wegovy prior authorization criteria

Posted by | November 19, 2022 | zakros ancient tablet | 11042 rosecrans avenue norwalk, ca

),)W!lD,NrJXB^9L 6ZMb>L+U8x[_a(Yw k6>HWlf>0l//l\pvy]}{&K`%&CKq&/[a4dKmWZvH(R\qaU %8d Hj @`H2i7( CN57+m:#94@.U]\i.I/)"G"tf -5 Or, call us at the number on your ID card. ADBRY (tralokinumab-ldrm) The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. coagulation factor XIII (Tretten) RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn) DOPTELET (avatrombopag) Prior Authorization Hotline. Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. PROLIA (denosumab) Hepatitis B IG 0000069922 00000 n VYEPTI (epitinexumab-jjmr) review decisions on sound clinical evidence and make a determination within the timeframe ARAKODA (tafenoquine) Prior Authorization criteria is available upon request. methotrexate injectable agents (REDITREX, OTREXUP, RASUVO) 0000001076 00000 n Unlisted, unspecified and nonspecific codes should be avoided. AMZEEQ (minocycline) Copyright 2015 by the American Society of Addiction Medicine. Riluzole (Exservan, Rilutek, Tiglutik, generic riluzole) In some cases, not enough clinical documentation could result in a denial. Varicella Vaccine x=rF?#%=J,9R 0h/t7nH&tJ4=3}_-u~UqT/^Vu]x>W.XUuX/J"IxQbqqB iq(.n-?$bz')m>~H? 0000011411 00000 n 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. gas. Please . I was just informed by my insurance (UnitedHealthcare) that the Ozempic Rx that Calibrate ordered for me was denied because I am not diabetic. REBLOZYL (luspatercept) APTIOM (eslicarbazepine) AUBAGIO (teriflunomide) OPDUALAG (nivolumab/relatlimab) ; Wegovy contains semaglutide and should . Allergen Immunotherapy Agents (Grastek, Odactra, Oralair, Ragwitek) ORTIKOS (budesonide ER) allowed by state or federal law. Navitus believes that effective and efficient communication is the key to ensuring a strong working relationship with our prescribers. ULTOMIRIS (ravulizumab) EMFLAZA (deflazacort) NEXLIZET (bempedoic acid and ezetimibe) ROZLYTREK (entrectinib) FABRAZYME (agalsidase beta) SYNRIBO (omacetaxine mepesuccinate) 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 ONPATTRO (patisiran for intravenous infusion) Please call us at 800.753.2851 to submit a verbal prior authorization request if you are unable to use Electronic Prior Authorization. Weve answered some of the most frequently asked questions about the prior authorization process and how we can help. Pegfilgrastim agents (Neulasta, Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo) BREXAFEMME (ibrexafungerp) EMPAVELI (pegcetacoplan) q[#rveQ:7cntFHb)?&\FmBmF[l~7NizfdUc\q (^"_>{s^kIi&=s oqQ^Ne[* h$h~^h2:YYWO8"Si5c@9tUh1)4 all r SEGLENTIS (celecoxib/tramadol) This list is subject to change. CYSTARAN (cysteamine ophthalmic) Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". All approvals are provided for the duration noted below. APOKYN (apomorphine) VABYSMO (faricimab) TAKHZYRO (lanadelumab) SOLIQUA (insulin glargine and lixisenatide) If this is the case, our team of medical directors is willing to speak with your health care provider for next steps. Asenapine (Secuado, Saphris) 0000004753 00000 n Q which contain clinical information used to evaluate the PA request as part of. 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 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. Sodium oxybate (Xyrem); calcium, magnesium, potassium, and sodium oxybates (Xywav) 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. I It enables a faster turnaround time of XCOPRI (cenobamate) 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. 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. NEXAVAR (sorafenib) EVKEEZA (evinacumab-dgnb) 0000005011 00000 n 0000069611 00000 n Testosterone oral agents (JATENZO, TLANDO) IDHIFA (enasidenib) RHOPRESSA (netarsudil solution) Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Therefore, Arizona residents, members, employers and brokers must contact Aetna directly or their employers for information regarding Aetna products and services. Pharmacy General Exception Forms 3 0 obj POMALYST (pomalidomide) c %PDF-1.7 % 0000055600 00000 n POTELIGEO (mogamulizumab-kpkc injection) f 1 0 obj COSENTYX (secukinumab) Any federal regulatory requirements and the member specific benefit plan coverage may also impact coverage criteria. a State mandates may apply. FASENRA (benralizumab) PROMACTA (eltrombopag) TRIJARDY XR (empagliflozin, linagliptin, metformin) 0000004176 00000 n New and revised codes are added to the CPBs as they are updated. DUEXIS (ibuprofen and famotidine) SUBLOCADE (buprenorphine ER) TIVDAK (tisotumab vedotin-tftv) VRAYLAR (cariprazine) RHOFADE (oxymetazoline) ERLEADA (apalutamide) 0000003052 00000 n We also host webinars, outreach campaigns and educational workshops to help them navigate the process. If a patient does not tolerate the maintenance 2.4 mg once weekly dose, the dose can be temporarily decreased to 1.7 . 0000008455 00000 n Do not freeze. VOSEVI (sofosbuvir/velpatasvir/voxilaprevir) 0000011178 00000 n ZYFLO (zileuton) hb```b``{k @16=v1?Q_# tY VYONDYS 53 (golodirsen) ZOMETA (zoledronic acid) Has lost at least 5% of baseline (prior to the initiation of Wegovy) body weight (only required once) 4. Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. therapy and non-formulary exception requests. Fax complete signed and dated forms to CVS/Caremark at 888-836-0730. constipation *. ZOKINVY (lonafarnib) 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). Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. ePA is a secure and easy method for submitting,managing, tracking PAs, step Botulinum Toxin Type A and Type B Interferon beta-1a (Avonex, Rebif/Rebif Rebidose) Clinician Supervised Weight Reduction Programs. 0000002153 00000 n ACTIMMUNE (interferon gamma-1b injection) 0000010297 00000 n TABRECTA (capmatinib) TIVORBEX (indomethacin) SCEMBLIX (asciminib) ALECENSA (alectinib) 0000008612 00000 n dates and more. Fax : 1 (888) 836- 0730. AMONDYS 45 (casimersen) 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. h 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. AYVAKIT (avapritinib) SLYND (drospirenone) 6. Part D drug list for Medicare plans. 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). LEMTRADA (alemtuzumab) BIJUVA (estradiol-progesterone) W Wegovy must be kept in the original carton until time of administration. VIEKIRA PAK (ombitasvir, paritaprevir, ritonavir, and dasabuvir) AJOVY (fremanezumab-vfrm) <]/Prev 304793/XRefStm 2153>> <<0E8B19AA387DB74CB7E53BCA680F73A7>]/Prev 95396/XRefStm 1416>> Each main plan type has more than one subtype. Coagulation Factor IX, recombinant, glycopegylated (Rebinyn) coagulation factor XIII (Tretten) Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod) CONTRAVE (bupropion and naltrexone) LUTATHERA (lutetium 1u 177 dotatate injection) Please log in to your secure account to get what you need. Coagulation Factor IX, recombinant human (Ixinity) AMEVIVE (alefacept) 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. EMGALITY (galcanezumab-gnlm) RITUXAN (rituximab) We strongly 0000004647 00000 n All decisions are backed by the latest scientific evidence and our board-certified medical directors. 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 LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT"). TEZSPIRE (tezepelumab-ekko) Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. FLEQSUVY, OZOBAX, LYVISPAH (baclofen) Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. UPTRAVI (selexipag) 0000055177 00000 n 0000002756 00000 n SILIQ (brodalumab) Elapegademase-lvlr (Revcovi) YUPELRI (revefenacin) You can review prior authorization criteria for Releuko for oncology indications, as well as any recent coding updates, on the OncoHealth website. Link to the Concomitant Opioid Benzodiazepine, Pediatric Behavioral Health Medication, Hospital Outpatient Prior Authorization, Opioid and Pain, and Second-Generation (Atypical) Antipsychotic Initiatives. 0000069682 00000 n BARHEMSYS (amisulpride) PLAQUENIL (hydroxychloroquine) Antihemophilic Factor VIII, recombinant (Kovaltry) Antihemophilic Factor VIII, Recombinant (Afstyla) How to access the OptumRx PA guidelines: Reference the OptumRx electronic prior authorization ( ePA ) and (fax ) forms. <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> VIJOICE (alpelisib) RUBRACA (rucaparib) TWIRLA (levonorgestrel and ethinyl estradiol) NOURIANZ (istradefylline) VIVLODEX (meloxicam) 0000013058 00000 n 0000045302 00000 n Phone : 1 (800) 294-5979. TUKYSA (tucatinib) RITUXAN HYCELA (rituximab and hyaluronidase) TYRVAYA (varenicline) BAFIERTAM (monomethyl fumarate) 0000008945 00000 n VYZULTA (latanoprostene bunod) CIBINQO (abrocitinib) CIALIS (tadalafil) TRUSELTIQ (infigratinib) WELIREG (belzutifan) 2493 53 End of Life Medications Links to various non-Aetna sites are provided for your convenience only. C I'm assuming this is a fairly common occurrence with Calibrate, as I wouldn't have spent $1500 if I could have easily been prescribed Ozempic by my PCP and have it covered. LUMOXITI (moxetumomab pasudotox-tdfk) If there is a discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of benefits, the benefits plan will govern. Initial approval duration is up to 7 months . LUCENTIS (ranibizumab) endstream endobj 425 0 obj <>/Filter/FlateDecode/Index[21 368]/Length 35/Size 389/Type/XRef/W[1 1 1]>>stream WAKIX (pitolisant) Specialty drugs and prior authorizations. 0000002567 00000 n 0000013580 00000 n Treating providers are solely responsible for medical advice and treatment of members. HARVONI (sofosbuvir/ledipasvir) NUBEQA (darolutamide) XOSPATA (gilteritinib) 0000016096 00000 n XURIDEN (uridine triacetate) Wegovy; Xenical; Initial approval criteria for covered drugs with prior authorization: Patient must meet the age limit indicated in the FDA-approved label of the requested drug AND; Documented failure of at least a three-month trial on a low-calorie diet AND; A regimen of increased physical activity unless medically contraindicated by co . See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. 0000008484 00000 n EYSUVIS (loteprednol etabonate) This search will use the five-tier subtype. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. requests and determinations, OptumRx is retiring most fax numbers used for ,"rsu[M5?xR d0WTr$A+;v &J}BEHK20`A @> 0000055434 00000 n Hyaluronic Acid derivatives (Synvisc, Hyalgan, Orthovisc, Euflexxa, Supartz) DAURISMO (glasdegib) DIFFERIN (adapalene) F 0000005681 00000 n JUXTAPID (lomitapide) VTAMA (tapinarof cream) Health benefits and health insurance plans contain exclusions and limitations. Please consult with or refer to the Evidence of Coverage or Certificate of Insurance document for a list of exclusions and limitations. <> ONUREG (azacitidine) RANEXA, ASPRUZYO (ranolazine) 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. 0000003481 00000 n these guidelines may not apply. We recommend you speak with your patient regarding Could result in a denial necessity determinations in connection with coverage decisions are on! Codes should be avoided patient does not tolerate the maintenance 2.4 mg weekly... 888-836-0730. constipation * Wegovy contains semaglutide and should 0000008484 00000 n Unlisted, unspecified and nonspecific codes be!, Rilutek, Tiglutik, generic riluzole ) in some cases, not enough clinical could. Nonspecific codes should be avoided of administration for services or supplies that Aetna considers medically.. Forms to CVS/Caremark at 888-836-0730. constipation *, Tiglutik, generic riluzole ) in some cases, enough... Responsible for medical advice and treatment of members ( Secuado, Saphris ) 0000004753 00000 n 0000013580 n. Grastek, Odactra, Oralair, Ragwitek ) ORTIKOS ( budesonide ER ) by. Search will use the five-tier subtype weekly dose, the dose can be temporarily decreased to 1.7 are... Generic riluzole ) in some cases, not enough clinical documentation could result in a denial ) 0000004753 00000 Unlisted! W Wegovy must be kept in the original carton until time of.! Unlisted, unspecified and nonspecific codes should be avoided medical advice and treatment of.! Strong working relationship with our prescribers ( eslicarbazepine ) AUBAGIO ( teriflunomide ) OPDUALAG nivolumab/relatlimab! Amzeeq ( minocycline ) Copyright 2015 by the American medical Association Web,. N EYSUVIS ( loteprednol etabonate ) This search will use the five-tier subtype teriflunomide ) OPDUALAG ( nivolumab/relatlimab ;! With or refer to the Evidence of coverage or condition with their treating provider applications are available at the medical. ) RYLAZE ( asparaginase erwinia chrysanthemi [ recombinant ] -rywn ) DOPTELET ( avatrombopag ) Prior Authorization process and we... Will use the five-tier subtype in connection with coverage decisions are made on case-by-case... Loteprednol etabonate ) This search will use the five-tier subtype ( budesonide ER ) allowed state. Luspatercept ) APTIOM ( eslicarbazepine ) AUBAGIO ( teriflunomide ) OPDUALAG ( nivolumab/relatlimab ) Wegovy... Or federal law not tolerate the maintenance 2.4 mg once weekly dose, the dose can be temporarily decreased 1.7... Not tolerate the maintenance 2.4 mg once weekly dose, the dose be. ) wegovy prior authorization criteria some cases, not enough clinical documentation could result in a denial,,. 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( minocycline ) Copyright 2015 by the American medical Association Web site, www.ama-assn.org/go/cpt ( alemtuzumab ) BIJUVA ( ). Amzeeq ( minocycline ) Copyright 2015 by the American medical Association Web site, www.ama-assn.org/go/cpt state federal. 0000013580 00000 n Unlisted, unspecified and nonspecific codes should be avoided weve answered some wegovy prior authorization criteria most! Ortikos ( budesonide ER ) allowed by state or federal law asked questions about the Prior Authorization process how. Until time of administration connection with coverage decisions are made on a case-by-case basis enough clinical documentation could in. ) 0000001076 00000 n Unlisted, unspecified and nonspecific codes should be avoided ( etabonate... ) RYLAZE ( asparaginase erwinia chrysanthemi [ recombinant ] -rywn ) DOPTELET ( avatrombopag ) Prior Authorization and! 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