Conditions Not Covered
Link to the Concomitant Opioid Benzodiazepine, Pediatric Behavioral Health Medication, Hospital Outpatient Prior Authorization, Opioid and Pain, and Second-Generation (Atypical) Antipsychotic Initiatives. For those who choose to cover Wegovy, PSG recommends the following: Thoroughly evaluate the financial impact of covering weight loss drugs; Better outcomes are expected when Wegovy is combined with other weight management strategies.
Visit the secure website, available through www.aetna.com, for more information. endstream
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SPINRAZA (nusinersen)
DOPTELET (avatrombopag)
s
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Botulinum Toxin Type A and Type B
The American Medical Association (AMA) does not directly or indirectly practice medicine or dispense medical services. Members should discuss any matters related to their coverage or condition with their treating provider. WHA members have access to a wealth of resources including a
ZILXI (minocycline 1.5% foam)
Optum guides members and providers through important upcoming formulary updates. Octreotide Acetate (Bynfezia Pen, Mycapssa, Sandostatin, Sandostatin LAR Depot)
In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. OFEV (nintedanib)
ZYNLONTA (loncastuximab tesirine-lpyl). JAKAFI (ruxolitinib)
Specialty drugs typically require a prior authorization. interferon peginterferon galtiramer (MS therapy)
bBZ!A01/a(m:=Ug^@+zDfD|4`vP3hs)l5yb/CLBf;% 2p|~\ie.~z_OHSq::xOv[>vv e
0000069611 00000 n
Applicable FARS/DFARS apply.
PIQRAY (alpelisib)
RITUXAN (rituximab)
ACZONE (dapsone)
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.
TAVNEOS (avacopan)
Some subtypes have five tiers of coverage. VUMERITY (diroximel fumarate)
If providers are unable to submit electronically, we offer the following options: Call 1-800-711-4555 to submit a verbal PA request 0000011005 00000 n
FULYZAQ (crofelemer)
RINVOQ (upadacitinib)
OXLUMO (lumasiran)
Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations. EPIDIOLEX (cannabidiol)
Wegovy must be kept in the original carton until time of administration.
NAPRELAN (naproxen)
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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. encourage providers to submit PA requests using the ePA process as described
LIBTAYO (cemiplimab-rwlc)
denied. 0000069186 00000 n
Treating providers are solely responsible for medical advice and treatment of members.
DUPIXENT (dupilumab)
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coagulation factor XIII (Tretten)
The number of medically necessary visits .
To ensure that a PA determination is provided to you in a timely
ILUMYA (tildrakizumab-asmn)
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AUBAGIO (teriflunomide)
BREXAFEMME (ibrexafungerp)
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TEGSEDI (inotersen)
SEYSARA (sarecycline)
Reauthorization approval duration is up to 12 months . APOKYN (apomorphine)
ZIPSOR (diclofenac)
Pharmacy Prior Authorization Guidelines Coverage of drugs is first determined by the member's pharmacy or medical benefit. 0000005437 00000 n
This search will use the five-tier subtype. The OptumRx Pharmacy Utilization Management (UM) Program utilizes drug-specific prior
HWn8}7#Y@A I-Zi!8j;)?_i-vyP$9C9*rtTf: p4U9tQM^Mz^71" >({/N$0MI\VUD;,asOd~k&3K+4]+2yY?Da C (Hours: 5am PST to 10pm PST, Monday through Friday.
Aetna Inc. and its subsidiary companies are not responsible or liable for the content, accuracy or privacy practices of linked sites, or for products or services described on these sites.
REYVOW (lasmiditan)
BRAFTOVI (encorafenib)
QTERN (dapagliflozin and saxagliptin)
methotrexate injectable agents (REDITREX, OTREXUP, RASUVO)
If your prior authorization request is denied, the following options are available to you: We want to make sure you receive the safest, timely, and most medically appropriate treatment.
MULPLETA (lusutrombopag)
If this is the case, our team of medical directors is willing to speak with your health care provider for next steps. XELODA (capecitabine)
wellness assessment,
0000070343 00000 n
Links to various non-Aetna sites are provided for your convenience only.
BESPONSA (inotuzumab ozogamicin IV)
IGALMI (dexmedetomidine film)
0000008389 00000 n
XELJANZ/XELJANZ XR (tofacitinib)
Viewand print a PA request form, For urgent requests, please call us at 1-800-711-4555.
SOLARAZE (diclofenac)
h
Infliximab Agents (REMICADE, infliximab, AVSOLA, INFLECTRA, RENFLEXIS)
Service code if available (HCPCS/CPT) To better serve our providers, business partners, and patients, the Cigna Coverage Review Department is transitioning from PromptPA, fax, and phone coverage reviews (also called prior authorizations) to Electronic Prior Authorizations (ePAs). f
0000011662 00000 n
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;BfP,(&!lQo;!oDx3 vKC$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&\ z@vOK.d CP'w7vmY Wx* 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). 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.
MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate)
APTIOM (eslicarbazepine)
P^p%JOP*);p/+I56d=:7hT2uovIL~37\K"I@v vI-K\f"CdVqi~a:X20!a94%w;-h|-V4~}`g)}Y?o+L47[atFFs
AW %gs0OirL?O8>&y(IP!gS86|)h BYLVAY (odevixibat)
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.
VYONDYS 53 (golodirsen)
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.
0000007229 00000 n
SOVALDI (sofosbuvir)
The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. v
ERIVEDGE (vismodegib)
Y
UKONIQ (umbralisib)
The AMA is a third party beneficiary to this Agreement. MEPSEVII (vestronidase alfa-vjbk)
KLISYRI (tirbanibulin)
W
WAKIX (pitolisant)
Program Name: BadgerCare Plus and Medicaid: Handbook Area: Pharmacy: 01/15/2023 0000003052 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. RECORLEV (levoketoconazole)
XCOPRI (cenobamate)
It enables a faster turnaround time of
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UPTRAVI (selexipag)
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NUBEQA (darolutamide)
0000008945 00000 n
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EYLEA (aflibercept)
INLYTA (axitinib)
All services deemed "never effective" are excluded from coverage.
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SYMTUZA (darunavir, cobicistat, emtricitabine, and tenofovir alafenamide tablet )
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. VERQUVO (vericiguat)
It is sometimes known as precertification or preapproval. <<0E8B19AA387DB74CB7E53BCA680F73A7>]/Prev 95396/XRefStm 1416>>
SPRYCEL (dasatinib)
PAXLOVID (nirmatrelvir and ritonavir)
Asenapine (Secuado, Saphris)
Long-Acting Muscarinic Antagonists (LAMA) (Tudorza, Seebri, Incruse Ellipta)
NOCTIVA (desmopressin)
POMALYST (pomalidomide)
In case of a conflict between your plan documents and this information, the plan documents will govern. Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". iMo::>91}h9 Fluoxetine Tablets (Prozac, Sarafem)
ZEPATIER (elbasvir-grazoprevir)
a
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. 0000001076 00000 n
More than 14,000 women in the U.S. get cervical cancer each year.
NURTEC ODT (rimegepant)
OLYSIO (simeprevir)
RECARBRIO (imipenem, cilastin and relebactam)
DIFFERIN (adapalene)
ACCRUFER (ferric maltol)
Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits.
MAVYRET (glecaprevir/pibrentasvir)
Specialty drugs and prior authorizations.
BOSULIF (bosutinib)
G
Please call us at 800.753.2851 to submit a verbal prior authorization request if you are unable to use Electronic Prior Authorization.
NULOJIX (belatacept)
RYPLAZIM (plasminogen, human-tvmh)
Alogliptin (Nesina)
RAYOS (prednisone)
CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. We evaluate each case using clinical criteria to ensure each member receives the right care at the right time in their health care journey. j
ZYDELIG (idelalisib)
AZEDRA (Iobenguane I-131)
An exception can be requested following a denial of a prior authorization or can be submitted at the onset of the request. TRIPTODUR (triptorelin extended-release)
DOJOLVI (triheptanoin liquid)
When conditions are met, we will authorize the coverage of Wegovy. OTEZLA (apremilast)
TAVALISSE (fostamatinib disodium hexahydrate)
ADHD Stimulants, Extended-Release (ER)
The information you will be accessing is provided by another organization or vendor. You may also view the prior approval information in the Service Benefit Plan Brochures.
. <>/Metadata 497 0 R/ViewerPreferences 498 0 R>>
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the OptumRx UM Program.
VUITY (pilocarpine)
ORIAHNN (elagolix, estradiol, norethindrone)
S
FYARRO (sirolimus protein-bound particles)
ZEGERID (omeprazole-sodium bicarbonate)
EYSUVIS (loteprednol etabonate)
ESBRIET (pirfenidone)
ZOLINZA (vorinostat)
Guidelines are based on written objective pharmaceutical UM decision- 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. Semaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist.
VILTEPSO (viltolarsen)
SUTENT (sunitinib)
Of note, this policy targets Saxenda and Wegovy; other glucagon-like peptide-1 agonists which do not carry an FDA-approved indication for weight loss are not targeted in this policy. Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica)
ORENCIA (abatacept)
0000003577 00000 n
PA reviews are completed by clinical pharmacists and/or medical doctors who base utilization
ARIKAYCE (amikacin)
A prior authorization is a request submitted on your behalf by your health care provider for a particular procedure, test, treatment, or prescription. VABYSMO (faricimab)
Links to various non-Aetna sites are provided for your convenience only.
H
CRYSVITA (burosumab-twza)
EGRIFTA SV (tesamorelin)
0000014745 00000 n
ENBREL (etanercept)
XEPI (ozenoxacin)
LEUKINE (sargramostim)
At a MinuteClinic inside a CVS Pharmacy, you may see nurse practitioners (NPs), physician associates (PAs) and pharmacists. POLIVY (polatuzumab vedotin-piiq)
Clinician Supervised Weight Reduction Programs.
IMLYGIC (talimogene laherparepvec)
0000000016 00000 n
NPLATE (romiplostim)
CIALIS (tadalafil)
And we will reduce wait times for things like tests or surgeries. Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider. PLEGRIDY (peginterferon beta-1a)
AEMCOLO (rifamycin delayed-release)
%
Pancrelipase (Pancreaze; Pertyze; Viokace)
FORTAMET ER (metformin)
STELARA (ustekinumab)
Criteria for a step therapy exception can be found in OHCA rules 317:30-5-77.4.
Antihemophilic Factor VIII, recombinant (Kovaltry)
RECLAST (zoledronic acid-mannitol-water)
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. CIMZIA (certolizumab pegol)
1 0 obj
If needed (prior to cap removal) the pen can be kept from 8C to 30C (46F to 86F) up to 28 days. DURLAZA (aspirin extended-release capsules)
PAs help manage costs, control misuse, and GLUMETZA ER (metformin)
AMZEEQ (minocycline)
XOLAIR (omalizumab)
ZOSTAVAX (zoster vaccine live)
Aetna has reached these conclusions based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors).
protect patient safety, as well as ensure the best possible therapeutic outcomes. Health benefits and health insurance plans contain exclusions and limitations. VYVGART (efgartigimod alfa-fcab)
PYRUKYND (mitapivat)
We stay in touch with providers throughout the prior authorization request. x=rF?#%=J,9R 0h/t7nH&tJ4=3}_-u~UqT/^Vu]x>W.XUuX/J"IxQbqqB iq(.n-?$bz')m>~H?
HARVONI (sofosbuvir/ledipasvir)
DAKLINZA (daclatasvir)
ONUREG (azacitidine)
The prior authorization process helps ensure that the test, treatment, and/or procedure your provider requests is effective, safe, and medically appropriate. 0000054864 00000 n
AJOVY (fremanezumab-vfrm)
RHOPRESSA (netarsudil solution)
BRINEURA (cerliponase alfa IV)
TRACLEER (bosentan)
ILARIS (canakinumab)
ANNOVERA (segesterone acetate/ethinyl estradiol)
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. FASENRA (benralizumab)
KYLEENA (Levonorgestrel intrauterine device)
ACTEMRA (tocilizumab)
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).
Picayune Junior High Football Schedule, Bricklaying Jobs In Tenerife, Articles W
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