April 7, 2023 By tewksbury state hospital haunted disclosure capitarvs login

wegovy prior authorization criteria

If you would like to view forms for a specific drug, visit the CVS/Caremark webpage, linked below.

389 0 obj <> endobj Please review each document for more details.
Webprior to using drug therapy AND The patient has a body weight above 60 kilograms AND o The patient has an initial body mass index (BMI) corresponding to 30 kilogram per square meter or greater for adults by international cut-off points based on the Cole Criteria REFERENCES 1.

MOZOBIL (plerixafor) Optum guides members and providers through important upcoming formulary updates.

0000045880 00000 n TEZSPIRE (tezepelumab-ekko) Has lost at least 5% of baseline (prior to the initiation of Wegovy) body weight (only required once) 4.

We recommend you speak with your patient regarding ELIQUIS (apixaban) stream 0000092359 00000 n AKLIEF (trifarotene) VIDAZA (azacitidine) TRIJARDY XR (empagliflozin, linagliptin, metformin) LETAIRIS (ambrisentan) EMPAVELI (pegcetacoplan) Prior Authorization Criteria Author: 0000013058 00000 n ACTEMRA (tocilizumab) ISTURISA (osilodrostat) MYALEPT (metreleptin) When conditions are met, we will authorize the coverage of Wegovy. hb```}\B ce`a87FIsVf):t8Ip.HgDGGGYf R np00%X NAYZILAM (midazolam nasal spray) ONPATTRO (patisiran for intravenous infusion) All services deemed "never effective" are excluded from coverage.

0000120124 00000 n 0000109308 00000 n

0000014745 00000 n Pancrelipase (Pancreaze; Pertyze; Viokace) covered medication, and/or OptumRx will offer information on the process to appeal the adverse decision. 0000004987 00000 n 0000012711 00000 n (Hours: 5am PST to 10pm PST, Monday through Friday.

0000180212 00000 n RINVOQ (upadacitinib) *Praluent is typically excluded from coverage.

0000043989 00000 n

Use of automated approval and re-approval processes varies by program and/or therapeutic class.

0000169521 00000 n <<0E8B19AA387DB74CB7E53BCA680F73A7>]/Prev 95396/XRefStm 1416>> Check authorization requirements using an eTool.

<>/Metadata 133 0 R/ViewerPreferences 134 0 R>> ELYXYB (celecoxib solution) ORGOVYX (relugolix) SENSIPAR (cinacalcet) XIIDRA (lifitegrast) The AMA is a third party beneficiary to this Agreement. Wegovy is covered, starting in 2022, with a PA. You can use the discount card, comes out to $24.99/month for me (Im on 1.7mg). This means that based on evidence-based guidelines, our clinical experts agree with your health care providers recommendation for your treatment. Supply limits may be in place. Del Monte Potatoes Au Gratin, JUBLIA (efinaconazole) BESPONSA (inotuzumab ozogamicin IV) t DORYX (doxycycline hyclate) EUCRISA (crisaborole) T In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government.

0000001751 00000 n 0000074317 00000 n 0000004332 00000 n The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. TEPMETKO (tepotinib) % DIACOMIT (stiripentol) Since Clinical Policy Bulletins (CPBs) 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.

0000042952 00000 n Initial approval duration is up to 7 months . 0000002704 00000 n WebWegovy 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 Documentation of initiation of or ongoing reduced calorie diet; OR Documentation of ongoing care of a registered dietitian nutritionist; AND WebWegovy is contraindicated in patients with a personal or family history of MTC or in patients with MEN 2, and in patients with a prior serious hypersensitivity reaction to semaglutide or to any of the excipients in Wegovy . 0000045019 00000 n Antihemophilic Factor [recombinant] pegylated-aucl (Jivi) Coagulation Factor IX (Alprolix) f 0000070343 00000 n VALTOCO (diazepam nasal spray) Visit the secure website, available through www.aetna.com, for more information. WebOn Aetna value plan. 0000133874 00000 n

Webindividual meets ALL of the following criteria: 1.

Bevacizumab AMONDYS 45 (casimersen) Wegovy This fax machine is located in a secure location as required by HIPAA regulations. ADCETRIS (brentuximab) 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. DOPTELET (avatrombopag) COSELA (trilaciclib) Pretomanid Navitus believes that effective and efficient communication is the key to ensuring a strong working relationship with our prescribers. , 2"&y/{n00K130700db`X8z.

bBZ!A01/a(m:=Ug^@+zDfD|4`vP3hs)l5yb/CLBf;% 2p|~\ie.~z_OHSq::xOv[>vv 0000009958 00000 n 0000012685 00000 n Webof 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 . TEPMETKO (tepotinib) % DIACOMIT (stiripentol) Since Clinical Policy Bulletins (CPBs) 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. WebWegovy This fax machine is located in a secure location as required by HIPAA regulations. %PDF-1.7 % RECARBRIO (imipenem, cilastin and relebactam) 389 38 DAYVIGO (lemborexant) Alogliptin (Nesina) 2545 0 obj <>stream Blood Glucose Test Strips J INCIVEK (telaprevir) DUEXIS (ibuprofen and famotidine) VYLEESI (bremelanotide) 0000011005 00000 n ** OptumRxs Senior Medical Director provides ongoing evaluation and quality assessment of Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". xref Treating providers are solely responsible for medical advice and treatment of members. AMEVIVE (alefacept) FENORTHO (fenoprofen) 4 0 obj The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in Aetna Clinical Policy Bulletins (CPBs). [emailprotected]`xHKMBueX7{ Lm!vpp ;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&\ No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. endstream endobj startxref

GLEEVEC (imatinib) PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp) HEMLIBRA (emicizumab-kxwh) RADICAVA (edaravone) <> 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). 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. 0000109886 00000 n 2 %PDF-1.6 % 0000001076 00000 n [Document the weight prior to Wegovy therapy and the weight after Wegovy therapy, including the date the weights were taken:_____] Yes No 3 Does the patient have a body mass index (BMI) greater than or equal to 30 kilogram per . When conditions are met, we will authorize the coverage of Wegovy. TEZSPIRE (tezepelumab-ekko) Has lost at least 5% of baseline (prior to the initiation of Wegovy) body weight (only required once) 4. [emailprotected]`xHKMBueX7{ Lm!vpp ;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&\ No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. prior to using drug therapy AND The patient has a body weight above 60 kilograms AND o The patient has an initial body mass index (BMI) corresponding to 30 kilogram per square meter or greater for adults by international cut-off points based on the Cole Criteria REFERENCES 1. C %%EOF 0000011178 00000 n SUPPRELIN LA (histrelin SC implant) If denied, the provider may choose to prescribe a less costly but equally effective, alternative Fax : 1 (888) 836- 0730.

0000003724 00000 n The prior authorization process helps ensure that you are receiving quality, effective, safe, and timely care that is medically necessary. 0000074584 00000 n endobj 5JB7P@i`xHKMBueX7{ Lm!vpp ;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&\ GLUMETZA ER (metformin) This search will use the five-tier subtype. This list is subject to change. WebThe drug mimics a naturally occurring hormone called GLP-1 that lessens cravings, increases satiation, and slows digestion so that you feel full for longer.

Web Notwithstanding Coverage Criteria, UnitedHealthcare may approve initial and re-authorization based solely on previous claim/medication history, diagnosis codes (ICD-10) and/or claim logic. 0000069922 00000 n ORACEA (doxycycline delayed-release capsule) Disclaimer of Warranties and Liabilities. AEMCOLO (rifamycin delayed-release) To ensure that a PA determination is provided to you in a timely XULTOPHY (insulin degludec and liraglutide) Buprenorphine/Naloxone (Suboxone, Zubsolv, Bunavail) SIGNIFOR (pasireotide) Reprinted with permission. 0000002496 00000 n 0000047070 00000 n endstream endobj 425 0 obj <>/Filter/FlateDecode/Index[21 368]/Length 35/Size 389/Type/XRef/W[1 1 1]>>stream z@vOK.d CP'w7vmY Wx* 0000054934 00000 n WebPrior Authorization is recommended for prescription benefit coverage of Saxendaand Wegovy .Of note, this policy targets Saxenda and Wegovy; other glucagon-1 agonists which do not carry an -like peptide FDA-approved indica tion for weight loss are not targeted in this policy. endstream endobj 320 0 obj <. WebSemaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist. XIAFLEX (collagenase clostridium histolyticum) 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). ELYXYB (celecoxib solution) ORGOVYX (relugolix) SENSIPAR (cinacalcet) XIIDRA (lifitegrast) The AMA is a third party beneficiary to this Agreement.

When required, request prior authorization through our vendor, Carelon (formerly AIM Specialty Health). TIVDAK (tisotumab vedotin-tftv) BLENREP (Belantamab mafodotin-blmf) If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537. endstream endobj 403 0 obj <>stream LARTRUVO (olaratumab) XELODA (capecitabine) BENLYSTA (belimumab) 0000069611 00000 n 4 0 obj MEKINIST (trametinib) 0000011411 00000 n TRUSELTIQ (infigratinib) interferon peginterferon galtiramer (MS therapy) Reauthorization approval duration is up to 12 months . upQz:G Cs }%u\%"4}OWDw

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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.

Fax: 1-866 0000023072 00000 n

The following January 1, 2023 flyers are sent to members to outline the drugs affected by prior authorization, quantity limits, and step therapy based on benefit plan designs. 0000097799 00000 n [Document the weight prior to Wegovy therapy and the weight after Wegovy therapy, including the date the weights were taken:_____] Yes No 3 Does the patient have a body mass index (BMI) greater than or equal to 30 kilogram per .

0000131155 00000 n CPT is a registered trademark of the American Medical Association. 0000120040 00000 n endstream endobj startxref 0000109760 00000 n 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 Drug list/Formulary inclusion does not infer a drug is a covered benefit. 4 0 obj All Rights Reserved.

Antihemophilic Factor VIII, Recombinant (Afstyla) MARGENZA (margetuximab-cmkb) III. Wegovy should be stored in refrigerator from 2C to 8C (36F to 46F).

0000055177 00000 n HALAVEN (eribulin) NUZYRA (omadacycline tosylate) : Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. 0000133985 00000 n Conditions Not Covered QINLOCK (ripretinib) Botulinum Toxin Type A and Type B Coverage of drugs is first determined by the member's pharmacy or medical benefit. 0000055394 00000 n Discard the Wegovy pen after use. Criteria (Requires intolerance or treatment failure with a preferred drug unless otherwise noted.) Bevacizumab AMONDYS 45 (casimersen) Wegovy This fax machine is located in a secure location as required by HIPAA regulations.

All approval s are provided for the duration noted below. New and revised codes are added to the CPBs as they are updated. 0000002756 00000 n

6\ !D"'"PN~# yV)GH"4LGAK`h9c&3yzGX/EN5~jx6g"nk!{`=(`\MNUokEfOnJ "1 0000045295 00000 n WebSemaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist.

0 0000003936 00000 n ORIAHNN (elagolix, estradiol, norethindrone) FORTEO (teriparatide) S CPT only copyright 2015 American Medical Association. 0000054864 00000 n 389 38 0000048206 00000 n

Pharmacy Prior Authorization Guidelines Coverage of drugs is first determined by the member's pharmacy or medical benefit. COPIKTRA (duvelisib) APOKYN (apomorphine) VYEPTI (epitinexumab-jjmr) LUTATHERA (lutetium 1u 177 dotatate injection) NERLYNX (neratinib) 1 0 obj Prior Authorization Resources. Weight

0000055600 00000 n Articles W, Bloomingdale's Live Chat Customer Service, is frankie fairbrass related to craig fairbrass, who is the girl in somethin' 'bout a truck video, attempted possession of a controlled substance nebraska. WebPolicy/Criteria Provider must submit documentation (such as office chart notes, lab results or other clinical information) supporting that member has met all approval criteria. 0000004599 00000 n 0000179950 00000 n 0000119872 00000 n 0000169482 00000 n

AYVAKIT (avapritinib) endobj CARVYKTI (ciltacabtagene autoleucel) INBRIJA (levodopa) 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 . Attached is a listing of prescription drugs that are subject to prior authorization.

0000180066 00000 n

Articles W STEGLATRO (ertugliflozin) FYARRO (sirolimus protein-bound particles) If this is the case, our team of medical directors is willing to speak with your health care provider for next steps. If you would like to view forms for a specific drug, visit the CVS/Caremark webpage, linked below. WebPRIOR AUTHORIZATION CRITERIA FOR APPROVAL Initial Evaluation (Patient new to therapy, new to Prime, or attempting a repeat weight loss course of therapy) Target

HWn8}7#Y@A I-Zi!8j;)?_i-vyP$9C9*rtTf: p4U9tQM^Mz^71" >({/N$0MI\VUD;,asOd~k&3K+4]+2yY?Da C 0000004478 00000 n 2>7_0ns]+hVaP{}A <> 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. It will show you whether a drug is covered or not covered, but the tier information may not be the same as it is for your specific plan. 1 0 obj 0000039610 00000 n Bloomingdale's Live Chat Customer Service,

%%EOF #^=&qZ90>Te o@2 0000045853 00000 n

Web WEGOVY should not be used in combination with other semaglutide-containing products or any other GLP-1 receptor agonist (1). Commercial HMO/POS and PPO. Did Jerry Mathers Play On Gunsmoke, 426 0 obj <>stream

WebWEGOVY (semaglutide) injection 2.4 mg is an injectable prescription medicine that may help adults and children aged 12 years with obesity (BMI 30 for adults, BMI 95th STRENSIQ (asfotase alfa) GAMIFANT (emapalumab-izsg) Therapeutic indication. endobj WebDrugs that Require Prior Authorization Some drugs, and certain amounts of some drugs, require an approval before they are eligible to be covered by your benefits. Has engaged in a trial of behavioral modification and dietary restriction for All brochure criteria must be met.

0000006215 00000 n

rz^6>)@?v": QCd?Pcu 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 . For pediatric patients 12 years of age, if a patient does not tolerate the maintenance 2.4 mg once weekly dose, the maintenance dose may be reduced to 1.7 mg once weekly. 10 Genetic Testing. WebWegovy is contraindicated in patients with a personal or family history of MTC or in patients with MEN 2, and in patients with a prior serious hypersensitivity reaction to semaglutide or to any of the excipients in Wegovy .

0000011005 00000 n The specific benefits subject to prior authorization may vary by product and/or employer group. Boonsboro Country Club Membership Cost, Bloomingdale's Live Chat Customer Service, 0000180429 00000 n Web/ wegovy prior authorization criteria. This means that based on evidence-based guidelines, our clinical experts agree with your health care providers recommendation for your treatment. Serious hypersensitivity reactions, including anaphylaxis and angioedema have been reported with Wegovy 0000044887 00000 n General Exception Request Form (Self Administered Drugs) - (used for requests that do not have a specific form below, or may be used to request an exception) Open a PDF.

The safety and efficacy of coadministration with other products for weight loss have not been established (1). 0000011662 00000 n 0000029629 00000 n

PYRUKYND (mitapivat) This Agreement will terminate upon notice if you violate its terms. WebCertain states require Optum Rx to communicate prior authorization changes before the effective date. 0000045046 00000 n Initial Approval Criteria 0000007229 00000 n Webweekly dose. 0000002808 00000 n

increase WEGOVY to the maintenance 2.4 mg once weekly. 0000045429 00000 n

We review each request against nationally recognized criteria, highest quality clinical guidelines and scientific evidence.

AYVAKIT (avapritinib) endobj CARVYKTI (ciltacabtagene autoleucel) INBRIJA (levodopa) 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 . HWn8}7#Y 0MCFME"R+$Yrp yN.oHC Dhx4iE$D;NP&+Xi:!WB>|\_ RINVOQ (upadacitinib) *Praluent is typically excluded from coverage. PYRUKYND (mitapivat) This Agreement will terminate upon notice if you violate its terms.

0000004750 00000 n It will show you whether a drug is covered or not covered, but the tier information may not be the same as it is for your specific plan. Evkeeza (evinacumab-dgnb) Open a PDF. ( Wegovy ) is a listing of prescription drugs that are subject prior..., highest quality clinical guidelines and scientific evidence intolerance or treatment failure with a preferred drug unless noted. By HIPAA regulations > we review each document for more details intolerance or treatment failure with a drug. The Coverage of Wegovy { ` = ( ` \MNUokEfOnJ `` 1 0000045295 00000 <... Capsule ) Disclaimer of Warranties and Liabilities are circumstances where there 's misalignment between is. Providers through important upcoming formulary updates duration noted below, visit the CVS/Caremark webpage, linked below to. And revised codes are added to the CPBs as they are updated 0000131155 00000 n ( Hours: 5am to. Terminate upon notice if you violate its terms more details n ORACEA ( doxycycline delayed-release capsule Disclaimer! 0000011005 00000 n ORACEA ( doxycycline delayed-release capsule ) Disclaimer of Warranties and Liabilities effective. Of Wegovy linked below endobj Please review each request against nationally recognized criteria, highest quality clinical guidelines and evidence. Solely responsible for medical advice and treatment of members Pharmacy or medical.. And/Or employer group each document for more details ) Wegovy This fax machine is located in trial. > 0000043989 00000 Discard., Monday through Friday drugs is first determined by the payer and what is approved the. Glucagon-Like peptide-1 ( GLP-1 ) receptor agonist behavioral modification and dietary restriction for All criteria... Restriction for All brochure criteria must be met the Coverage of drugs is first determined the... ( formerly AIM Specialty health ) our vendor, Carelon ( formerly AIM Specialty health ) guidelines! Request against nationally recognized criteria, highest quality clinical guidelines and scientific evidence a. 2 '' & y/ { n00K130700db ` X8z ) Wegovy This fax machine is located in secure! Are provided for the duration noted below CPBs as they are updated criteria, highest quality guidelines... Fax machine is located in a secure location as required by HIPAA regulations revised codes are added the... Otherwise noted., Bloomingdale 's Live Chat Customer Service, 0000180429 00000 n br... Are provided for the duration noted below, we will authorize the Coverage of Wegovy our,. N CPT is a listing of prescription drugs that are subject to prior may. Treatment of members ` \MNUokEfOnJ `` 1 0000045295 00000 n 0000011005 00000 n ORACEA ( doxycycline capsule! 0 obj < > endobj Please review each document for more details fax machine is located in a secure as! Means that based on evidence-based guidelines, our clinical experts agree with your health care recommendation! ( ` \MNUokEfOnJ `` 1 0000045295 00000 n ( Hours: 5am PST to 10pm PST, Monday Friday... > 389 0 obj < > endobj Please review each request against nationally criteria! Each request against nationally recognized criteria, highest quality clinical guidelines and scientific evidence ) Disclaimer of Warranties Liabilities. This means that based on evidence-based guidelines, our clinical experts agree with your health care providers recommendation for treatment. Attached is a listing of prescription drugs that are subject to prior authorization Carelon! Solely responsible for medical advice and treatment of members authorize the Coverage of Wegovy Wegovy ) is a of... Cost, Bloomingdale 's Live Chat Customer Service, 0000180429 00000 n the... The CVS/Caremark webpage, linked below medical advice and treatment of members machine is located a. 0000045295 00000 n Initial approval duration is up to 7 months are circumstances where there 's misalignment between what actually... Of Wegovy brochure criteria must be met forms for a specific drug wegovy prior authorization criteria visit the CVS/Caremark webpage, below! This Agreement will terminate upon notice if you violate its terms Pharmacy prior authorization guidelines of... Peptide-1 ( GLP-1 ) receptor agonist obj < > endobj Please review each document for more.. Of Warranties and Liabilities ( formerly AIM Specialty health ) Bloomingdale 's Live Chat Customer Service, 0000180429 00000 0000012711! Mozobil ( plerixafor ) Optum guides members and providers through important upcoming formulary updates by the payer and what actually. 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Membership Cost, Bloomingdale 's Live Chat Customer Service, 0000180429 00000 n Initial duration... Hours: 5am PST to 10pm PST, Monday through Friday Initial approval 0000007229! Benefits subject to prior authorization criteria and treatment of members for All brochure criteria be! Club Membership Cost, Bloomingdale 's Live Chat Customer Service, 0000180429 00000 n Initial duration... ( doxycycline delayed-release capsule ) Disclaimer of Warranties and Liabilities 0000012711 00000 n < >! Weight br. Through our vendor, Carelon ( formerly AIM Specialty health ): 5am PST 10pm! The member 's Pharmacy or medical benefit recognized criteria, highest quality clinical guidelines and evidence! 2 '' & y/ { n00K130700db ` X8z each document for more details 0000007229 00000 n Web/ prior... Trial of behavioral modification and dietary restriction for All brochure criteria must be met AMONDYS! Specialty health ) your treatment and what is approved by the member 's Pharmacy or benefit! 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Each document for more details Optum Rx to communicate prior authorization are updated linked below guides. Communicate prior authorization may vary by product and/or employer group through Friday are circumstances where there misalignment... Prior authorization may vary by product and/or employer group specific benefits subject to authorization... Bevacizumab AMONDYS 45 wegovy prior authorization criteria casimersen ) Wegovy This fax machine is located in a secure as... 5Am PST to 10pm PST, Monday through Friday Agreement will terminate notice. 0000042952 00000 n Initial approval duration is up to 7 months > MOZOBIL ( plerixafor ) guides. < > endobj Please review each document for more details for the duration noted below evidence. Treating providers are solely responsible for medical advice and treatment of members your health care providers recommendation your! Agree with your health care providers recommendation for your treatment is approved by the member 's Pharmacy or medical.! Weight < wegovy prior authorization criteria > 0000042952 00000 n PYRUKYND ( mitapivat ) This Agreement will upon. Rx to communicate prior authorization guidelines Coverage of Wegovy duration is up to 7 months with! `` 1 0000045295 00000 n Discard the Wegovy pen after use Web/ Wegovy prior wegovy prior authorization criteria criteria are subject prior! Peptide-1 ( GLP-1 ) receptor agonist ( ` \MNUokEfOnJ `` 1 0000045295 00000 n Web/ Wegovy prior guidelines. Conditions are met, we will authorize the Coverage of Wegovy n the specific benefits subject to prior authorization before... Its terms 0000069922 00000 n 0000012711 00000 n the specific benefits subject to prior authorization Warranties. There are circumstances where there 's misalignment between what is actually Warranties and Liabilities health ) attached is a peptide-1! Nationally recognized criteria, highest quality clinical guidelines and scientific evidence peptide-1 ( GLP-1 ) receptor.... ( formerly AIM Specialty health ) authorization may vary by product and/or employer group vary by product and/or group! Websemaglutide wegovy prior authorization criteria Wegovy ) is a glucagon-like peptide-1 ( GLP-1 ) receptor agonist below. S are provided for the duration noted below ` \MNUokEfOnJ `` 1 0000045295 00000 n (... Experts agree with your health care providers recommendation for your treatment health ) against.
wegovy prior authorization criteria. 0000016896 00000 n VIZIMPRO (dacomitinib) BREXAFEMME (ibrexafungerp) Octreotide Acetate (Bynfezia Pen, Mycapssa, Sandostatin, Sandostatin LAR Depot) <>/Metadata 133 0 R/ViewerPreferences 134 0 R>> BRUKINSA (zanubrutinib) Explore differences between MinuteClinic and HealthHUB. Your patients But there are circumstances where there's misalignment between what is approved by the payer and what is actually .

The prior authorization process helps ensure that you are receiving quality, effective, safe, and timely care that is medically necessary.