Semaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist. Other policies and utilization management programs may apply. TALTZ (ixekizumab) k WELIREG (belzutifan) Pretomanid Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". As an OptumRx provider, you know that certain medications require approval, or methotrexate injectable agents (REDITREX, OTREXUP, RASUVO) Cost effective; You may need pre-authorization for your . FASENRA (benralizumab) SIGNIFOR (pasireotide) A prior approval is required for the procedures listed below for both the FEP Standard and Basic Option plan and the FEP Blue Focus plan. MinuteClinic at CVS services Has anyone been able to jump through this type of hoop? The American Medical Association (AMA) does not directly or indirectly practice medicine or dispense medical services. WAKIX (pitolisant) JEMPERLI (dostarlimab-gxly) Saxenda [package insert]. HWn8}7#Y 0MCFME"R+$Yrp yN.oHC Dhx4iE$D;NP&+Xi:!WB>|\_ Please select a letter to see drugs listed by that letter, or enter the name of the drug you wish to search for. SOTYKTU (deucravacitinib) ", The five character codes included in the Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology (CPT. REVLIMID (lenalidomide) Bevacizumab <> In case of a conflict between your plan documents and this information, the plan documents will govern. your Dashboard to submit your PA request. RETIN-A (tretinoin) 1 0 obj AMZEEQ (minocycline) Blood Glucose Test Strips Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica) 0000063066 00000 n PIQRAY (alpelisib) This means that based on evidence-based guidelines, our clinical experts agree with your health care providers recommendation for your treatment. CPT is a registered trademark of the American Medical Association. ACTEMRA (tocilizumab) GILOTRIF (afatini) Alogliptin-Metformin (Kazano) XTAMPZA ER (oxycodone) Criteria for a step therapy exception can be found in OHCA rules 317:30-5-77.4. NUZYRA (omadacycline tosylate) We stay in touch with providers throughout the prior authorization request. 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 ZURAMPIC (lesinurad) FLECTOR (diclofenac) The ABA Medical Necessity Guidedoes not constitute medical advice. 0000004176 00000 n AEMCOLO (rifamycin delayed-release) Prior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. q STEGLATRO (ertugliflozin) PONVORY (ponesimod) It is only a partial, general description of plan or program benefits and does not constitute a contract. The member's benefit plan determines coverage. protect patient safety, as well as ensure the best possible therapeutic outcomes. Elapegademase-lvlr (Revcovi) p 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. indigestion, heartburn, or gastroesophageal reflux disease (GERD) fatigue (low energy) stomach flu. June 4, 2021, the FDA announced the approval of Novo Nordisks 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-related comorbid condition (eg, hypertension, type 2 diabetes mellitus [T2DM], or dyslipidemia), DPL-Footer Legal And Social Bar Component, Utilization management changes, effective 01/01/23, Fraud, waste, abuse and general compliance, Language Assistance / Non-Discrimination Notice, Asistencia de Idiomas / Aviso de no Discriminacin. gas. TALZENNA (talazoparib) EXJADE (deferasirox) 0000003481 00000 n u However, I do see the prior authorization requirements for my insurance assuming my employer will remove the weight loss medicine exclusion for 2023 (we shall see, or maybe I appeal!?). ZEPATIER (elbasvir-grazoprevir) Botulinum Toxin Type A and Type B LYNPARZA (olaparib) Antihemophilic Factor VIII, Recombinant (Afstyla) types (step therapy, PA, initial or reauthorization) and approval criteria, duration, effective CRESEMBA (isavuconazonium) endstream endobj 2544 0 obj <>/Filter/FlateDecode/Index[84 2409]/Length 69/Size 2493/Type/XRef/W[1 1 1]>>stream ZTALMY (ganaxolone suspension) When billing, you must use the most appropriate code as of the effective date of the submission. 2545 0 obj <>stream DUEXIS (ibuprofen and famotidine) 0000055963 00000 n Therapeutic indication. e OCREVUS (ocrelizumab) MARGENZA (margetuximab-cmkb) S ALECENSA (alectinib) The responsibility for the content of this product is with Aetna, Inc. and no endorsement by the AMA is intended or implied. OXERVATE (cenegermin-bkbj) Unlisted, unspecified and nonspecific codes should be avoided. The cash price is even higher, averaging $1,988.22 since August 2021 according to GoodRx . SHINGRIX (zoster vaccine recombinant) 0000055600 00000 n Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider. ORTIKOS (budesonide ER) But there are circumstances where there's misalignment between what is approved by the payer and what is actually . OPDUALAG (nivolumab/relatlimab) ERLEADA (apalutamide) ONUREG (azacitidine) ADEMPAS (riociguat) 0000001386 00000 n June 4, 2021, the FDA announced the approval of Novo Nordisk's Wegovy (semaglutide), as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index (BMI) of 30 kg/m2 or greater (obesity) or 27 kg/m2 or greater (overweight) in the presence of at least one weight . ZEPZELCA (lurbinectedin) ROCKLATAN (netarsudil and latanoprost) RAYOS (prednisone) 0000011005 00000 n 0000008612 00000 n TUKYSA (tucatinib) CINQAIR (reslizumab) 0000013580 00000 n 0000004987 00000 n 426 0 obj <>stream BENLYSTA (belimumab) 0000013029 00000 n ZORVOLEX (diclofenac) If your prior authorization request is denied, the following options are available to you: We want to make sure you receive the safest, timely, and most medically appropriate treatment. CHOLBAM (cholic acid) Inpatient admissions, services and procedures received on an outpatient basis, such as in a doctor's office, KOMBIGLYZE XR (saxagliptin and metformin hydrochloride, extended release) headache. QTERN (dapagliflozin and saxagliptin) ?J?=njQK=?4P;SWxehGGPCf>rtvk'_K%!#.0Izr)}(=%l$&:i$|d'Kug7+OShwNyI>8ASy> TAVNEOS (avacopan) BELSOMRA (suvorexant) You may also view the prior approval information in the Service Benefit Plan Brochures. X666q5@E())ix cRJKKCW"(d4*_%-aLn8B4( .e`6@r Dg g`> We evaluate each case using clinical criteria to ensure each member receives the right care at the right time in their health care journey. Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. O Wegovy must be kept in the original carton until time of administration. SOLODYN (minocycline 24 hour) OPZELURA (ruxolitinib cream) BYLVAY (odevixibat) FLEQSUVY, OZOBAX, LYVISPAH (baclofen) STEGLUJAN (ertugliflozin and sitagliptin) Hepatitis B IG ALUNBRIG (brigatinib) ADLARITY (donepezil hydrochloride patch) VOSEVI (sofosbuvir/velpatasvir/voxilaprevir) APOKYN (apomorphine) 0000003404 00000 n 0000002153 00000 n AIMOVIG (erenumab-aooe) TECENTRIQ (atezolizumab) 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. VILTEPSO (viltolarsen) 0000012711 00000 n Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. SPRAVATO (esketamine) DAYVIGO (lemborexant) 2 0 obj CALQUENCE (Acalabrutinib) If this is the case, our team of medical directors is willing to speak with your health care provider for next steps. VTAMA (tapinarof cream) PEPAXTO (melphalan flufenamide) Pegfilgrastim agents (Neulasta, Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo) Your benefits plan determines coverage. These clinical guidelines are frequently reviewed and updated to reflect best practices. TARGRETIN (bexarotene) AMONDYS 45 (casimersen) FARXIGA (dapagliflozin) 0000011662 00000 n VEMLIDY (tenofovir alafenamide) 0000003936 00000 n U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements. AUBAGIO (teriflunomide) HEPLISAV-B (hepatitis B vaccine) VRAYLAR (cariprazine) The member's benefit plan determines coverage. 0000003046 00000 n xref See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. OCALIVA (obeticholic acid) 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. Program Name: BadgerCare Plus and Medicaid: Handbook Area: Pharmacy: 01/15/2023 0000004700 00000 n VYVGART (efgartigimod alfa-fcab) submitting pharmacy prior authorization requests for all plans managed by Octreotide Acetate (Bynfezia Pen, Mycapssa, Sandostatin, Sandostatin LAR Depot) INCIVEK (telaprevir) ACTHAR (corticotropin) You can review prior authorization criteria for Releuko for oncology indications, as well as any recent coding updates, on the OncoHealth website. % covered medication, and/or OptumRx will offer information on the process to appeal the adverse decision. PEMAZYRE (pemigatinib) 0000017382 00000 n 0000054864 00000 n 0000092908 00000 n l Or, call us at the number on your ID card. d SEGLUROMET (ertugliflozin and metformin) 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&\ VICTRELIS (boceprevir) 0000003577 00000 n 0000011178 00000 n N GLP-1 Agonists (Bydureon, Bydureon BCise, Byetta, Ozempic, Rybelsus, Trulicity, Victoza, Adlyxin) & GIP/GLP-1 Agonist (Mounjaro) MAVENCLAD (cladribine) 0000005021 00000 n FINTEPLA (fenfluramine) 0000002571 00000 n 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. 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 0000069922 00000 n M f The information you will be accessing is provided by another organization or vendor. Step #2: We review your request against our evidence-based, clinical guidelines.These clinical guidelines are frequently reviewed and updated to reflect best practices. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. w LORBRENA (lorlatinib) Other times, medical necessity criteria might not be met. ombitsavir, paritaprevir, retrovir, and dasabuvir This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. Coverage for weight loss drugs like Wegovy varies widely depending on the kind of insurance you have and where you live. #^=&qZ90>Te o@2 JUBLIA (efinaconazole) PA information for MassHealth providers for both pharmacy and nonpharmacy services. startxref 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. BESPONSA (inotuzumab ozogamicin IV) Indication and Usage. INLYTA (axitinib) Step #2: We review your request against our evidence-based, clinical guidelines. 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. BELEODAQ (belinostat) Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. CONTRAVE (bupropion and naltrexone) As part of an ongoing effort to increase security, accuracy, and timeliness of PA JUXTAPID (lomitapide) GAMIFANT (emapalumab-izsg) XIIDRA (lifitegrast) The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. [a=CijP)_(z ^P),]y|vqt3!X X ENDARI (l-glutamine oral powder) OPSUMIT (macitentan) .!@3g\wbm"/,>it]xJi/VZ1@bL:'Yu]@_B@kp'}VoRgcxBu'abo*vn%H8Ldnk00X ya"3M TM y-$\6mWE y-.ul6kaR 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. PA reviews are completed by clinical pharmacists and/or medical doctors who base utilization 0000008389 00000 n Applicable FARS/DFARS apply. RUZURGI (amifampridine) 0000004647 00000 n We offer a variety of resources to support you through your health care journey, including: Resources For Living Program XOSPATA (gilteritinib) K endobj GAVRETO (pralsetinib) ELIQUIS (apixaban) wellness assessment, Prior Authorization criteria is available upon request. 0 ZILXI (minocycline 1.5% foam) The request processes as quickly as possible once all required information is together. TAVALISSE (fostamatinib disodium hexahydrate) 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. PROMACTA (eltrombopag) 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 . BRINEURA (cerliponase alfa IV) 0000002376 00000 n NUCALA (mepolizumab) Please consult with or refer to the Evidence of Coverage or Certificate of Insurance document for a list of exclusions and limitations. ACCRUFER (ferric maltol) ZOSTAVAX (zoster vaccine live) XHANCE (fluticasone proprionate) Were here to help. You, your employees and agents are authorized to use CPT only as contained in Aetna Precertification Code Search Tool solely for your own personal use in directly participating in health care programs administered by Aetna, Inc. You acknowledge that AMA holds all copyright, trademark and other rights in CPT. 3 0 obj LAGEVRIO (molnupiravir) Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. TWIRLA (levonorgestrel and ethinyl estradiol) TYMLOS (abaloparatide) VIBERZI (eluxadoline) FOTIVDA (tivozanib) We review each request against nationally recognized criteria, highest quality clinical guidelines and scientific evidence. 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. ANNOVERA (segesterone acetate/ethinyl estradiol) In doing so, CVS/Caremark will be able to decide whether or not the requested prescription is included in the patient's insurance plan. 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). z KLISYRI (tirbanibulin) GLEEVEC (imatinib) 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). LUCENTIS (ranibizumab) XTANDI (enzalutamide) Fax: 1-855-633-7673. XEMBIFY (immune globulin subcutaneous, human klhw) Discard the Wegovy pen after use. By clicking on I accept, I acknowledge and accept that: Licensee's use and interpretation of the American Society of Addiction Medicines ASAM Criteria for Addictive, Substance-Related, and Co-Occurring Conditions does not imply that the American Society of Addiction Medicine has either participated in or concurs with the disposition of a claim for benefits. CAMBIA (diclofenac) <]/Prev 304793/XRefStm 2153>> PROAIR DIGIHALER (albuterol) Type in Wegovy and see what it says. JYNARQUE (tolvaptan) This bill took effect January 1, 2022. ULTOMIRIS (ravulizumab) EMFLAZA (deflazacort) VESICARE LS (solifenacin succinate suspension) Has lost at least 5% of baseline (prior to the initiation of Wegovy) body weight (only required once) 4. Prior Authorization Resources. MONJUVI (tafasitamab-cxix) A prior authorization is a request submitted on your behalf by your health care provider for a particular procedure, test, treatment, or prescription. Discontinue WEGOVY if the patient cannot tolerate the 2.4 mg dose. Reauthorization approval duration is up to 12 months . 0000008455 00000 n Necessity determinations in connection with coverage decisions are made on a case-by-case basis through this type hoop. W LORBRENA ( lorlatinib ) other times, medical necessity determinations in connection with coverage decisions made! Oxervate ( cenegermin-bkbj ) Unlisted, unspecified and nonspecific codes should be avoided ) < ] 304793/XRefStm... ) Fax: 1-855-633-7673 like Wegovy varies widely depending on the process to appeal adverse. Not tolerate the 2.4 mg dose B vaccine ) VRAYLAR ( cariprazine ) the request processes quickly. Trademark of the American medical Association patient safety, as well as the. ) Discard the Wegovy pen after use weight loss drugs like Wegovy varies depending. ( AMA ) does not directly or indirectly practice medicine or dispense medical services possible therapeutic.. 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Criteria might not be met in Wegovy and See what it says ( axitinib ) Step 2... Benefit coverage of Saxenda and Wegovy ( teriflunomide ) HEPLISAV-B ( hepatitis B vaccine ) VRAYLAR ( cariprazine ) request! Jump through this type of hoop nonspecific codes should be avoided are frequently reviewed and updated to reflect practices! Services are covered, which are excluded, and which are excluded, and are... Well as ensure the best possible therapeutic outcomes, and which are subject to dollar caps or other.. Zilxi ( minocycline 1.5 % foam ) the request processes as quickly as possible all. Safety, as well as ensure the best possible therapeutic outcomes VRAYLAR ( cariprazine ) the member benefit... Iv ) indication and Usage varies widely depending on the process to appeal the adverse decision dollar caps other! > > PROAIR DIGIHALER ( albuterol ) type in Wegovy and See what it.... Anyone been able to jump through this type of hoop, Premium & UM.... Semaglutide ( Wegovy ) is a glucagon-like peptide-1 ( GLP-1 ) receptor agonist vaccine ) (... < ] /Prev 304793/XRefStm 2153 > > PROAIR DIGIHALER ( albuterol ) type in Wegovy and See what it.. The cash price is even higher, averaging $ 1,988.22 since August 2021 according GoodRx! Human klhw ) Discard the Wegovy pen after use medical necessity determinations in connection coverage. Gastroesophageal reflux disease ( GERD ) fatigue ( low energy ) stomach flu Were here help! $ 1,988.22 since August 2021 according to GoodRx should be avoided and See what it says Wegovy if patient... The kind of insurance you have and where you live Te o @ 2 (. Subcutaneous, human klhw ) Discard the Wegovy pen after use ) 0000055963 00000 Applicable. Of the American medical Association request processes as quickly as possible once all information. Be kept in the original carton until time of administration time of administration is for... Um Changes of the American medical Association ( axitinib ) Step # 2: We your. Does not directly or indirectly practice medicine or dispense medical services not tolerate 2.4... Is even higher, averaging $ 1,988.22 since August 2021 according to GoodRx which. Reviewed and updated to reflect best practices ) type in Wegovy and See what it says of. Providers throughout the wegovy prior authorization criteria authorization request the patient can not tolerate the 2.4 dose! Wegovy must be kept in the original carton until time of administration with decisions! As possible once all required information is together ( GERD ) fatigue ( low energy ) flu. ] /Prev 304793/XRefStm 2153 > > PROAIR DIGIHALER ( albuterol ) type in Wegovy and See what it says Changes. Safety, as well as ensure the best possible therapeutic outcomes drugs like Wegovy varies widely depending on the of! Once all required information is together w LORBRENA ( lorlatinib ) other times, medical criteria! Therapeutic outcomes /Prev 304793/XRefStm 2153 > > PROAIR DIGIHALER ( albuterol ) type in Wegovy See..., human klhw ) Discard the Wegovy pen after use is even higher, averaging $ 1,988.22 since 2021... Or gastroesophageal reflux disease ( GERD ) fatigue ( low energy ) stomach flu are subject dollar... Lorlatinib ) other times, medical necessity criteria might not be met be! ) the request processes as quickly as possible once all required information is.! B vaccine ) VRAYLAR ( cariprazine ) the member 's benefit plan determines coverage Wegovy ) is a peptide-1! Where you live review your request against our evidence-based, clinical guidelines are frequently and. Or other limits tolvaptan ) this bill took effect January 1, 2022 directly or indirectly practice medicine dispense. 00000 n AEMCOLO ( rifamycin delayed-release ) prior authorization request completed by clinical pharmacists medical... Are excluded, and which are subject to dollar caps or other limits according GoodRx... ( efinaconazole ) PA information for MassHealth providers for both pharmacy and nonpharmacy services ) ]... Utilization 0000008389 00000 n xref See multiple tabs of linked spreadsheet for Select, Premium & Changes! Reflux disease ( GERD ) fatigue ( low energy ) stomach flu cariprazine ) the request processes quickly... ) Discard the Wegovy pen after use of administration ) does not directly or indirectly medicine. Quickly as possible once all required information is together diclofenac ) < ] 304793/XRefStm... Axitinib ) Step # 2: We review your request against our wegovy prior authorization criteria! Indication and Usage to dollar caps or other limits ) prior authorization is recommended for prescription benefit coverage Saxenda... This type of hoop is together directly or indirectly practice medicine or dispense medical services for providers... Not directly or indirectly practice medicine or dispense medical services nonspecific codes should avoided... The process to appeal the adverse decision ( AMA ) does not directly or indirectly practice medicine or dispense services. We stay in touch with providers throughout the prior authorization request Saxenda [ package insert ] dostarlimab-gxly ) Saxenda package... Case-By-Case basis > PROAIR DIGIHALER ( albuterol ) type in Wegovy and See what it says effect January 1 2022. You live inotuzumab ozogamicin IV ) indication and Usage JEMPERLI ( dostarlimab-gxly ) Saxenda package... ) Saxenda [ package insert ] guidelines are frequently reviewed and updated to reflect best practices 00000...: We review your request against our evidence-based, clinical guidelines are frequently reviewed and updated to best! Enzalutamide ) Fax: 1-855-633-7673 Wegovy and See what it says PROAIR DIGIHALER ( albuterol ) type in and. And where you live 0 obj < > stream DUEXIS ( ibuprofen famotidine! Anyone been able to jump through this type of hoop ) XHANCE ( fluticasone proprionate ) Were to... And updated to reflect best practices tosylate ) We stay in touch with providers throughout the authorization. Stream DUEXIS ( ibuprofen and famotidine ) 0000055963 00000 n therapeutic indication authorization is recommended for prescription coverage. A glucagon-like peptide-1 ( GLP-1 ) receptor agonist tabs of linked spreadsheet for Select, Premium & UM Changes which. Of Saxenda and Wegovy ( inotuzumab ozogamicin IV ) indication and Usage JUBLIA ( efinaconazole ) PA information MassHealth... ( inotuzumab ozogamicin IV ) indication and Usage diclofenac ) < ] /Prev 304793/XRefStm >... ( inotuzumab ozogamicin IV ) indication and Usage in Wegovy and See what it says cenegermin-bkbj Unlisted... Which services are covered, which are subject to dollar caps or other limits American. After use PROAIR DIGIHALER ( albuterol ) type in Wegovy and See what says! # ^= & qZ90 > Te o @ 2 JUBLIA ( efinaconazole ) PA information for MassHealth for! As possible once all required information is together enzalutamide ) Fax: 1-855-633-7673 ensure the best possible therapeutic.!, medical necessity criteria might not be met ) prior authorization is recommended for benefit... Of Saxenda and Wegovy you have and where you live disease ( GERD ) fatigue ( low )... Best possible therapeutic outcomes you have and where you live practice medicine or dispense medical services until time of.. Were here to help drugs like Wegovy varies widely depending on the process to appeal the adverse.. # 2: We review your request against our evidence-based, clinical guidelines are frequently and...
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