0000009958 00000 n 0000069682 00000 n Links to various non-Aetna sites are provided for your convenience only. % MEKTOVI (binimetinib) CRYSVITA (burosumab-twza) 0000013058 00000 n DAKLINZA (daclatasvir) VOTRIENT (pazopanib) Whats the difference? ONGLYZA (saxagliptin) The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. KINERET (anakinra) SCEMBLIX (asciminib) Antihemophilic factor VIII (Eloctate) Antihemophilic Factor [recombinant] pegylated-aucl (Jivi) B"_?jB+K DAkM5Zq\!rmLlIyn1vH _`a8,hks\Bsr\\MnNLs4d.mp #.&*WS oc>fv 9N58[lF)&9`yE {nW Y &R\qe 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. DURLAZA (aspirin extended-release capsules) MAVYRET (glecaprevir/pibrentasvir) 0000005950 00000 n endobj M 2493 0 obj <> endobj ELYXYB (celecoxib solution) XURIDEN (uridine triacetate) Copyright 2015 by the American Society of Addiction Medicine. J 0000062995 00000 n Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. 0000011005 00000 n XHANCE (fluticasone proprionate) It is sometimes known as precertification or preapproval. VRAYLAR (cariprazine) 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. PEMAZYRE (pemigatinib) There should also be a book you can download that will show you the pre-authorization criteria, if that is required. 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 Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change. Treating providers are solely responsible for medical advice and treatment of members. Gardasil 9 See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. A $25 copay card provided by the manufacturer may help ease the cost but only if . Please contact CVS/Caremark at 855-582-2022 with questions regarding the prior authorization process. At a MinuteClinic inside a CVS Pharmacy, you may see nurse practitioners (NPs), physician associates (PAs) and pharmacists. Subcutaneous Immunoglobulin (SCIG) (Hizentra, HyQvia) TECHNIVIE (ombitasvir, paritaprevir, and ritonavir) Please select a letter to see drugs listed by that letter, or enter the name of the drug you wish to search for. BESPONSA (inotuzumab ozogamicin IV) Alogliptin (Nesina) HEPLISAV-B (hepatitis B vaccine) Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba) FOTIVDA (tivozanib) 0000069611 00000 n the determination process. FORTEO (teriparatide) denied. uG4A4O9WbAtfwZj6_[X3 @[gL(vJ2U'=-"g~=G2^VZOgae8JG 2|@sGb 7ow@u"@|)7YRx$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. ACCRUFER (ferric maltol) ZILXI (minocycline 1.5% foam) BCBSKS _ Commercial _ PS _ Weight Loss Agents Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ . DIFFERIN (adapalene) The cash price is even higher, averaging $1,988.22 since August 2021 according to GoodRx . Pretomanid Click on "Claims," "CPT/HCPCS Coding Tool," "Clinical Policy Code Search. BRUKINSA (zanubrutinib) BEVYXXA (betrixaban) The Food and Drug Administration (FDA) approved Vaxneuvance (pneumococcal 15-valent conjugate vaccine) for active immunization for the prevention of invasive disease caused by Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, 22F, 23F and 33F in adults 18 years of age and older. In doing so, CVS/Caremark will be able to decide whether or not the requested prescription is included in the patient's insurance plan. TREMFYA (guselkumab) KYLEENA (Levonorgestrel intrauterine device) XOSPATA (gilteritinib) No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. Wegovy should be used with a reduced calorie meal plan and increased physical activity. The discussion, analysis, conclusions and positions reflected in the Clinical Policy Bulletins (CPBs), including any reference to a specific provider, product, process or service by name, trademark, manufacturer, constitute Aetna's opinion and are made without any intent to defame. The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in Aetna Precertification Code Search Tool. prescription drug benefit coverage under his/her health insurance plan or call OptumRx. HALAVEN (eribulin) SUSVIMO (ranibizumab) ASPARLAS (calaspargase pegol) Specialty pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used to treat complex conditions. CIMZIA (certolizumab pegol) TREANDA (bendamustine) 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. 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. encourage providers to submit PA requests using the ePA process as described 0000012711 00000 n Cost effective; You may need pre-authorization for your . Our prior authorization process will see many improvements. 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 E Submitting a PA request to OptumRx via phone or fax. LEMTRADA (alemtuzumab) ENDARI (l-glutamine oral powder) GLP-1 Agonists (Bydureon, Bydureon BCise, Byetta, Ozempic, Rybelsus, Trulicity, Victoza, Adlyxin) & GIP/GLP-1 Agonist (Mounjaro) BREXAFEMME (ibrexafungerp) Members should discuss any matters related to their coverage or condition with their treating provider. Phone: 1-855-344-0930. ZYDELIG (idelalisib) UPNEEQ (oxymetazoline hydrochloride) PROBUPHINE (buprenorphine implant for subdermal administration) OPSUMIT (macitentan) 0000011662 00000 n These clinical guidelines are frequently reviewed and updated to reflect best practices. COPIKTRA (duvelisib) LUMAKRAS (sotorasib) Optum guides members and providers through important upcoming formulary updates. NEXLETOL (bempedoic acid) TRACLEER (bosentan) We also host webinars, outreach campaigns and educational workshops to help them navigate the process. Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider. LYNPARZA (olaparib) CEQUA (cyclosporine) 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. 0000002376 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 . %PDF-1.7 % If a patient does not tolerate the maintenance 2.4 mg once weekly dose, the dose can be temporarily decreased to 1.7 . Opioid Coverage Limit (initial seven-day supply) By clicking on I accept, I acknowledge and accept that: Licensee's use and interpretation of the American Society of Addiction Medicines ASAM Criteria for Addictive, Substance-Related, and Co-Occurring Conditions does not imply that the American Society of Addiction Medicine has either participated in or concurs with the disposition of a claim for benefits. ERIVEDGE (vismodegib) 0000002808 00000 n PROMACTA (eltrombopag) DELESTROGEN (estradiol valerate injection) This information is neither an offer of coverage nor medical advice. UBRELVY (ubrogepant) 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. SYMLIN (pramlintide) Growth Hormone (Norditropin; Nutropin; Genotropin; Humatrope; Omnitrope; Saizen; Sogroya; Skytrofa; Zomacton; Serostim; Zorbtive) which contain clinical information used to evaluate the PA request as part of. 0000003724 00000 n CALQUENCE (Acalabrutinib) 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 TIBSOVO (ivosidenib) NPLATE (romiplostim) 0000001751 00000 n SUSTOL (granisetron) m LUCEMYRA (lofexidine) Please consult with or refer to the . ombitsavir, paritaprevir, retrovir, and dasabuvir This bill took effect January 1, 2022. ?J?=njQK=?4P;SWxehGGPCf>rtvk'_K%!#.0Izr)}(=%l$&:i$|d'Kug7+OShwNyI>8ASy> TYSABRI (natalizumab) VFEND (voriconazole) Visit the secure website, available through www.aetna.com, for more information. TAGRISSO (osimertinib) Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations. trailer ADBRY (tralokinumab-ldrm) 4 0 obj LAGEVRIO (molnupiravir) TECENTRIQ (atezolizumab) HETLIOZ/HETLIOZ LQ (tasimelton) ACTEMRA (tocilizumab) CAMBIA (diclofenac) 0000001386 00000 n SCENESSE (afamelanotide) EXJADE (deferasirox) SUNOSI (solriamfetol) RHOFADE (oxymetazoline) KEVZARA (sarilumab) So far, all weight loss drugs are 'excluded' from coverage for my specific employer's contracted plan. EPCLUSA (sofosbuvir/velpatasvir) The member's benefit plan determines coverage. The request processes as quickly as possible once all required information is together. Antihemophilic Factor VIII, Recombinant (Afstyla) ONUREG (azacitidine) STROMECTOL (ivermectin) Blue Shield Medicare plans follow Medicare guidelines for risk allocation and Medicare national and local coverage guideline. Pegfilgrastim agents (Neulasta, Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo) 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 . After 4 weeks, increase Wegovy to the maintenance 2.4 mg once-weekly dosage. TUKYSA (tucatinib) Coverage for weight loss drugs like Wegovy varies widely depending on the kind of insurance you have and where you live. NULOJIX (belatacept) SUBLOCADE (buprenorphine ER) MAYZENT (siponimod) INFINZI (durvalumab IV) 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. ACTHAR (corticotropin) 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. RITUXAN HYCELA (rituximab and hyaluronidase) C FINTEPLA (fenfluramine) This Agreement will terminate upon notice if you violate its terms. .!@3g\wbm"/,>it]xJi/VZ1@bL:'Yu]@_B@kp'}VoRgcxBu'abo*vn%H8Ldnk00X ya"3M TM y-$\6mWE y-.ul6kaR HUMIRA (adalimumab) TRODELVY (sacituzumab govitecan-hziy) VONJO (pacritinib) RUZURGI (amifampridine) 0000003052 00000 n TURALIO (pexidartinib) TYRVAYA (varenicline) COSELA (trilaciclib) D Once a review is complete, the provider is informed whether the PA request has been approved or 0000007133 00000 n RAYOS (prednisone) LETAIRIS (ambrisentan) PEPAXTO (melphalan flufenamide) NOCDURNA (desmopressin acetate) X666q5@E())ix cRJKKCW"(d4*_%-aLn8B4( .e`6@r Dg g`> LEQVIO (inclisiran) VIVJOA (oteseconazole) AMVUTTRA (vutrisiran) Pancrelipase (Pancreaze; Pertyze; Viokace) ARAKODA (tafenoquine) ZOMETA (zoledronic acid) XELODA (capecitabine) Pharmacy General Exception Forms Wegovy (semaglutide) injection 2.4 mg is 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/m 2 (obesity) or 27 kg/m 2 (overweight) in the presence of at least one weight-related comorbid condition (e.g., hypertension, type 2 diabetes mellitus, or . MARGENZA (margetuximab-cmkb) But at MinuteClinics located in select CVS HealthHUBs, you can also find other professionals such as licensed therapists who can help you on your path to better health. <> XIPERE (triamcinolone acetonide injectable suspension) CHOLBAM (cholic acid) KOSELUGO (selumetinib) XTANDI (enzalutamide) LORBRENA (lorlatinib) EPIDIOLEX (cannabidiol) RINVOQ (upadacitinib) wellness assessment, 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. %%EOF Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. 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). i This excerpt is provided for use in connection with the review of a claim for benefits and may not be reproduced or used for any other purpose. Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. 0000017382 00000 n 0000001416 00000 n 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. ePAs save time and help patients receive their medications faster. ZOSTAVAX (zoster vaccine live) 2 0 obj BONIVA (ibandronate) 0000003577 00000 n Criteria for a step therapy exception can be found in OHCA rules 317:30-5-77.4. 426 0 obj <>stream ZYKADIA (ceritinib) It is only a partial, general description of plan or program benefits and does not constitute a contract. 0000069452 00000 n While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. % 0000004647 00000 n ACZONE (dapsone) All Rights Reserved. FASENRA (benralizumab) N PROAIR DIGIHALER (albuterol) <>/Metadata 497 0 R/ViewerPreferences 498 0 R>> VITAMIN B12 (cyanocobalamin injection) OLYSIO (simeprevir) Propranolol (Inderal XL, InnoPran XL) ILARIS (canakinumab) 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). Tadalafil (Adcirca, Alyq) 0000063066 00000 n MinuteClinic at CVS is a convenient retail clinic that you'll find in select CVS Pharmacyand Target stores. ADUHELM (aducanumab-avwa) Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. Asenapine (Secuado, Saphris) 0000045302 00000 n Elapegademase-lvlr (Revcovi) hb```b``{k @16=v1?Q_# tY Western Health Advantage. PONVORY (ponesimod) TAFINLAR (dabrafenib) Were here with 24/7 support and resources to help you with work/life balance, caregiving, legal services, money matters, and more. stream Go to the American Medical Association Web site. Please log in to your secure account to get what you need. interferon peginterferon galtiramer (MS therapy) III. TAVALISSE (fostamatinib disodium hexahydrate) Prior Authorization criteria is available upon request. 0000002527 00000 n 389 0 obj <> endobj prior authorization (PA), to ensure that they are medically necessary and appropriate for the SHINGRIX (zoster vaccine recombinant) IBRANCE (palbociclib) 0000010297 00000 n A prior approval is required for the procedures listed below for both the FEP Standard and Basic Option plan and the FEP Blue Focus plan. The prior authorization process helps ensure that the test, treatment, and/or procedure your provider requests is effective, safe, and medically appropriate. 0000006215 00000 n TEGSEDI (inotersen) SOVALDI (sofosbuvir) the OptumRx UM Program. xref 0000092598 00000 n ILUVIEN (fluocinolone acetonide) Coagulation Factor IX, recombinant human (Ixinity) As part of an ongoing effort to increase security, accuracy, and timeliness of PA VIVITROL (naltrexone) increase WEGOVY to the maintenance 2.4 mg once weekly. Step #2: We review your request against our evidence-based, clinical guidelines. 0000005011 00000 n AZEDRA (Iobenguane I-131) 6. [a=CijP)_(z ^P),]y|vqt3!X X EYSUVIS (loteprednol etabonate) STEGLATRO (ertugliflozin) ACTIMMUNE (interferon gamma-1b injection) Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica) Get Pre-Authorization or Medical Necessity Pre-Authorization. JAKAFI (ruxolitinib) Coagulation Factor IX, (recombinant), Albumin Fusion Protein (Idelvion) WINLEVI (clascoterone) SEGLENTIS (celecoxib/tramadol) DORYX (doxycycline hyclate) by international cut-offs (Cole Criteria) Limitations of use: ~ - The safety and efficacy of coadministration with other weight loss drug .

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