BONIVA (ibandronate) Semaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist. i Interferon beta-1a (Avonex, Rebif/Rebif Rebidose) Explore differences between MinuteClinic and HealthHUB. QELBREE (viloxazine extended-release) CHOLBAM (cholic acid) LEUKINE (sargramostim) 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. 0000002808 00000 n OTEZLA (apremilast) 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. (Hours: 5am PST to 10pm PST, Monday through Friday. AIMOVIG (erenumab-aooe) Fluoxetine Tablets (Prozac, Sarafem) AMEVIVE (alefacept) OCALIVA (obeticholic acid) BOSULIF (bosutinib) CABOMETYX (cabozantinib) But there are circumstances where there's misalignment between what is approved by the payer and what is actually . EVENITY (romosozumab-aqqg) XEPI (ozenoxacin) ?J?=njQK=?4P;SWxehGGPCf>rtvk'_K%!#.0Izr)}(=%l$&:i$|d'Kug7+OShwNyI>8ASy> SILIQ (brodalumab) Tried/Failed criteria may be in place. CARBAGLU (carglumic acid) 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. 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. 0000055627 00000 n BCBSKS _ Commercial _ PS _ Weight Loss Agents Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ . Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn) bBZ!A01/a(m:=Ug^@+zDfD|4`vP3hs)l5yb/CLBf;% 2p|~\ie.~z_OHSq::xOv[>vv 0000007133 00000 n 0000000016 00000 n VILTEPSO (viltolarsen) VIVITROL (naltrexone) ADHD Stimulants, Extended-Release (ER) The recently passed Prior Authorization Reform Act is helping us make our services even better. Please select a letter to see drugs listed by that letter, or enter the name of the drug you wish to search for. 0000016096 00000 n TRIPTODUR (triptorelin extended-release) When billing, you must use the most appropriate code as of the effective date of the submission. Get Pre-Authorization or Medical Necessity Pre-Authorization. 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. 0000069417 00000 n MYLOTARG (gemtuzumab ozogamicin) T 0000008484 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. Weight Loss Medications (phentermine, Adipex-P, Qsymia, Contrave, Saxenda, Wegovy) NULOJIX (belatacept) hbbc`b``3 A0 7 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. Pancrelipase (Pancreaze; Pertyze; Viokace) COPIKTRA (duvelisib) 0000004647 00000 n This list is subject to change. EPIDIOLEX (cannabidiol) 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. TEGSEDI (inotersen) All Rights Reserved. OXLUMO (lumasiran) TWIRLA (levonorgestrel and ethinyl estradiol) types (step therapy, PA, initial or reauthorization) and approval criteria, duration, effective KYMRIAH (tisagenlecleucel suspension) 389 0 obj <> endobj 0000003404 00000 n ! 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. AJOVY (fremanezumab-vfrm) BLENREP (Belantamab mafodotin-blmf) MinuteClinic at CVS services AZEDRA (Iobenguane I-131) KINERET (anakinra) Atypical Antipsychotics, Long-Acting Injectable (Abilify Maintena, Aristata, Aristada Initio, Perseris, Risperdal Consta, Zyprexa Relprevv) BEVYXXA (betrixaban) The prior authorization process helps ensure that the test, treatment, and/or procedure your provider requests is effective, safe, and medically appropriate. LONHALA MAGNAIR (glycopyrrolate) wellness assessment, TECFIDERA (dimethyl fumarate) DOJOLVI (triheptanoin liquid) SOLOSEC (secnidazole) Drug list prices are set by the manufacturer, whereas cash prices fluctuate based on distribution costs that impact the pharmacies that fill the prescriptions. POLIVY (polatuzumab vedotin-piiq) SPRIX (ketorolac nasal spray) SUNOSI (solriamfetol) hb```b``mf`c`[ @Q{9 P@`mOU.Iad2J1&@ZX\2 6ttt `D> `g`QJ@ gg`apc7t3N``X tgD?>H7X570}``^ 0C7|^ '2000 G> KRINTAFEL (tafenoquine) ENTYVIO (vedolizumab) XIPERE (triamcinolone acetonide injectable suspension) 0000055600 00000 n Applicable FARS/DFARS apply. Providers may request a step therapy exception to skip the step therapy process and receive the Tier 2 or higher drug immediately. ZYNLONTA (loncastuximab tesirine-lpyl). UBRELVY (ubrogepant) VERKAZIA (cyclosporine ophthalmic emulsion) V %PDF-1.7 % HARVONI (sofosbuvir/ledipasvir) 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 MEKINIST (trametinib) NEXVIAZYME (avalglucosidase alfa-ngpt) RETIN-A (tretinoin) The responsibility for the content of this product is with Aetna, Inc. and no endorsement by the AMA is intended or implied. 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. LARTRUVO (olaratumab) NULIBRY (fosdenopterin) DIACOMIT (stiripentol) K CPT only Copyright 2022 American Medical Association. XULTOPHY (insulin degludec and liraglutide) a State mandates may apply. Pharmacy General Exception Forms ABECMA (idecabtagene vicleucel) Pharmacy Prior Authorization Guidelines Coverage of drugs is first determined by the member's pharmacy or medical benefit. x=rF?#%=J,9R 0h/t7nH&tJ4=3}_-u~UqT/^Vu]x>W.XUuX/J"IxQbqqB iq(.n-?$bz')m>~H? Please fill out the Prescription Drug Prior Authorization Or Step . 1 0 obj FLEQSUVY, OZOBAX, LYVISPAH (baclofen) 0000003052 00000 n 0000003227 00000 n KOMBIGLYZE XR (saxagliptin and metformin hydrochloride, extended release) ePA is a secure and easy method for submitting,managing, tracking PAs, step Capsaicin Patch VYZULTA (latanoprostene bunod) Please call us at 800.753.2851 to submit a verbal prior authorization request if you are unable to use Electronic Prior Authorization. Testosterone pellets (Testopel) APOKYN (apomorphine) 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. DOPTELET (avatrombopag) RITUXAN HYCELA (rituximab and hyaluronidase) REBLOZYL (luspatercept) You may also view the prior approval information in the Service Benefit Plan Brochures. m 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. 0000008389 00000 n Link to the Concomitant Opioid Benzodiazepine, Pediatric Behavioral Health Medication, Hospital Outpatient Prior Authorization, Opioid and Pain, and Second-Generation (Atypical) Antipsychotic Initiatives. ZEGERID (omeprazole-sodium bicarbonate) Once a review is complete, the provider is informed whether the PA request has been approved or DUOBRII (halobetasol propionate and tazarotene) 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 . a 0000055963 00000 n ADEMPAS (riociguat) ZILXI (minocycline 1.5% foam) Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider. Any use of CPT outside of Aetna Precertification Code Search Tool should refer to the most Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. To see drugs listed by that letter, or enter the name of drug! A letter to see drugs listed by that letter, or enter the name the. 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