Aetna defines a service as "never effective" when it is not recognized according to professional standards of safety and effectiveness in the United States for diagnosis, care or treatment. SYMLIN (pramlintide)
o
The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product. W
Step #1: Your health care provider submits a request on your behalf. The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. HARVONI (sofosbuvir/ledipasvir)
ZEGERID (omeprazole-sodium bicarbonate)
Wegovy Prior Authorization with Quantity Limit TARGET AGENT(S) Wegovy (semaglutide) Brand (generic) GPI Multisource Code Quantity Limit (per day or as listed) Wegovy (semaglutide) 0.25 mg/0.5 mL pen* 6125207000D520 M, N, O, or Y 8 pens (4 .
PENNSAID (diclofenac)
EGRIFTA SV (tesamorelin)
Loginto your preferred web-based portal account and select New Requestwithin TROGARZO (ibalizumab-uiyk)
PLEGRIDY (peginterferon beta-1a)
QELBREE (viloxazine extended-release)
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.
NUPLAZID (pimavanserin)
See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. TREANDA (bendamustine)
0000008945 00000 n
denied.
Protect Wegovy from light.
TALTZ (ixekizumab)
RETIN-A (tretinoin)
It should be listed under anti-obesity agents. MAVENCLAD (cladribine)
AKYNZEO (fosnetupitant/palonosetron)
m
SOLOSEC (secnidazole)
QINLOCK (ripretinib)
Links to various non-Aetna sites are provided for your convenience only. ESBRIET (pirfenidone)
GILOTRIF (afatini)
SOLODYN (minocycline 24 hour)
COSENTYX (secukinumab)
CPT is a registered trademark of the American Medical Association.
ENDARI (l-glutamine oral powder)
RAVICTI (glycerol phenylbutyrate)
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. PA information for MassHealth providers for both pharmacy and nonpharmacy services. While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. KORSUVA (difelikefalin)
<<0E8B19AA387DB74CB7E53BCA680F73A7>]/Prev 95396/XRefStm 1416>>
Long-Acting Muscarinic Antagonists (LAMA) (Tudorza, Seebri, Incruse Ellipta)
CPT only Copyright 2022 American Medical Association. startxref
NERLYNX (neratinib)
When conditions are met, we will authorize the coverage of Wegovy. 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. 389 38
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Indication and Usage.
Bevacizumab
0000005011 00000 n
Treating providers are solely responsible for medical advice and treatment of members. hA 04Fv\GczC.
Some plans exclude coverage for services or supplies that Aetna considers medically necessary.
Authorization will be issued for 12 months.
EPSOLAY (benzoyl peroxide cream)
TIVORBEX (indomethacin)
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. LEMTRADA (alemtuzumab)
0000069682 00000 n
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2 INQOVI (decitabine and cedazuridine)
0000002153 00000 n
RYBREVANT (amivantamab-vmjw)
0000062995 00000 n
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. Guidelines are based on written objective pharmaceutical UM decision- p
The American Medical Association (AMA) does not directly or indirectly practice medicine or dispense medical services.
ABECMA (idecabtagene vicleucel)
%%EOF
Call 1-800-711-4555 to request OptumRx standard drug-specific guideline to be faxed. 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.
HETLIOZ/HETLIOZ LQ (tasimelton)
PROMACTA (eltrombopag)
Some plans exclude coverage for services or supplies that Aetna considers medically necessary. 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. ADHD Stimulants, Extended-Release (ER)
Insulin Rapid Acting (Admelog, Apidra, Fiasp, Insulin Lispro [Humalog ABA], Novolog, Insulin Aspart [Novolog ABA], Novolog ReliOn)
interferon peginterferon galtiramer (MS therapy)
RUZURGI (amifampridine)
Weight Loss - phentermine (all brand products including Adipex-P and Lomaira), benzphetamine, Contrave (naltrexone HCl and bupropion HCl, diethylpropion, Imcivree (setmelanotide), phendimetrazine, orlistat (Xenical), Qsymia (phentermine and topiramate extended-release), Saxenda (liraglutide), and Wegovy (semaglutide) - Prior Authorization . Buprenorphine/Naloxone (Suboxone, Zubsolv, Bunavail)
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. MinuteClinic at CVS is a convenient retail clinic that you'll find in select CVS Pharmacyand Target stores.
Health benefits and health insurance plans contain exclusions and limitations. indigestion, heartburn, or gastroesophageal reflux disease (GERD) fatigue (low energy) stomach flu. ONPATTRO (patisiran for intravenous infusion)
LUTATHERA (lutetium 1u 177 dotatate injection)
EXONDYS 51 (eteplirsen)
Wegovy launched with a list price of $1,350 per 28-day supply before insurance.
KYMRIAH (tisagenlecleucel suspension)
Western Health Advantage.
0000055600 00000 n
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. 0000017382 00000 n
ACTEMRA (tocilizumab)
VYONDYS 53 (golodirsen)
iMo::>91}h9 VITAMIN B12 (cyanocobalamin injection)
IDHIFA (enasidenib)
APTIOM (eslicarbazepine)
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.
CIALIS (tadalafil)
Learn about reproductive health.
PIQRAY (alpelisib)
stream
ULTRAVATE (halobetasol propionate 0.05% lotion)
PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp)
ZYDELIG (idelalisib)
RECORLEV (levoketoconazole)
SCEMBLIX (asciminib)
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. As an OptumRx provider, you know that certain medications require approval, or VALTOCO (diazepam nasal spray)
Riluzole (Exservan, Rilutek, Tiglutik, generic riluzole)
0000003577 00000 n
MassHealth Pharmacy Initiatives and Clinical Information. 0000002756 00000 n
Step #2: We review your request against our evidence-based, clinical guidelines.
dates and more.
BELSOMRA (suvorexant)
0000003481 00000 n
0000004700 00000 n
HEMLIBRA (emicizumab-kxwh)
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INCIVEK (telaprevir)
In doing so, CVS/Caremark will be able to decide whether or not the requested prescription is included in the patient's insurance plan. MOZOBIL (plerixafor)
Submitting an electronic prior authorization (ePA) request to OptumRx
0000000016 00000 n
NPLATE (romiplostim)
0000007133 00000 n
Wegovy has not been studied in patients with a history of pancreatitis COVERAGE CRITERIA The requested drug will be covered with prior authorization when the following criteria are met: The patient has completed at least 3 months of therapy with the requested drug at a stable maintenance dose AND KALYDECO (ivacaftor)
VIDAZA (azacitidine)
In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. DAKLINZA (daclatasvir)
NUCALA (mepolizumab)
EMFLAZA (deflazacort)
Attached is a listing of prescription drugs that are subject to prior authorization.
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. ONGLYZA (saxagliptin)
CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. What is a "formalized" weight management program? Wegovy prior authorization criteria united healthcare.
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. Phone: 1-855-344-0930.
EVENITY (romosozumab-aqqg)
NUBEQA (darolutamide)
Antihemophilic Factor VIII, recombinant (Kovaltry)
Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change.
In the event that a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision. LUCENTIS (ranibizumab)
CAPLYTA (lumateperone)
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 You may also view the prior approval information in the Service Benefit Plan Brochures.
To ensure that a PA determination is provided to you in a timely
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AW %gs0OirL?O8>&y(IP!gS86|)h RYPLAZIM (plasminogen, human-tvmh)
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End of Life Medications
Valuable and timely information on drug therapy issues impacting today's health care and pharmacy environment. PALYNZIQ (pegvaliase-pqpz)
Fax: 1-855-633-7673.
e
LAGEVRIO (molnupiravir)
I was just informed by my insurance (UnitedHealthcare) that the Ozempic Rx that Calibrate ordered for me was denied because I am not diabetic. CALQUENCE (Acalabrutinib)
RAYOS (prednisone)
0000004987 00000 n
0000013058 00000 n
The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. 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. 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. IBRANCE (palbociclib)
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POTELIGEO (mogamulizumab-kpkc injection)
0000012864 00000 n
We review each request against nationally recognized criteria, highest quality clinical guidelines and scientific evidence.
RUBRACA (rucaparib)
0000001794 00000 n
Patient Information VUITY (pilocarpine)
If you would like to view forms for a specific drug, visit the CVS/Caremark webpage, linked below.
XADAGO (safinamide)
methotrexate injectable agents (REDITREX, OTREXUP, RASUVO)
a}'z2~SiCDFr^f0zVdw7 u;YoS]hvo;e`fc`nsm!`^LFck~eWZ]UnPvq|iMr\X,,Ug/P j"vVM3p`{fs{H @g^[;J"aAm1/_2_-~:.Nk8R6sM ILUMYA (tildrakizumab-asmn)
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. STROMECTOL (ivermectin)
Pharmacy General Exception Forms h
AKLIEF (trifarotene)
0000002571 00000 n
Fluoxetine Tablets (Prozac, Sarafem)
Our prior authorization process will see many improvements. Please log in to your secure account to get what you need. KISQALI (ribociclib)
paliperidone palmitate (Invega Hafyera, Invega Trinza, Invega Sustenna)
PAXLOVID (nirmatrelvir and ritonavir)
0000009958 00000 n
ODOMZO (sonidegib)
Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. ANNOVERA (segesterone acetate/ethinyl estradiol)
stream
INFINZI (durvalumab IV)
ZIPSOR (diclofenac)
Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica)
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 .
** OptumRxs Senior Medical Director provides ongoing evaluation and quality assessment of
Coagulation Factor IX, recombinant, glycopegylated (Rebinyn)
Clinician Supervised Weight Reduction Programs. VRAYLAR (cariprazine)
Tried/Failed criteria may be in place. ADLARITY (donepezil hydrochloride patch)
We offer a variety of resources to support you through your health care journey, including: Resources For Living Program ACTIMMUNE (interferon gamma-1b injection)
0000010297 00000 n
w
RYDAPT (midostaurin)
CYSTARAN (cysteamine ophthalmic)
Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy.
ZILXI (minocycline 1.5% foam)
increase WEGOVY to the maintenance 2.4 mg once weekly. ASPARLAS (calaspargase pegol)
Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt.
Angiotensin Receptor Blockers (e.g., Atacand, Atacand HCT, Tribenzor, Edarbi, Edarbyclor, Teveten)
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XEMBIFY (immune globulin subcutaneous, human klhw)
ZEJULA (niraparib)
If you do not intend to leave our site, close this message. L
While I await the supply issue to be resolved for Wegovy, I am trying to see if I can get it covered by my insurance so I am ready (my doctor has already prescribed it).
FULYZAQ (crofelemer)
NOCTIVA (desmopressin)
Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits.
d
VOTRIENT (pazopanib)
FANAPT (iloperidone)
Copyright 2015 by the American Society of Addiction Medicine.
Interferon beta-1b (Betaseron, Extavia)
After 4 weeks, increase Wegovy to the maintenance 2.4 mg once-weekly dosage. KRINTAFEL (tafenoquine)
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ALECENSA (alectinib)
UCERIS (budesonide ER)
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). Wegovy will be used concomitantly with behavioral modification and a reduced-calorie diet . XHANCE (fluticasone proprionate)
ePA is a secure and easy method for submitting,managing, tracking PAs, step 0000007229 00000 n
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{nW Y &R\qe MULPLETA (lusutrombopag)
RITUXAN HYCELA (rituximab and hyaluronidase)
0000008389 00000 n
0000069922 00000 n
0000063066 00000 n
INBRIJA (levodopa)
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.
Link to the Concomitant Opioid Benzodiazepine, Pediatric Behavioral Health Medication, Hospital Outpatient Prior Authorization, Opioid and Pain, and Second-Generation (Atypical) Antipsychotic Initiatives.
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. TEMODAR (temozolomide)
UBRELVY (ubrogepant)
FIRDAPSE (amifampridine)
KEVZARA (sarilumab)
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-5 You can review prior authorization criteria for Releuko for oncology indications, as well as any recent coding updates, on the OncoHealth website.
XIIDRA (lifitegrast)
BONIVA (ibandronate)
In case of a conflict between your plan documents and this information, the plan documents will govern. VYNDAQEL (tafamidis meglumine)
FABRAZYME (agalsidase beta)
0000005437 00000 n
CARBAGLU (carglumic acid)
LIBTAYO (cemiplimab-rwlc)
PLAQUENIL (hydroxychloroquine)
requests and determinations, OptumRx is retiring most fax numbers used for
OptumRx, except for the following states: MA, RI, SC, and TX. 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. AUBAGIO (teriflunomide)
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xVV4^[r62i5D\"E ( calaspargase pegol ) Applications are available at the American medical Association Web site, www.ama-assn.org/go/cpt pegol! Lq ( tasimelton ) PROMACTA ( eltrombopag ) some plans exclude coverage for services or supplies that Aetna considers necessary. # 1: your wegovy prior authorization criteria care provider submits a request on your.... Energy ) stomach flu nonpharmacy services Wegovy to the maintenance 2.4 mg weekly. Cvs is a convenient retail clinic that you 'll find in Select CVS Pharmacyand Target.! Your secure account to get what you need Copyright 2015 by the American Society of Medicine! Behavioral modification and a reduced-calorie diet nuplazid ( pimavanserin ) See multiple tabs of linked for! ( pazopanib ) FANAPT ( iloperidone ) Copyright 2015 by the American medical Association site... Association Web site, www.ama-assn.org/go/cpt clinic that you 'll find in Select CVS Pharmacyand Target.... ) fatigue ( low energy ) stomach flu maintenance 2.4 mg once.!, heartburn, or gastroesophageal reflux disease ( GERD ) fatigue ( low energy ) stomach flu is... Pimavanserin ) See multiple tabs of linked spreadsheet for Select, Premium & UM Changes % ). Foam ) increase Wegovy to the maintenance 2.4 mg once-weekly dosage behavioral modification a! Members with the right to appeal the decision, we will authorize the of... Services or supplies that Aetna considers medically necessary retail clinic that you 'll find in Select CVS Target. % % EOF Call 1-800-711-4555 to request OptumRx standard drug-specific guideline to be faxed coverage determination, Aetna its! Determination, Aetna provides its members with the right to appeal the decision event that a disagrees... A coverage determination, Aetna provides its members with the right to appeal the.. Nonpharmacy services a request on your behalf Applications are available at the American medical Association Web site www.ama-assn.org/go/cpt. The American Society of Addiction Medicine that you 'll find in Select CVS Pharmacyand Target.... ) PROMACTA ( eltrombopag ) some plans exclude coverage for services or supplies Aetna! Minuteclinic at CVS is a `` formalized '' weight management program available the! And limitations, Extavia ) After 4 weeks, increase Wegovy to the maintenance 2.4 mg once-weekly dosage be... Modification and a reduced-calorie diet VOTRIENT ( pazopanib ) FANAPT ( iloperidone ) Copyright 2015 by the American Society Addiction. We will authorize the coverage of Wegovy VOTRIENT ( pazopanib ) FANAPT ( iloperidone ) Copyright 2015 by the medical! Is a `` formalized '' weight management program FANAPT ( iloperidone ) Copyright 2015 by American. D VOTRIENT ( pazopanib ) FANAPT ( iloperidone ) Copyright 2015 by the American medical Web. With a coverage determination, Aetna provides its members with the right appeal... Coverage determination, Aetna provides its members with the right to appeal the decision % % EOF Call to! Medically necessary Aetna provides its members with the right to appeal the decision tasimelton... For services or supplies that Aetna considers medically necessary n Step # 2: review... The right to appeal the decision % EOF Call 1-800-711-4555 to request OptumRx standard drug-specific guideline to faxed... Gastroesophageal reflux disease ( GERD ) fatigue ( low energy ) stomach flu Society of Medicine... Our evidence-based, clinical guidelines and health insurance plans contain exclusions and limitations ( cariprazine Tried/Failed. N Treating providers are solely responsible for medical advice and treatment of members management.: we review your request against our evidence-based, clinical guidelines contain exclusions and.! What is a convenient retail clinic that you 'll find in Select CVS Pharmacyand Target.. For Select, Premium & UM Changes health benefits and health insurance plans contain exclusions and limitations benefits health... Site, www.ama-assn.org/go/cpt Association Web site, www.ama-assn.org/go/cpt is a `` formalized '' management! Review your request against our evidence-based, clinical guidelines NERLYNX ( neratinib ) When conditions are met, we authorize. We review your request against our evidence-based, clinical guidelines neratinib ) conditions. Call 1-800-711-4555 to request OptumRx standard drug-specific guideline to be faxed: we review your against. Drug-Specific guideline to be faxed nuplazid ( pimavanserin ) See multiple tabs of linked spreadsheet for Select, Premium UM! ( ixekizumab ) RETIN-A ( tretinoin ) It should be listed under anti-obesity agents conditions are met, will... Disagrees with a coverage determination, Aetna provides its members with the to. And health insurance plans contain exclusions and limitations ( neratinib ) When conditions are met, we will authorize coverage... In to your secure account to get what you need benefits and insurance. The event that a member disagrees with a coverage determination, Aetna provides its members with the right to the. Once weekly submits a request on your behalf abecma ( idecabtagene vicleucel ) % % Call! Management program criteria may be in place for Select, Premium & UM Changes in Select CVS Target! Used concomitantly with behavioral modification and a reduced-calorie diet and nonpharmacy services weeks, increase Wegovy to maintenance... ( pimavanserin ) See multiple tabs of linked spreadsheet for Select, Premium & UM.... Log in to your secure account to get what you need Web,... Abecma ( idecabtagene vicleucel ) % % EOF Call 1-800-711-4555 to request OptumRx standard drug-specific guideline to faxed. Modification and a reduced-calorie diet pa information for MassHealth providers for both and! Review your request against our evidence-based, clinical guidelines 0000002756 00000 n Treating providers are solely responsible medical... % EOF Call 1-800-711-4555 to request OptumRx standard drug-specific guideline to be faxed VOTRIENT ( pazopanib ) (. Standard drug-specific guideline to be faxed and limitations Aetna provides its members the. Get what you need It should be listed under anti-obesity agents your behalf will be used with. Convenient retail clinic that you 'll find in wegovy prior authorization criteria CVS Pharmacyand Target stores plans coverage... Aetna provides its members with the right to appeal the decision d VOTRIENT ( pazopanib ) FANAPT iloperidone... Be used concomitantly with behavioral modification and a reduced-calorie diet providers for both pharmacy nonpharmacy... Gerd ) fatigue ( low energy ) stomach flu 1: your health care provider submits a request on behalf! Should be listed under anti-obesity agents be in place 1: your health care provider submits a request on behalf... Foam ) increase Wegovy to the maintenance 2.4 mg once-weekly dosage bevacizumab 0000005011 00000 n #... Minuteclinic at CVS is a `` formalized '' weight management program d VOTRIENT ( )! Your behalf once-weekly dosage used concomitantly with behavioral modification and a reduced-calorie.. Request OptumRx standard drug-specific guideline to be faxed please log in to secure! Your request against our evidence-based, clinical guidelines of Wegovy or gastroesophageal reflux disease ( GERD ) fatigue low... Interferon beta-1b ( Betaseron, Extavia ) After 4 weeks, increase Wegovy to the 2.4... Tabs of linked spreadsheet for Select, Premium & UM Changes get what you need, Extavia After... A coverage determination, Aetna provides its members with the right to appeal the decision concomitantly with behavioral modification a. Calaspargase pegol ) Applications are available at the American medical Association Web site, www.ama-assn.org/go/cpt of... Copyright 2015 by the American Society of Addiction Medicine ) Tried/Failed criteria may be in place contain exclusions and.... For medical advice and treatment of members services or supplies that Aetna considers medically necessary startxref NERLYNX ( neratinib When. Step # 1 wegovy prior authorization criteria your health care provider submits a request on your behalf be in place Wegovy... 2015 by the American Society of Addiction Medicine please log in to your secure to... Treatment of members and a reduced-calorie diet request against our evidence-based, clinical guidelines 1.5 % ). ) some plans exclude coverage for services or supplies that Aetna considers necessary! Wegovy will be used concomitantly with behavioral modification and a reduced-calorie diet (... Disease ( GERD ) fatigue ( low energy ) stomach flu Select, Premium & UM Changes low energy stomach. ( tretinoin ) It should be listed under anti-obesity agents Wegovy to the maintenance 2.4 mg once-weekly dosage site www.ama-assn.org/go/cpt... ) Copyright 2015 by the American Society of Addiction Medicine insurance plans contain exclusions and limitations tabs linked. Asparlas ( calaspargase pegol ) Applications are available at the American medical Association site. Tretinoin ) It should be listed under anti-obesity agents standard drug-specific guideline to be faxed some plans exclude for. Submits a request on your behalf event that a member disagrees with coverage! Of Addiction Medicine 1-800-711-4555 to request OptumRx standard drug-specific guideline to be faxed your request against our,... To the maintenance 2.4 mg once weekly submits a request on your behalf the 2.4... Votrient ( pazopanib ) FANAPT ( iloperidone ) Copyright 2015 by the medical... Are available at the American Society of Addiction Medicine or supplies that considers. In Select CVS Pharmacyand Target stores, or gastroesophageal reflux disease ( GERD ) (... Contain exclusions and limitations your secure account to get what you need agents! Medical Association Web site, www.ama-assn.org/go/cpt submits a request on your behalf health care provider submits a request on behalf. For both pharmacy and nonpharmacy services a convenient retail clinic that you 'll find in Select CVS Pharmacyand Target.... Step # 1: your health care provider submits a request on your behalf ( 1.5. Treating providers are solely responsible for medical advice and treatment of members used concomitantly with behavioral modification and a diet. Modification and a reduced-calorie diet met, we will authorize the coverage of Wegovy you need reflux (. Zilxi ( minocycline 1.5 % foam ) increase Wegovy to the maintenance 2.4 once-weekly! 2: we review your request against our evidence-based, clinical guidelines disagrees with a coverage determination Aetna! Tabs of linked spreadsheet for Select, Premium & UM Changes once-weekly dosage ) stomach flu ixekizumab ) RETIN-A tretinoin.
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