Viewand print a PA request form, For urgent requests, please call us at 1-800-711-4555. FYARRO (sirolimus protein-bound particles) Erythropoietin, Epoetin Alpha 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. N ONZETRA XSAIL (sumatriptan nasal) LIVMARLI (maralixibat solution) View Medicare formularies, prior authorization, and step therapy criteria by selecting the appropriate plan and county.. Part B Medication Policy for Blue Shield Medicare PPO. 0000055600 00000 n DUEXIS (ibuprofen and famotidine) TEZSPIRE (tezepelumab-ekko) BAVENCIO (avelumab) ,"rsu[M5?xR d0WTr$A+;v &J}BEHK20`A @> 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. Riluzole (Exservan, Rilutek, Tiglutik, generic riluzole) 0000003577 00000 n UPNEEQ (oxymetazoline hydrochloride) methotrexate injectable agents (REDITREX, OTREXUP, RASUVO) Unlisted, unspecified and nonspecific codes should be avoided. Patient Information The requested drug will be covered with prior authorization when the following criteria are met: The patient is 18 years of age or . 1 0 obj Pre-authorization is a routine process. ULORIC (febuxostat) XOLAIR (omalizumab) We also host webinars, outreach campaigns and educational workshops to help them navigate the process. MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate) Visit the secure website, available through www.aetna.com, for more information. This list is subject to change. PEPAXTO (melphalan flufenamide) SKYRIZI (risankizumab-rzaa) LAGEVRIO (molnupiravir) 0000004700 00000 n 0000000016 00000 n RECLAST (zoledronic acid-mannitol-water) We will be more clear with processes. 0000004647 00000 n Do you want to continue? Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica) Prior Authorization Criteria Author: QUVIVIQ (daridorexant) ACTEMRA (tocilizumab) FORTAMET ER (metformin) YUPELRI (revefenacin) VFEND (voriconazole) SPRAVATO (esketamine) TYVASO (treprostinil) FASENRA (benralizumab) prescription drug benefit coverage under his/her health insurance plan or call OptumRx. The recently passed Prior Authorization Reform Act is helping us make our services even better. 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 Sodium oxybate (Xyrem); calcium, magnesium, potassium, and sodium oxybates (Xywav) 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. To ensure that a PA determination is provided to you in a timely PSG suggests the inclusion of those strategies within prior authorization (PA) criteria. Wegovy is indicated for adults who are obese (body mass index 30) or overweight (body mass index 27), and who also have certain weight-related medical conditions, such as type 2 diabetes . PHEXXI (lactic acid, citric acid, and potassium bitartrate) Or, call us at the number on your ID card. TASIGNA (nilotinib) All Rights Reserved. X Some subtypes have five tiers of coverage. 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. BAFIERTAM (monomethyl fumarate) FINTEPLA (fenfluramine) ; Wegovy contains semaglutide and should . DOJOLVI (triheptanoin liquid) PADCEV (enfortumab vendotin-ejfv) 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.. Wegovy should be used with a reduced calorie meal plan and increased physical activity. KRYSTEXXA (pegloticase) KADCYLA (Ado-trastuzumab emtansine) TUKYSA (tucatinib) See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. New and revised codes are added to the CPBs as they are updated. 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 . BONIVA (ibandronate) DUOBRII (halobetasol propionate and tazarotene) 0000003404 00000 n PIQRAY (alpelisib) 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. GLP-1 Agonists (Bydureon, Bydureon BCise, Byetta, Ozempic, Rybelsus, Trulicity, Victoza, Adlyxin) & GIP/GLP-1 Agonist (Mounjaro) NOURIANZ (istradefylline) Guidelines are based on written objective pharmaceutical UM decision- MOZOBIL (plerixafor) Asenapine (Secuado, Saphris) Semaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist. t ADDYI (flibanserin) XADAGO (safinamide) EPCLUSA (sofosbuvir/velpatasvir) 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. SENSIPAR (cinacalcet) EVENITY (romosozumab-aqqg) endstream endobj 2544 0 obj <>/Filter/FlateDecode/Index[84 2409]/Length 69/Size 2493/Type/XRef/W[1 1 1]>>stream 0000003936 00000 n VABYSMO (faricimab) 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). RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn) The prior authorization process helps ensure that the test, treatment, and/or procedure your provider requests is effective, safe, and medically appropriate. <<0E8B19AA387DB74CB7E53BCA680F73A7>]/Prev 95396/XRefStm 1416>> VYZULTA (latanoprostene bunod) SOLIQUA (insulin glargine and lixisenatide) 0000002392 00000 n Of note, Saxenda (liraglutide subcutaneous injection) and Wegovy (semaglutide subcutaneous injection) are indicated for chronic weight . Wegovy This fax machine is located in a secure location as required by HIPAA regulations. <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> WAKIX (pitolisant) ROCKLATAN (netarsudil and latanoprost) AYVAKIT (avapritinib) CPT only Copyright 2022 American Medical Association. LUTATHERA (lutetium 1u 177 dotatate injection) Learn about reproductive health. 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. It is sometimes known as precertification or preapproval. % Please log in to your secure account to get what you need. endobj (Hours: 5am PST to 10pm PST, Monday through Friday. <> You can take advantage of a wide range of services across a variety of categories, including: CVS HealthHUBservices 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. OptumRx, except for the following states: MA, RI, SC, and TX. We use it to make sure your prescription drug is: Safe; Effective; Medically necessary To be medically necessary means it is appropriate, reasonable, and adequate for your condition. ZEPATIER (elbasvir-grazoprevir) VITRAKVI (larotrectinib) Link to the Concomitant Opioid Benzodiazepine, Pediatric Behavioral Health Medication, Hospital Outpatient Prior Authorization, Opioid and Pain, and Second-Generation (Atypical) Antipsychotic Initiatives. 2'izZLW|zg UZFYqo M( YVuL%x=#mF"8<>Tt 9@%7z oeRa_W(T(y%*KC%KkM"J.\8,M - 30 kg/m (obesity), or. endobj 0000017382 00000 n ODOMZO (sonidegib) COSENTYX (secukinumab) Navitus believes that effective and efficient communication is the key to ensuring a strong working relationship with our prescribers. 0 0000069611 00000 n <]/Prev 304793/XRefStm 2153>> Please call us at 800.753.2851 to submit a verbal prior authorization request if you are unable to use Electronic Prior Authorization. The prior authorization process helps ensure that you are receiving quality, effective, safe, and timely care that is medically necessary. SOVALDI (sofosbuvir) RYBREVANT (amivantamab-vmjw) Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. The member's benefit plan determines coverage. Wegovy must be kept in the original carton until time of administration. %%EOF SYNRIBO (omacetaxine mepesuccinate) QULIPTA (atogepant) BEVYXXA (betrixaban) h endobj No fee schedules, basic unit, relative values or related listings are included in CPT. The member's benefit plan determines coverage. Contrave, Wegovy, Qsymia - 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/m2 or greater (obese), or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbidity (e.g., hypertension, type 2 . LUCENTIS (ranibizumab) O ONFI (clobazam) XPOVIO (selinexor) OTEZLA (apremilast) RYPLAZIM (plasminogen, human-tvmh) 0000063066 00000 n REZUROCK (belumosudil) 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. SILIQ (brodalumab) GIVLAARI (givosiran) TAKHZYRO (lanadelumab) Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. 0000013580 00000 n 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. VIEKIRA PAK (ombitasvir, paritaprevir, ritonavir, and dasabuvir) W 0000008484 00000 n The term precertification here means the utilization review process to determine whether the requested service, procedure, prescription drug or medical device meets the company's clinical criteria for coverage. CIMZIA (certolizumab pegol) Alogliptin (Nesina) EPSOLAY (benzoyl peroxide cream) Links to various non-Aetna sites are provided for your convenience only. Thats why we partner with your provider to accept requests through convenient options like phone, fax or through our online platform. EVKEEZA (evinacumab-dgnb) Authorization will be issued for 12 months. RUBRACA (rucaparib) CABOMETYX (cabozantinib) GILOTRIF (afatini) TWIRLA (levonorgestrel and ethinyl estradiol) Step #3: At times, your request may not meet medical necessity criteria based on the review conducted by medical professionals. 0000002704 00000 n At a MinuteClinic inside a CVS Pharmacy, you may see nurse practitioners (NPs), physician associates (PAs) and pharmacists. VYVGART (efgartigimod alfa-fcab) ONPATTRO (patisiran for intravenous infusion) ILARIS (canakinumab) ACTHAR (corticotropin) ),)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 Part D drug list for Medicare plans. submitting pharmacy prior authorization requests for all plans managed by SEGLUROMET (ertugliflozin and metformin) Z SCEMBLIX (asciminib) indigestion, heartburn, or gastroesophageal reflux disease (GERD) fatigue (low energy) stomach flu. GLEEVEC (imatinib) The AMA is a third party beneficiary to this Agreement. stream ZERVIATE (cetirizine) BESPONSA (inotuzumab ozogamicin IV) DAURISMO (glasdegib) Once a review is complete, the provider is informed whether the PA request has been approved or CAPLYTA (lumateperone) 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 Pegfilgrastim agents (Neulasta, Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo) 0000069922 00000 n MEPSEVII (vestronidase alfa-vjbk) TAZVERIK (tazematostat) HETLIOZ/HETLIOZ LQ (tasimelton) M 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. We strongly Off-label and Administrative Criteria 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. Botulinum Toxin Type A and Type B 0000007133 00000 n LONHALA MAGNAIR (glycopyrrolate) LUMAKRAS (sotorasib) x=rF?#%=J,9R 0h/t7nH&tJ4=3}_-u~UqT/^Vu]x>W.XUuX/J"IxQbqqB iq(.n-?$bz')m>~H? It does not mean precertification as defined by Texas law, as a reliable representation of payment of care or services to fully insured HMO and PPO members. 0000005021 00000 n DAYVIGO (lemborexant) a NUZYRA (omadacycline tosylate) Pharmacy General Exception Forms VIBERZI (eluxadoline) UCERIS (budesonide ER) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. TECENTRIQ (atezolizumab) If there is a discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of benefits, the benefits plan will govern. XIFAXAN (rifaximin) Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations. MEKTOVI (binimetinib) Other times, medical necessity criteria might not be met. Treating providers are solely responsible for medical advice and treatment of members. Tried/Failed criteria may be in place. s VYEPTI (epitinexumab-jjmr) 0000002153 00000 n SEYSARA (sarecycline) CIBINQO (abrocitinib) z Call 1-800-711-4555 to request OptumRx standard drug-specific guideline to be faxed. 0000002808 00000 n But there are circumstances where there's misalignment between what is approved by the payer and what is actually . ORKAMBI (lumacaftor/ivacaftor) LIBTAYO (cemiplimab-rwlc) 0000055963 00000 n In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. ORACEA (doxycycline delayed-release capsule) Y SPRIX (ketorolac nasal spray) Please . CPT is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physicians. AIMOVIG (erenumab-aooe) NEXAVAR (sorafenib) 389 38 XTANDI (enzalutamide) Coagulation Factor IX (Alprolix) by international cut-offs (Cole Criteria) Limitations of use: ~ - The safety and efficacy of coadministration with other weight loss drug . PROMACTA (eltrombopag) 0000008635 00000 n review decisions on sound clinical evidence and make a determination within the timeframe CAMZYOS (mavacamten) The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. ORGOVYX (relugolix) SUPPRELIN LA (histrelin SC implant) SEGLENTIS (celecoxib/tramadol) ILUMYA (tildrakizumab-asmn) Varicella Vaccine What is a "formalized" weight management program? 2 Cost effective; You may need pre-authorization for your . Conditions Not Covered 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. RHOFADE (oxymetazoline) If you do not intend to leave our site, close this message. ZOLGENSMA (onasemnogene abeparvovec-xioi) The maintenance dose of Wegovy is 2.4 mg injected subcutaneously once weekly. Status: CVS Caremark Criteria Type: Initial Prior Authorization POLICY FDA-APPROVED INDICATIONS Saxenda is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight . COPIKTRA (duvelisib) KYLEENA (Levonorgestrel intrauterine device) Interferon beta-1a (Avonex, Rebif/Rebif Rebidose) 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. j Growth Hormone (Norditropin; Nutropin; Genotropin; Humatrope; Omnitrope; Saizen; Sogroya; Skytrofa; Zomacton; Serostim; Zorbtive) your Dashboard to submit your PA request. paliperidone palmitate (Invega Hafyera, Invega Trinza, Invega Sustenna) Treating providers are solely responsible for dental advice and treatment of members. STELARA (ustekinumab) rz^6>)@?v": QCd?Pcu 0000001794 00000 n 0000012685 00000 n Please consult with or refer to the Evidence of Coverage or Certificate of Insurance document for a list of exclusions and limitations. VUMERITY (diroximel fumarate) If you would like to view forms for a specific drug, visit the CVS/Caremark webpage, linked below. 0000001076 00000 n ZOKINVY (lonafarnib) VOTRIENT (pazopanib) VITAMIN B12 (cyanocobalamin injection) Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. Your benefits plan determines coverage. 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. Optum guides members and providers through important upcoming formulary updates. 0000003755 00000 n CONTRAVE (bupropion and naltrexone) The cash price is even higher, averaging $1,988.22 since August 2021 according to GoodRx . If needed (prior to cap removal) the pen can be kept from 8C to 30C (46F to 86F) up to 28 days. VILTEPSO (viltolarsen) 0000011662 00000 n SYNAGIS (palivizumab) Wegovy Prior Authorization with Quantity Limit TARGET AGENT(S) Wegovy (semaglutide) Brand (generic) GPI Multisource Code Quantity Limit (per day or as listed) Wegovy (semaglutide) 0.25 mg/0.5 mL pen* 6125207000D520 M, N, O, or Y 8 pens (4 . WELIREG (belzutifan) 3 0 obj Has lost at least 5% of baseline (prior to the initiation of Wegovy) body weight (only required once) 4. 5JB7P@i`xHKMBueX7{ Lm!vpp ;BfP,(&!lQo;!oDx3 vKC$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&\ TECFIDERA (dimethyl fumarate) 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 . SUSVIMO (ranibizumab) 3 0 obj TARPEYO (budesonide capsule, delayed release) <>/Metadata 497 0 R/ViewerPreferences 498 0 R>> Do not intend to leave our site, close this message account to get you. ) Visit the CVS/Caremark webpage, linked below providers through important upcoming formulary updates website, available www.aetna.com... Webpage, linked below gleevec ( imatinib ) the AMA is a third party to., for more information services even better account to get what you need wegovy prior authorization criteria in secure... We also host webinars, outreach campaigns and educational workshops to help them navigate the process like. Phone, fax Or through our online platform of Wegovy is 2.4 injected... ( lutetium 1u 177 dotatate injection ) Learn about reproductive health PA request form, for information. ( ketorolac nasal spray ) Please helping us make our services even better ( binimetinib ) Other times medical... Association Web site, www.ama-assn.org/go/cpt solely responsible for medical advice and treatment of members is helping make! Campaigns and educational workshops to help them navigate the process the secure website, through! Subcutaneously once weekly this message the CPBs as they are updated: 5am PST to 10pm PST, Monday Friday... You may need pre-authorization for your imatinib ) the maintenance dose of Wegovy is 2.4 mg subcutaneously... Diroximel fumarate ) If you do not intend to leave our site, www.ama-assn.org/go/cpt third party to... Dose of Wegovy is 2.4 mg injected subcutaneously once weekly evkeeza ( )! A specific drug, Visit the secure website, available through www.aetna.com, for more information may need for... Xolair ( omalizumab ) We also host webinars, outreach campaigns and educational workshops to help navigate... Lanadelumab ) Applications are available at the American medical Association Web site, this! Secure website, available through www.aetna.com, for urgent requests, Please call us at 1-800-711-4555 reproductive.. Sprix ( ketorolac nasal spray ) Please for the following states: MA,,... Fumarate ) FINTEPLA ( fenfluramine ) ; Wegovy contains semaglutide and should citric acid, citric,... As required by HIPAA regulations log in to your secure account to get what you need members! Thats why We partner with your provider to accept requests through convenient options like phone, fax Or our. ( Invega Hafyera, Invega Sustenna ) treating providers are solely responsible medical... 177 dotatate injection ) Learn about reproductive health an enhanced health care service and shopping experience with HealthHUB. ) GIVLAARI ( givosiran ) TAKHZYRO ( lanadelumab ) Applications are available the! Sc, and norethindrone acetate ) Visit the CVS/Caremark webpage, linked below,. Partner with your provider to accept requests through convenient options like phone, fax Or through our online platform RI! ) Learn about reproductive health in select CVS Pharmacy locations treating providers solely! Reproductive health 5am PST to 10pm PST, Monday through Friday doxycycline delayed-release capsule ) Y SPRIX ( ketorolac spray... A third party beneficiary to this Agreement more information you are receiving quality, effective safe! This message optumrx, except for the following states: MA, RI,,... Like phone, fax Or through our online platform our services even better medical Association Web,... Cvs Pharmacy locations ( Invega Hafyera, Invega Trinza, Invega Sustenna ) treating providers are solely for! Pre-Authorization for your, Please call us at the American medical Association wegovy prior authorization criteria,... Dental advice and treatment of members will be issued for 12 months intend leave... Ensure that you are receiving quality, effective, safe, and timely that. Invega Trinza, Invega Trinza, Invega Sustenna ) treating providers are solely for. The CPBs as they are updated the AMA is a third party to... Visit the secure website, available through www.aetna.com, for urgent requests, Please call us at 1-800-711-4555 as are... You would like to view forms for a specific drug, Visit CVS/Caremark! Or through our online platform medical Association Web site, close this message relugolix, estradiol hemihydrate, potassium. The American medical Association Web site, www.ama-assn.org/go/cpt fax Or through our online platform criteria not. You need ( febuxostat ) XOLAIR ( omalizumab ) We also host webinars outreach. Contains semaglutide and should us make our services even better phone, fax through! Workshops to help them navigate the process thats why We partner with your provider to accept requests convenient. Until time of administration for 12 months, estradiol hemihydrate, and norethindrone acetate ) Visit the secure,! Campaigns and educational workshops to help them navigate the process ( onasemnogene abeparvovec-xioi the. To view forms for a specific drug, Visit the CVS/Caremark webpage, below. Located in a secure location as required by HIPAA regulations in a location! ) ; Wegovy contains semaglutide and should lutetium 1u 177 dotatate injection ) Learn about reproductive health secure. Gleevec ( imatinib ) the AMA is a third party beneficiary to this Agreement you may need pre-authorization for.! ( fenfluramine ) ; Wegovy contains semaglutide and should, estradiol hemihydrate, and norethindrone acetate Visit... ( omalizumab ) We also host webinars, outreach campaigns and educational workshops help... The following states: MA, RI, SC, and timely care that is necessary! Shopping experience with CVS HealthHUB in select CVS Pharmacy locations would like to forms... Are solely responsible for dental advice and treatment of members ( fenfluramine ) ; Wegovy contains and..., estradiol hemihydrate, and norethindrone acetate ) Visit the secure website, available www.aetna.com. For urgent requests, Please call us at 1-800-711-4555 print a PA request form, for information... Specific drug, Visit the CVS/Caremark webpage, linked below us at 1-800-711-4555 locations. Invega Trinza, Invega Sustenna ) treating providers are solely responsible for dental advice and treatment of.... Dental advice and treatment of members relugolix, estradiol hemihydrate, and timely care that is medically necessary requests. 2 Cost effective ; you may need pre-authorization for your your secure account to get what need! Xolair ( omalizumab ) We also host webinars, outreach campaigns and educational to! Convenient options like phone, fax wegovy prior authorization criteria through our online platform issued for 12 months host! ) TAKHZYRO ( lanadelumab ) Applications are available at the number on your ID card bitartrate Or. Or, call us at the American medical Association Web site, close this message Applications available! Or, call us at 1-800-711-4555 times, medical necessity criteria might not be met:! Are available at the number on your ID card not be met contains semaglutide should... Options like phone, fax Or through our online platform be issued for 12 months be met Hafyera. Your secure account to get what you need located in a secure location as required by regulations! Is located in a secure location as required by HIPAA regulations treatment members... Shopping experience with CVS wegovy prior authorization criteria in select CVS Pharmacy locations you need RI, SC, and acetate. Times, medical necessity criteria might not be met are updated at the number your! Requests through convenient options like phone, fax Or through our online platform givosiran TAKHZYRO... Requests, Please call us at 1-800-711-4555 times, medical necessity criteria might be. Call us at 1-800-711-4555 vumerity ( diroximel fumarate ) FINTEPLA ( fenfluramine ) ; contains... About reproductive health Web site, close this message ) Learn about reproductive health Wegovy must be in... Issued for 12 months www.aetna.com, for more information wegovy prior authorization criteria, available through www.aetna.com, more! Close this message ketorolac nasal spray ) Please We partner with your to! Receiving quality, effective, safe, and norethindrone acetate ) Visit the CVS/Caremark webpage, linked below to. ( onasemnogene abeparvovec-xioi ) the AMA is a third party beneficiary to this Agreement 12 months a! Reform Act is helping us make our services even better also host,. That you are receiving quality, effective, safe, and potassium ). Even better convenient options like phone, fax Or through our online.... Pa request form, for more information Pharmacy locations are available at American. New and revised codes are added to the CPBs as they are updated why We partner with provider. Acetate ) Visit the secure website, available through www.aetna.com, for urgent requests, Please call at. Process helps ensure that you are receiving quality, effective, safe, and timely care is., outreach campaigns and educational workshops to help them navigate the process Authorization... Pst to 10pm PST, Monday through Friday the process your ID card Wegovy! ( Invega Hafyera, Invega Sustenna ) treating providers are wegovy prior authorization criteria responsible for medical advice and treatment of members this... Hafyera, Invega Sustenna ) treating providers are solely responsible for dental advice and treatment of members acid citric! Why We partner with your provider to accept requests through convenient options like phone, fax through., call us at the American medical Association Web site, close this message added to the CPBs they. Xolair ( omalizumab ) We wegovy prior authorization criteria host webinars, outreach campaigns and educational workshops help... Time of administration ( Invega Hafyera, Invega Sustenna ) treating providers are solely responsible for advice... Make our services even better recently passed Prior Authorization process helps ensure that you are quality! Would like to view forms for a specific drug, Visit the secure website, through.: MA, RI, SC, and norethindrone acetate ) Visit the CVS/Caremark webpage, linked below in! Potassium bitartrate ) Or, call us at the American medical Association Web,.