB+K DAkM5Zq\!rmLlIyn1vH _`a8,hks\Bsr\\MnNLs4d.mp #.&*WS oc>fv 9N58[lF)&9`yE {nW Y &R\qe Buprenorphine/Naloxone (Suboxone, Zubsolv, Bunavail) KADCYLA (Ado-trastuzumab emtansine) 0000008945 00000 n 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 . MAVYRET (glecaprevir/pibrentasvir) x=rF?#%=J,9R 0h/t7nH&tJ4=3}_-u~UqT/^Vu]x>W.XUuX/J"IxQbqqB iq(.n-?$bz')m>~H? VUMERITY (diroximel fumarate) 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 . SUSVIMO (ranibizumab) SOLIQUA (insulin glargine and lixisenatide) JUBLIA (efinaconazole) BARHEMSYS (amisulpride) 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. OCREVUS (ocrelizumab) b ILARIS (canakinumab) SILIQ (brodalumab) FORTAMET ER (metformin) SYMLIN (pramlintide) AYVAKIT (avapritinib) KYLEENA (Levonorgestrel intrauterine device) Indication and Usage. SOLODYN (minocycline 24 hour) The prior authorization process helps ensure that the test, treatment, and/or procedure your provider requests is effective, safe, and medically appropriate. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. 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. LYBALVI (olanzapine/samidorphan) Learn about reproductive health. A prior authorization is a request submitted on your behalf by your health care provider for a particular procedure, test, treatment, or prescription. Specialty drugs typically require a prior authorization. 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). UBRELVY (ubrogepant) TALZENNA (talazoparib) For language services, please call the number on your member ID card and request an operator. LIBTAYO (cemiplimab-rwlc) OZURDEX (dexamethasone intravitreal implant) In the event that a member disagrees with a coverage determination, member may be eligible for the right to an internal appeal and/or an independent external appeal in accordance with applicable federal or state law. XADAGO (safinamide) LEMTRADA (alemtuzumab)
Eight Club Moorgate Dress Code, How Did Austin James And Gatlin Green Meet, Articles W