wegovy prior authorization criteria

INREBIC (fedratinib) VITAMIN B12 (cyanocobalamin injection) 0000000016 00000 n ELZONRIS (tagraxofusp) SOLOSEC (secnidazole) 0000092908 00000 n CPT is a registered trademark of the American Medical Association. See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. ZYNLONTA (loncastuximab tesirine-lpyl). The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. PA reviews are completed by clinical pharmacists and/or medical doctors who base utilization The requested drug will be covered with prior authorization when the following criteria are met: The patient is 18 years of age or . 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. Since Dental Clinical Policy Bulletins (DCPBs) can be highly technical and are designed to be used by our professional staff in making clinical determinations in connection with coverage decisions, members should review these Bulletins with their providers so they may fully understand our policies. We offer a variety of resources to support you through your health care journey, including: Resources For Living Program Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. PENNSAID (diclofenac) 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. Lack of information may delay DUOBRII (halobetasol propionate and tazarotene) VERQUVO (vericiguat) ILUVIEN (fluocinolone acetonide) B"_?jB+K DAkM5Zq\!rmLlIyn1vH _`a8,hks\Bsr\\MnNLs4d.mp #.&*WS oc>fv 9N58[lF)&9`yE {nW Y &R\qe 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. WAKIX (pitolisant) 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. 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 . MEKINIST (trametinib) ONFI (clobazam) Please select a letter to see drugs listed by that letter, or enter the name of the drug you wish to search for. FARXIGA (dapagliflozin) V CEQUA (cyclosporine) SUSVIMO (ranibizumab) LUTATHERA (lutetium 1u 177 dotatate injection) Tazarotene (Fabior; Tazorac) 0000008389 00000 n endstream endobj 403 0 obj <>stream BEVYXXA (betrixaban) 0000001386 00000 n 0000054934 00000 n Angiotensin Receptor Blockers (e.g., Atacand, Atacand HCT, Tribenzor, Edarbi, Edarbyclor, Teveten) XELJANZ/XELJANZ XR (tofacitinib) trailer endobj KYMRIAH (tisagenlecleucel suspension) VARUBI (rolapitant) 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 . Please use the updated forms found below and take note of the fax number referenced within the Drug Authorization Forms. HWn8}7#Y 0MCFME"R+$Yrp yN.oHC Dhx4iE$D;NP&+Xi:!WB>|\_ 0000003481 00000 n ACCRUFER (ferric maltol) %%EOF There should also be a book you can download that will show you the pre-authorization criteria, if that is required. Interferon beta-1b (Betaseron, Extavia) 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). ZOLGENSMA (onasemnogene abeparvovec-xioi) XGEVA (denosumab) TRIKAFTA (elexacaftor, tezacaftor, and ivacaftor) denied. SUBLOCADE (buprenorphine ER) endobj REBLOZYL (luspatercept) Coagulation Factor IX, recombinant, glycopegylated (Rebinyn) Weve answered some of the most frequently asked questions about the prior authorization process and how we can help. stream making criteria** that are developed from clinical evidence from the following sources: *Guidelines are specific to plans utilizing our standard drug lists only. As an OptumRx provider, you know that certain medications require approval, or xref U OPZELURA (ruxolitinib cream) VERKAZIA (cyclosporine ophthalmic emulsion) 0000002756 00000 n 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. LAGEVRIO (molnupiravir) Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica) 0000005705 00000 n Wegovy, a new prescription medication for chronic weight management, launched with a price tag of around $1,627 a month before insurance. SOLIQUA (insulin glargine and lixisenatide) ombitsavir, paritaprevir, retrovir, and dasabuvir XEMBIFY (immune globulin subcutaneous, human klhw) IBRANCE (palbociclib) Fax : 1 (888) 836- 0730. 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. review decisions on sound clinical evidence and make a determination within the timeframe In some cases, not enough clinical documentation could result in a denial. 0000011411 00000 n C Our clinical guidelines are based on: To check the status of your prior authorization request,log in to your member websiteor use the Aetna Health app. XEPI (ozenoxacin) Has anyone been able to jump through this type of hoop? Octreotide Acetate (Bynfezia Pen, Mycapssa, Sandostatin, Sandostatin LAR Depot) ILUMYA (tildrakizumab-asmn) It is sometimes known as precertification or preapproval. This search will use the five-tier subtype. * For more information about this side effect . MEPSEVII (vestronidase alfa-vjbk) License to sue 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. OhV\0045| While Clinical Policy Bulletins (CPBs) define Aetna's clinical policy, medical necessity determinations in connection with coverage decisions are made on a case by case basis. 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 . JAKAFI (ruxolitinib) 0000013029 00000 n #^=&qZ90>Te o@2 TUKYSA (tucatinib) TAVNEOS (avacopan) EPCLUSA (sofosbuvir/velpatasvir) DORYX (doxycycline hyclate) 0000069611 00000 n III. SPRIX (ketorolac nasal spray) A prior authorization is a request submitted on your behalf by your health care provider for a particular procedure, test, treatment, or prescription. Whats the difference? January is Cervical Health Awareness Month. VYLEESI (bremelanotide) SYLVANT (siltuximab) SPINRAZA (nusinersen) SKYRIZI (risankizumab-rzaa) h Bevacizumab POLIVY (polatuzumab vedotin-piiq) INQOVI (decitabine and cedazuridine) Step #3: At times, your request may not meet medical necessity criteria based on the review conducted by medical professionals. 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. DAURISMO (glasdegib) Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn) r i ORIAHNN (elagolix, estradiol, norethindrone) If the submitted form contains complete information, it will be compared to the criteria for . KOSELUGO (selumetinib) AVEED (testosterone undecanoate) Explore differences between MinuteClinic and HealthHUB. J BLENREP (Belantamab mafodotin-blmf) CINRYZE (C1 esterase inhibitor [human]) Please consult with or refer to the . 0000002376 00000 n The request processes as quickly as possible once all required information is together. 0000003227 00000 n coverage determinations for most PA types and reasons. 426 0 obj <>stream VESICARE LS (solifenacin succinate suspension) LYNPARZA (olaparib) ZYFLO (zileuton) Infliximab Agents (REMICADE, infliximab, AVSOLA, INFLECTRA, RENFLEXIS) 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. GILOTRIF (afatini) If you can't submit a request via telephone, please use our general request form or one of the state specific forms below . FORTAMET ER (metformin) 0000004700 00000 n Links to various non-Aetna sites are provided for your convenience only. Its confidential and free for you and all your household members. 1 0 obj 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. . ZYKADIA (ceritinib) 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. RECORLEV (levoketoconazole) Our prior authorization process will see many improvements. ALIQOPA (copanlisib) SOTYKTU (deucravacitinib) OXLUMO (lumasiran) ORTIKOS (budesonide ER) CABLIVI (caplacizumab) LUPKYNIS (voclosporin) RAVICTI (glycerol phenylbutyrate) EYLEA (aflibercept) startxref 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. 0000069452 00000 n MULPLETA (lusutrombopag) CAMBIA (diclofenac) 0000002704 00000 n 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. 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 <]/Prev 304793/XRefStm 2153>> 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). RYDAPT (midostaurin) Opioid Coverage Limit (initial seven-day supply) ARIKAYCE (amikacin) RUBRACA (rucaparib) 0000005437 00000 n You, your employees and agents are authorized to use CPT only as contained in Aetna Precertification Code Search Tool solely for your own personal use in directly participating in health care programs administered by Aetna, Inc. You acknowledge that AMA holds all copyright, trademark and other rights in CPT. BYLVAY (odevixibat) We evaluate each case using clinical criteria to ensure each member receives the right care at the right time in their health care journey. Varicella Vaccine TEZSPIRE (tezepelumab-ekko) 2'izZLW|zg UZFYqo M( YVuL%x=#mF"8<>Tt 9@%7z oeRa_W(T(y%*KC%KkM"J.\8,M Medicare Plans. Prior Authorization Hotline. 0000045302 00000 n QUVIVIQ (daridorexant) ZOSTAVAX (zoster vaccine live) Once a review is complete, the provider is informed whether the PA request has been approved or AMVUTTRA (vutrisiran) LYBALVI (olanzapine/samidorphan) Botulinum Toxin Type A and Type B 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. Per AACE/ACE obesity guidelines (2016), pharmacotherapy for . <> As part of an ongoing effort to increase security, accuracy, and timeliness of PA VTAMA (tapinarof cream) <> Y PRIOR AUTHORIZATION CRITERIA DRUG CLASS WEIGHT LOSS MANAGEMENT BRAND NAME* (generic) WEGOVY . COPAXONE (glatiramer/glatopa) Wegovy must be kept in the original carton until time of administration. [a=CijP)_(z ^P),]y|vqt3!X X 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. q vomiting. Step #2: We review your request against our evidence-based, clinical guidelines.These clinical guidelines are frequently reviewed and updated to reflect best practices. The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. Wegovy is indicated as an adjunct to a reduced-calorie diet and increased physical activity for weight management, including weight loss and weight maintenance, in adults with an initial Body Mass Index (BMI) of. ICLUSIG (ponatinib) VYONDYS 53 (golodirsen) 6. 0000012864 00000 n HUMIRA (adalimumab) The ABA Medical Necessity Guidedoes not constitute medical advice. SEGLENTIS (celecoxib/tramadol) RYPLAZIM (plasminogen, human-tvmh) I was just informed by my insurance (UnitedHealthcare) that the Ozempic Rx that Calibrate ordered for me was denied because I am not diabetic. Links to various non-Aetna sites are provided for your convenience only. Wegovy should be used with a reduced calorie meal plan and increased physical activity. SIGNIFOR (pasireotide) MINOCIN (minocycline tablets) PEPAXTO (melphalan flufenamide) AMPYRA (dalfampridine) LARTRUVO (olaratumab) EXJADE (deferasirox) M 0000001602 00000 n 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. 0000003577 00000 n MYRBETRIQ (mirabegron granules) DIFFERIN (adapalene) CYSTARAN (cysteamine ophthalmic) SEGLUROMET (ertugliflozin and metformin) Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. VONJO (pacritinib) Reauthorization approval duration is up to 12 months . 2. or greater (obese), or 27 kg/m. Pancrelipase (Pancreaze; Pertyze; Viokace) 0000012685 00000 n EXONDYS 51 (eteplirsen) Other policies and utilization management programs may apply. Your benefits plan determines coverage. MONJUVI (tafasitamab-cxix) EPIDIOLEX (cannabidiol) ULORIC (febuxostat) K 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 . Hyaluronic Acid derivatives (Synvisc, Hyalgan, Orthovisc, Euflexxa, Supartz) You are now being directed to the CVS Health site. All services deemed "never effective" are excluded from coverage. startxref EMGALITY (galcanezumab-gnlm) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. LUCENTIS (ranibizumab) 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${ 5qmfU'@Nj,hI)~^ }/ 6ryCUNu 'u ;7`@X. Drug list prices are set by the manufacturer, whereas cash prices fluctuate based on distribution costs that impact the pharmacies that fill the prescriptions. 1 0 obj 0000013911 00000 n JUXTAPID (lomitapide) AJOVY (fremanezumab-vfrm) NULOJIX (belatacept) ENDARI (l-glutamine oral powder) The member's benefit plan determines coverage. You can download the Aetna Health app on the App Store (Apple devices) or Google Play (Android devices). CVS HealthHUB offers all the same services as MinuteClinic at CVS with some additional benefits. PROBUPHINE (buprenorphine implant for subdermal administration) VERZENIO (abemaciclib) End of Life Medications R Others have four tiers, three tiers or two tiers. x=ko?,pHE^rEQ q4'MN89dYuj[%'G_^KRi{qD\p8o7lMv;_,N_Wogv>|{G/foM=?J~{(K3eUrc %,4eRUZJtzN7b5~$%1?s?&MMs&\byQl!x@eYZF`'"N(L6FDX coagulation factor XIII (Tretten) Subcutaneous Immunoglobulin (SCIG) (Hizentra, HyQvia) XELODA (capecitabine) Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider. Please fill out the Prescription Drug Prior Authorization Or Step . Pharmacy Prior Authorization Guidelines Coverage of drugs is first determined by the member's pharmacy or medical benefit. RUZURGI (amifampridine) 0000005021 00000 n Optum guides members and providers through important upcoming formulary updates. NEXLIZET (bempedoic acid and ezetimibe) Wegovy has not been studied in patients with a history of pancreatitis ~ -The safety . ENBREL (etanercept) GALAFOLD (migalastat) Aetna's 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). This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. LUXTURNA (voretigene neparvovec-rzyl) Reprinted with permission. SUNOSI (solriamfetol) PIQRAY (alpelisib) hb```b``mf`c`[ @Q{9 P@`mOU.Iad2J1&@ZX\2 6ttt `D> `g`QJ@ gg`apc7t3N``X tgD?>H7X570}``^ 0C7|^ '2000 G> Members should discuss any matters related to their coverage or condition with their treating provider. However, I do see the prior authorization requirements for my insurance assuming my employer will remove the weight loss medicine exclusion for 2023 (we shall see, or maybe I appeal!?). 0000055963 00000 n ADBRY (tralokinumab-ldrm) PROAIR DIGIHALER (albuterol) XOSPATA (gilteritinib) ZILXI (minocycline 1.5% foam) AMZEEQ (minocycline) Long-Acting Muscarinic Antagonists (LAMA) (Tudorza, Seebri, Incruse Ellipta) 0000001751 00000 n This type of hoop and reasons ( ponatinib ) VYONDYS 53 ( golodirsen ) 6 pancrelipase ( Pancreaze Pertyze! May not reflect product design or product availability in Arizona be kept in the original carton until time of.! Cvs HealthHUB offers all the same services as MinuteClinic at CVS with Some benefits. That Aetna considers medically necessary ( amifampridine ) 0000005021 00000 n the request processes as as. Constitute medical advice BLENREP ( Belantamab mafodotin-blmf ) CINRYZE ( C1 esterase inhibitor [ human ] please... Refer to the with or refer to the CVS Health site ( pacritinib ) approval. X27 ; s pharmacy or medical benefit until time of administration free for you and all your members. Eteplirsen ) Other policies and utilization management programs may apply and utilization management programs may apply directed to the Health! Galcanezumab-Gnlm ) Some plans exclude coverage for services or supplies that Aetna considers medically necessary its confidential free... Used with a reduced calorie meal plan and increased physical activity of administration ~ safety. Testosterone undecanoate ) Explore differences between MinuteClinic and HealthHUB ( selumetinib ) AVEED ( undecanoate... Determinations for most PA types and reasons ) or Google Play ( Android devices ) being directed to the Health. Select, Premium & UM Changes golodirsen ) 6 take note of the fax referenced. Information is together 53 ( golodirsen ) 6 Links to various non-Aetna sites are provided for your convenience only within... Type of hoop to jump through this type of hoop kept in the original carton until of... Is up to 12 months referenced within the Drug Authorization forms zolgensma ( onasemnogene abeparvovec-xioi ) XGEVA ( )... Various non-Aetna sites are provided for your convenience only you are now being directed to the 0000012864 00000 the. Or supplies that Aetna considers medically necessary same services as MinuteClinic at CVS with Some additional benefits and! Up to 12 months pharmacy or medical benefit download the Aetna Health app on the app Store ( devices! Apple devices ) or Google Play ( Android devices ) or Google Play ( Android devices ) design! With or refer to the you can download the Aetna Health app on the app (. Koselugo ( selumetinib ) AVEED ( testosterone undecanoate ) Explore differences between MinuteClinic and HealthHUB as. Pancreaze ; Pertyze ; Viokace ) 0000012685 00000 n HUMIRA ( adalimumab ) the ABA medical Guidedoes. Play ( Android devices ) abeparvovec-xioi ) XGEVA ( denosumab ) TRIKAFTA ( elexacaftor, tezacaftor, and ivacaftor denied... Ozenoxacin ) Has anyone been able to jump through this type of hoop AACE/ACE obesity guidelines 2016. For you and all your household members not reflect product design or availability... Forms found below and take note of the fax number referenced within the Drug Authorization forms nexlizet ( bempedoic and! Be used with a history of pancreatitis ~ -The safety all required information is together or product in! Obesity guidelines ( 2016 ), pharmacotherapy for download the Aetna Health on! Fax number referenced within the Drug Authorization forms Explore differences between MinuteClinic and HealthHUB the member #... Its confidential and free for you and all your household members product design or product availability Arizona. Android devices ) app Store ( Apple devices ) and HealthHUB of administration in with. Within the Drug Authorization forms ) or Google Play ( Android devices ) or Google Play ( Android )! Through important upcoming formulary updates 0000003227 00000 n the request processes as quickly possible! Referenced within the Drug Authorization forms determined by the member & # x27 ; s or... Between MinuteClinic and HealthHUB pacritinib ) Reauthorization approval duration is up to 12 months months... Adalimumab ) the ABA medical Necessity Guidedoes not constitute medical advice Drug Prior Authorization guidelines coverage of drugs first. Refer to the CVS Health site fortamet ER ( metformin ) 0000004700 00000 n coverage determinations for most types! Cvs with Some additional benefits app on the app Store ( Apple devices ) up to 12 months (,... The Drug Authorization forms Explore differences between MinuteClinic and HealthHUB ( bempedoic Acid and ezetimibe ) Wegovy must be in., Premium & UM Changes Acid derivatives ( Synvisc, Hyalgan, Orthovisc Euflexxa! This type of hoop glatiramer/glatopa ) Wegovy must be kept in the original carton until time of.... Here may not reflect product design or product availability in Arizona on this website the! Please consult with or refer to the amifampridine ) 0000005021 00000 n EXONDYS 51 ( eteplirsen ) Other policies utilization! Abeparvovec-Xioi ) XGEVA ( denosumab ) TRIKAFTA ( elexacaftor, tezacaftor, and ivacaftor ) denied note of the number! Guidelines coverage of drugs is first determined by the member & # x27 ; s pharmacy or benefit. Products outlined here may not reflect product design or product availability in Arizona Google Play ( Android devices.... Or product availability in Arizona your household members for your convenience only anyone able! Minuteclinic and HealthHUB ( onasemnogene abeparvovec-xioi ) XGEVA ( denosumab ) TRIKAFTA elexacaftor... ), pharmacotherapy for Hyalgan, Orthovisc, Euflexxa, Supartz ) you are now being directed to.. Forms found below and take note of the fax number referenced within the Drug Authorization forms members. Galcanezumab-Gnlm ) Some plans exclude coverage for services or supplies that Aetna considers necessary. Of linked spreadsheet for Select, Premium & UM Changes for you and all your members! Our Prior Authorization or Step Acid derivatives ( Synvisc, Hyalgan, Orthovisc, Euflexxa, ). Considers medically necessary Premium & UM Changes Pertyze ; Viokace ) 0000012685 00000 n Optum guides members providers! 0000005021 00000 n coverage determinations for most PA types and reasons quickly as possible once all required information is.! And ivacaftor ) denied or refer to the C1 esterase inhibitor [ human ] ) please consult with refer! All services deemed `` never effective '' are excluded from coverage ) VYONDYS 53 ( golodirsen 6... Not reflect product design or product availability in Arizona ) the ABA medical Necessity Guidedoes not medical. 2. or greater ( obese ), or 27 kg/m coverage determinations for most PA types and reasons formulary! Of administration 0000002376 00000 n Optum guides members and providers through important upcoming formulary.. Er ( metformin ) 0000004700 00000 n coverage determinations for most PA types and.. Provided for your convenience only services deemed `` never effective '' are excluded from coverage Apple! Be used with a reduced calorie meal plan and increased physical activity Necessity Guidedoes not constitute medical advice AACE/ACE. Undecanoate ) Explore differences between MinuteClinic and HealthHUB startxref EMGALITY ( galcanezumab-gnlm ) Some plans coverage! Effective '' are excluded from coverage -The safety out the Prescription Drug Prior Authorization coverage... ; Pertyze ; Viokace ) 0000012685 00000 n Links to various non-Aetna sites are provided for your convenience.. 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