ZOLGENSMA (onasemnogene abeparvovec-xioi) This is a listing of all of the drugs covered by MassHealth. making criteria** that are developed from clinical evidence from the following sources: *Guidelines are specific to plans utilizing our standard drug lists only. EMGALITY (galcanezumab-gnlm) CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. BRUKINSA (zanubrutinib) KALYDECO (ivacaftor) OXERVATE (cenegermin-bkbj) gym discounts, OPZELURA (ruxolitinib cream) Interferon beta-1b (Betaseron, Extavia) DUOBRII (halobetasol propionate and tazarotene) The most efficient way to initiate a prior authorization is to ask your physician to contact Express Scripts' prior authorization hotline at 1-800-753-2851. ,"rsu[M5?xR d0WTr$A+;v &J}BEHK20`A @> ", The five character codes included in the Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology (CPT. NOCDURNA (desmopressin acetate) ZOMETA (zoledronic acid) c CEQUA (cyclosporine) A $25 copay card provided by the manufacturer may help ease the cost but only if . The responsibility for the content of Aetna Precertification Code Search Tool is with Aetna and no endorsement by the AMA is intended or should be implied. PSG suggests the inclusion of those strategies within prior authorization (PA) criteria. ADEMPAS (riociguat) 0000002756 00000 n DORYX (doxycycline hyclate) License to use CPT for any use not authorized herein must be obtained through the American Medical Association, CPT Intellectual Property Services, 515 N. State Street, Chicago, Illinois 60610. PLEGRIDY (peginterferon beta-1a) Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba) 0000011662 00000 n Please note also that the ABA Medical Necessity Guidemay be updated and are, therefore, subject to change. l NOURIANZ (istradefylline) allowed by state or federal law. It would definitely be a good idea for your doctor to document that you have made attempts to lose weight, as this is one of the main criteria. [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 . Hepatitis B IG When billing, you must use the most appropriate code as of the effective date of the submission. PENNSAID (diclofenac) ENDARI (l-glutamine oral powder) KRINTAFEL (tafenoquine) Members should discuss any matters related to their coverage or condition with their treating provider. KYLEENA (Levonorgestrel intrauterine device) stream Alogliptin (Nesina) BENLYSTA (belimumab) The prior authorization includes a list of criteria that includes: Individual has attempted to lose weight through a formalized weight management program (hypocaloric diet, exercise, and behavior modification) for at least 6 months prior to requests for drug therapy. 0000002571 00000 n Please call us at 800.753.2851 to submit a verbal prior authorization request if you are unable to use Electronic Prior Authorization. 389 38 VONJO (pacritinib) VIJOICE (alpelisib) a 4 0 obj endstream endobj 2544 0 obj <>/Filter/FlateDecode/Index[84 2409]/Length 69/Size 2493/Type/XRef/W[1 1 1]>>stream NOCTIVA (desmopressin) The prior authorization process helps ensure that the test, treatment, and/or procedure your provider requests is effective, safe, and medically appropriate. NINLARO (ixazomib) RITUXAN (rituximab) the OptumRx UM Program. OFEV (nintedanib) ZINPLAVA (bezlotoxumab) LETAIRIS (ambrisentan) TECARTUS (brexucabtagene autoleucel) 0 Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn) Step #2: We review your request against our evidence-based, clinical guidelines.These clinical guidelines are frequently reviewed and updated to reflect best practices. LEMTRADA (alemtuzumab) Has lost at least 5% of baseline (prior to the initiation of Wegovy) body weight (only required once) 4. Specialty drugs typically require a prior authorization. SCEMBLIX (asciminib) 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. endobj XOSPATA (gilteritinib) 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. 0000055963 00000 n 3 0 obj Wegovy, a new prescription medication for chronic weight management, launched with a price tag of around $1,627 a month before insurance. the decision-making process and may result in a denial unless all required information is received. When conditions are met, we will authorize the coverage of Wegovy. It will show you whether a drug is covered or not covered, but the tier information may not be the same as it is for your specific plan. OCALIVA (obeticholic acid) w If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537. STEGLUJAN (ertugliflozin and sitagliptin) 0000002567 00000 n P^p%JOP*);p/+I56d=:7hT2uovIL~37\K"I@v vI-K\f"CdVqi~a:X20!a94%w;-h|-V4~}`g)}Y?o+L47[atFFs AW %gs0OirL?O8>&y(IP!gS86|)h which contain clinical information used to evaluate the PA request as part of. N QELBREE (viloxazine extended-release) VESICARE LS (solifenacin succinate suspension) Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. ONGLYZA (saxagliptin) 1 0 obj VYZULTA (latanoprostene bunod) 4 0 obj COPIKTRA (duvelisib) All Rights Reserved. b ACTEMRA (tocilizumab) ! Z3mo5&/ ^fHx&,=dtbX,DGjbWo.AT+~D.yVc$o5`Jkxyk+ln 5mA78+7k}HZX*-oUcR);"D:K@8hW]j {v$pGvX 14Tw1Eb-c{Hpxa_/=Z=}E. In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. 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. JAKAFI (ruxolitinib) Buprenorphine/Naloxone (Suboxone, Zubsolv, Bunavail) ZIPSOR (diclofenac) STEGLATRO (ertugliflozin) 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. 0000002153 00000 n FLEQSUVY, OZOBAX, LYVISPAH (baclofen) UPNEEQ (oxymetazoline hydrochloride) NAYZILAM (midazolam nasal spray) LUTATHERA (lutetium 1u 177 dotatate injection) AUVI-Q (epinephrine) Do you want to continue? WELIREG (belzutifan) Wegovy should be used with a reduced calorie meal plan and increased physical activity. Phone : 1 (800) 294-5979. The responsibility for the content of this product is with Aetna, Inc. and no endorsement by the AMA is intended or implied. Cost effective; You may need pre-authorization for your . Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. XURIDEN (uridine triacetate) ZEPZELCA (lurbinectedin) FOTIVDA (tivozanib) To request authorization for Leqvio, or to request authorization for Releuko for non-oncology purposes, please contact CVS Health-NovoLogix via phone (844-387-1435) or fax (844-851-0882). Prior Authorization criteria is available upon request. Antihemophilic Factor VIII, Recombinant (Afstyla) FORTAMET ER (metformin) ZYKADIA (ceritinib) Once a review is complete, the provider is informed whether the PA request has been approved or RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn) VITRAKVI (larotrectinib) XIAFLEX (collagenase clostridium histolyticum) 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. M vomiting. As part of an ongoing effort to increase security, accuracy, and timeliness of PA Off-label and Administrative Criteria #^=&qZ90>Te o@2 %PDF-1.7 % d End of Life Medications Botulinum Toxin Type A and Type B BIJUVA (estradiol-progesterone) Propranolol (Inderal XL, InnoPran XL) 0000003227 00000 n Elapegademase-lvlr (Revcovi) 6. SOTYKTU (deucravacitinib) SUPPRELIN LA (histrelin SC implant) Antihemophilic Factor [recombinant] pegylated-aucl (Jivi) TIBSOVO (ivosidenib) It is only a partial, general description of plan or program benefits and does not constitute a contract. NUPLAZID (pimavanserin) VYNDAQEL (tafamidis meglumine) Coagulation Factor IX, recombinant human (Ixinity) COSENTYX (secukinumab) The AMA is a third party beneficiary to this Agreement. 0000004700 00000 n Reauthorization approval duration is up to 12 months . Visit the secure website, available through www.aetna.com, for more information. 0000062995 00000 n Coverage of drugs is first determined by the member's pharmacy or medical benefit. 0000004176 00000 n SUNOSI (solriamfetol) - 27 kg/m to <30 kg/m (overweight) in the presence of at least one . 0000002222 00000 n 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. Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. TYSABRI (natalizumab) the following criteria are met for FDA Indications or Other Uses with Supportive Evidence: Prior Authorization is recommended for prescription benefit coverage of the GLP-1 agonists targeted in this policy. 0000011365 00000 n Erythropoietin, Epoetin Alpha MULPLETA (lusutrombopag) 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). 0000001416 00000 n your Dashboard to submit your PA request. wellness assessment, SYMDEKO (tezacaftor-ivacaftor)
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