L 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). KYLEENA (Levonorgestrel intrauterine device) Optum guides members and providers through important upcoming formulary updates. TWIRLA (levonorgestrel and ethinyl estradiol) 0000002567 00000 n Of note, this policy targets Saxenda and Wegovy; other glucagon-like peptide-1 agonists which do not carry an FDA-approved indication for weight loss are not targeted in this policy. BARHEMSYS (amisulpride) Any federal regulatory requirements and the member specific benefit plan coverage may also impact coverage criteria. 0000011662 00000 n VRAYLAR (cariprazine) BONIVA (ibandronate) CVS HealthHUB offers all the same services as MinuteClinic at CVS with some additional benefits. 0000004647 00000 n Riluzole (Exservan, Rilutek, Tiglutik, generic riluzole) Infliximab Agents (REMICADE, infliximab, AVSOLA, INFLECTRA, RENFLEXIS) 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. VOXZOGO (vosoritide) VITAMIN B12 (cyanocobalamin injection) RHOPRESSA (netarsudil solution) IMCIVREE (setmelanotide) The request processes as quickly as possible once all required information is together. NUEDEXTA (dextromethorphan and quinidine) Please note also that the ABA Medical Necessity Guidemay be updated and are, therefore, subject to change. MAVYRET (glecaprevir/pibrentasvir) DAURISMO (glasdegib) Amantadine Extended-Release (Gocovri) 0000092908 00000 n 0000069611 00000 n ERLEADA (apalutamide) Step #3: At times, your request may not meet medical necessity criteria based on the review conducted by medical professionals. Elapegademase-lvlr (Revcovi) CAPLYTA (lumateperone) ULTOMIRIS (ravulizumab) PRIOR AUTHORIZATION CRITERIA DRUG CLASS WEIGHT LOSS MANAGEMENT BRAND NAME* (generic) WEGOVY . indigestion, heartburn, or gastroesophageal reflux disease (GERD) fatigue (low energy) stomach flu. allowed by state or federal law. ZYKADIA (ceritinib) 0000006215 00000 n CYSTARAN (cysteamine ophthalmic) YUPELRI (revefenacin) 1 0 obj Some plans exclude coverage for services or supplies that Aetna considers medically necessary. KOMBIGLYZE XR (saxagliptin and metformin hydrochloride, extended release) 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. XPOVIO (selinexor) CARVYKTI (ciltacabtagene autoleucel) LUTATHERA (lutetium 1u 177 dotatate injection) Pharmacy Prior Authorization Guidelines Coverage of drugs is first determined by the member's pharmacy or medical benefit. PCSK9-Inhibitors (Repatha, Praluent) Please consult with or refer to the Evidence of Coverage or Certificate of Insurance document for a list of exclusions and limitations. ZILXI (minocycline 1.5% foam) hA 04Fv\GczC. Protect Wegovy from light. ARALEN (chloroquine phosphate) And we will reduce wait times for things like tests or surgeries. CINRYZE (C1 esterase inhibitor [human]) . 2 BESPONSA (inotuzumab ozogamicin IV) Aetna considers up to a combined limit of 26 individual or group visits by any recognized provider per 12-month period as medically necessary for weight reduction counseling in adults who are obese (as defined by BMI greater than or equal to 30 kg/m 2 ** ). Angiotensin Receptor Blockers (e.g., Atacand, Atacand HCT, Tribenzor, Edarbi, Edarbyclor, Teveten) MYRBETRIQ (mirabegron granules) prescription drug benefits may be covered under his/her plan-specific formulary for which We also host webinars, outreach campaigns and educational workshops to help them navigate the process. JEMPERLI (dostarlimab-gxly) KOSELUGO (selumetinib) d The American Medical Association (AMA) does not directly or indirectly practice medicine or dispense medical services. Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations. Specialty pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used to treat complex conditions. GLUMETZA ER (metformin) CYRAMZA (ramucirumab) b SOVALDI (sofosbuvir) MOZOBIL (plerixafor) % We strongly TAKHZYRO (lanadelumab) All approvals are provided for the duration noted below. NUCALA (mepolizumab) ADCETRIS (brentuximab) q Step #2: We review your request against our evidence-based, clinical guidelines. Wegovy is indicated as an adjunct to a reduced-calorie diet and increased physical activity for weight management, including weight loss and weight maintenance, in adults with an initial Body Mass Index (BMI) of. DELATESTRYL (testosterone cypionate 100mg/ml; 200mg/ml) In doing so, CVS/Caremark will be able to decide whether or not the requested prescription is included in the patient's insurance plan. How to access the OptumRx PA guidelines: Reference the OptumRx electronic prior authorization ( ePA ) and (fax ) forms. VYEPTI (epitinexumab-jjmr) U RECARBRIO (imipenem, cilastin and relebactam) covered medication, and/or OptumRx will offer information on the process to appeal the adverse decision. Antihemophilic Factor VIII, recombinant (Kovaltry) WAKIX (pitolisant) PIQRAY (alpelisib) PYRUKYND (mitapivat) Inpatient admissions, services and procedures received on an outpatient basis, such as in a doctor's office, Call 1-800-711-4555 to request OptumRx standard drug-specific guideline to be faxed. Gardasil 9 NUBEQA (darolutamide) PA reviews are completed by clinical pharmacists and/or medical doctors who base utilization Insulin Rapid Acting (Admelog, Apidra, Fiasp, Insulin Lispro [Humalog ABA], Novolog, Insulin Aspart [Novolog ABA], Novolog ReliOn) RITUXAN (rituximab) SEGLUROMET (ertugliflozin and metformin) ZEJULA (niraparib) There should also be a book you can download that will show you the pre-authorization criteria, if that is required. B EPSOLAY (benzoyl peroxide cream) SUNOSI (solriamfetol) Please be sure to add a 1 before your mobile number, ex: 19876543210, Guidelines from nationally recognized health care organizations such as the Centers for Medicare and Medicaid Services (CMS), Peer-reviewed, published medical journals, A review of available studies on a particular topic, Expert opinions of health care professionals. (Hours: 5am PST to 10pm PST, Monday through Friday. ACZONE (dapsone) CPT only Copyright 2022 American Medical Association. endstream endobj 425 0 obj <>/Filter/FlateDecode/Index[21 368]/Length 35/Size 389/Type/XRef/W[1 1 1]>>stream While I await the supply issue to be resolved for Wegovy, I am trying to see if I can get it covered by my insurance so I am ready (my doctor has already prescribed it). Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. s JUXTAPID (lomitapide) Click on "Claims," "CPT/HCPCS Coding Tool," "Clinical Policy Code Search. ADLARITY (donepezil hydrochloride patch) 0000005021 00000 n ADUHELM (aducanumab-avwa) RECLAST (zoledronic acid-mannitol-water) BREXAFEMME (ibrexafungerp) ILUVIEN (fluocinolone acetonide) AKYNZEO (fosnetupitant/palonosetron) Drug Prior Authorization Request Forms Vabysmo (faricimab-svoa) Open a PDF Viscosupplementation with Hyaluronic Acid - For Osteoarthritis of the Knee (Durolane, Gel-One, Gelsyn-3, Genvisc 850, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz FX, Synojoynt, Triluron, TriVisc, Visco-3) Open a PDF However, applicable state mandates will take precedence with respect to fully insured plans and self-funded non-ERISA (e.g., government, school boards, church) plans. ERIVEDGE (vismodegib) 0000003755 00000 n Weight Loss - phentermine (all brand products including Adipex-P and Lomaira), benzphetamine, Contrave (naltrexone HCl and bupropion HCl, diethylpropion, Imcivree (setmelanotide), phendimetrazine, orlistat (Xenical), Qsymia (phentermine and topiramate extended-release), Saxenda (liraglutide), and Wegovy (semaglutide) - Prior Authorization . 0000013580 00000 n Links to various non-Aetna sites are provided for your convenience only. HWn8}7#Y 0MCFME"R+$Yrp yN.oHC Dhx4iE$D;NP&+Xi:!WB>|\_ LONSURF (trifluridine and tipiracil) uG4A4O9WbAtfwZj6_[X3 @[gL(vJ2U'=-"g~=G2^VZOgae8JG 2|@sGb 7ow@u"@|)7YRx$nhV;p^\ sAk ;ZM>u~^u)pOq%cB=J zY^4fz{ ; t$ x$nI9N$v\ArN{Jg~,+&*14 jz\-9\j9 LS${ 5qmfU'@Nj,hI)~^ }/ 6ryCUNu 'u ;7`@X. If this is the case, our team of medical directors is willing to speak with your health care provider for next steps. Tried/Failed criteria may be in place. Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. DOJOLVI (triheptanoin liquid) 6\ !D"'"PN~# yV)GH"4LGAK`h9c&3yzGX/EN5~jx6g"nk!{`=(`\MNUokEfOnJ "1 0000017217 00000 n JUBLIA (efinaconazole) XOSPATA (gilteritinib) Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna). TAVNEOS (avacopan) V hb```b``{k @16=v1?Q_# tY If a patient does not tolerate the maintenance 2.4 mg once weekly dose, the dose can be temporarily decreased to 1.7 . TRUSELTIQ (infigratinib) SUPPRELIN LA (histrelin SC implant) ZEPZELCA (lurbinectedin) protect patient safety, as well as ensure the best possible therapeutic outcomes. If the submitted form contains complete information, it will be compared to the criteria for . LEUKINE (sargramostim) The recently passed Prior Authorization Reform Act is helping us make our services even better. <> Some plans exclude coverage for services or supplies that Aetna considers medically necessary. Long-Acting Muscarinic Antagonists (LAMA) (Tudorza, Seebri, Incruse Ellipta) RETIN-A (tretinoin) X666q5@E())ix cRJKKCW"(d4*_%-aLn8B4( .e`6@r Dg g`> constipation *. coverage determinations for most PA types and reasons. 0000002756 00000 n TASIGNA (nilotinib) the OptumRx UM Program. XIIDRA (lifitegrast) OPDUALAG (nivolumab/relatlimab) Wegovy, a new prescription medication for chronic weight management, launched with a price tag of around $1,627 a month before insurance. o Disclaimer of Warranties and Liabilities. x=rF?#%=J,9R 0h/t7nH&tJ4=3}_-u~UqT/^Vu]x>W.XUuX/J"IxQbqqB iq(.n-?$bz')m>~H? prescription drug benefit coverage under his/her health insurance plan or call OptumRx. 0000055627 00000 n MEKINIST (trametinib) 0000012711 00000 n Type in Wegovy and see what it says. Coagulation Factor IX, (recombinant), Albumin Fusion Protein (Idelvion) PEMAZYRE (pemigatinib) a State mandates may apply. DIACOMIT (stiripentol) 0000008227 00000 n POLIVY (polatuzumab vedotin-piiq) We will be more clear with processes. Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba) manner, please submit all information needed to make a decision. 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. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. PAs help manage costs, control misuse, and 0000003227 00000 n Octreotide Acetate (Bynfezia Pen, Mycapssa, Sandostatin, Sandostatin LAR Depot) Coagulation Factor IX, recombinant, glycopegylated (Rebinyn) 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. TEMODAR (temozolomide) The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in Aetna Precertification Code Search Tool. E [a=CijP)_(z ^P),]y|vqt3!X X XEMBIFY (immune globulin subcutaneous, human klhw) WHA members have access to a wealth of resources including a Attached is a listing of prescription drugs that are subject to prior authorization. Prior Authorization Resources. REBLOZYL (luspatercept) Criteria for a step therapy exception can be found in OHCA rules 317:30-5-77.4. - 30 kg/m (obesity), or. New and revised codes are added to the CPBs as they are updated. ZYDELIG (idelalisib) The responsibility for the content of this product is with Aetna, Inc. and no endorsement by the AMA is intended or implied. AMZEEQ (minocycline) This list is subject to change. COPAXONE (glatiramer/glatopa) Varicella Vaccine BLENREP (Belantamab mafodotin-blmf) Asenapine (Secuado, Saphris) ZOSTAVAX (zoster vaccine live) Has lost at least 5% of baseline (prior to the initiation of Wegovy) body weight (only required once) 4. Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". 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. 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. ELIQUIS (apixaban) endstream endobj 2544 0 obj <>/Filter/FlateDecode/Index[84 2409]/Length 69/Size 2493/Type/XRef/W[1 1 1]>>stream INVELTYS (loteprednol etabonate) 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. TECARTUS (brexucabtagene autoleucel) 0000011365 00000 n Subcutaneous Immunoglobulin (SCIG) (Hizentra, HyQvia) 0000069682 00000 n VYLEESI (bremelanotide) ILARIS (canakinumab) 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 . GILOTRIF (afatini) INFINZI (durvalumab IV) BRUKINSA (zanubrutinib) If you wish to request a Medicare Part Determination (Prior Authorization or Exception request), please see your plan's website for the appropriate form and instructions on how to submit your request. making criteria** that are developed from clinical evidence from the following sources: *Guidelines are specific to plans utilizing our standard drug lists only. MassHealth Pharmacy Initiatives and Clinical Information. nausea *. 0000005011 00000 n 0000011178 00000 n VARUBI (rolapitant) Applicable FARS/DFARS apply. ACCRUFER (ferric maltol) QTERN (dapagliflozin and saxagliptin) VFEND (voriconazole) Alogliptin and Pioglitazone (Oseni) ALECENSA (alectinib) 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). Of note, Saxenda (liraglutide subcutaneous injection) and Wegovy (semaglutide subcutaneous injection) are indicated for chronic weight . The AMA is a third party beneficiary to this Agreement. stream upQz:G Cs }%u\%"4}OWDw When conditions are met, we will authorize the coverage of Wegovy. IGALMI (dexmedetomidine film) COTELLIC (cobimetinib) 0000000016 00000 n Providers may request a step therapy exception to skip the step therapy process and receive the Tier 2 or higher drug immediately. patients were required to have a prior unsuccessful dietary weight loss attempt. XIFAXAN (rifaximin) VICTRELIS (boceprevir) An exception can be requested following a denial of a prior authorization or can be submitted at the onset of the request. This information is neither an offer of coverage nor medical advice. ", The five character codes included in the Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology (CPT. Amantadine Extended-Release (Osmolex ER) LIBTAYO (cemiplimab-rwlc) XEPI (ozenoxacin) If providers are unable to submit electronically, we offer the following options: Call 1-800-711-4555 to submit a verbal PA request FLEQSUVY, OZOBAX, LYVISPAH (baclofen) WINLEVI (clascoterone) No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. RANEXA, ASPRUZYO (ranolazine) MYALEPT (metreleptin) Wegovy should be stored in refrigerator from 2C to 8C (36F to 46F). SENSIPAR (cinacalcet) all VIDAZA (azacitidine) y Reprinted with permission. You are now being directed to CVS Caremark site. stream ISTURISA (osilodrostat) Do not freeze. hb```b``mf`c`[ @Q{9 P@`mOU.Iad2J1&@ZX\2 6ttt `D> `g`QJ@ gg`apc7t3N``X tgD?>H7X570}``^ 0C7|^ '2000 G> It enables a faster turnaround time of 0000001076 00000 n 0000001386 00000 n Discontinue WEGOVY if the patient cannot tolerate the 2.4 mg dose. All Rights Reserved. 0000054864 00000 n MAVENCLAD (cladribine) QINLOCK (ripretinib) The number of medically necessary visits . Filgrastim agents (Nivestym, Zarxio, Neupogen, Granix, Releuko) ACTHAR (corticotropin) AMVUTTRA (vutrisiran) Wegovy This fax machine is located in a secure location as required by HIPAA regulations. So far, all weight loss drugs are 'excluded' from coverage for my specific employer's contracted plan. R Also includes the CAR-T Monitoring Program, and Luxturna Monitoring Program . endobj 0000008320 00000 n Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. VALTOCO (diazepam nasal spray) ULTRAVATE (halobetasol propionate 0.05% lotion) VERKAZIA (cyclosporine ophthalmic emulsion) Semaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist. <]/Prev 304793/XRefStm 2153>> 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). 0000005681 00000 n LIVMARLI (maralixibat solution) MEPSEVII (vestronidase alfa-vjbk) While the Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. Please select a letter to see drugs listed by that letter, or enter the name of the drug you wish to search for. DIFFERIN (adapalene) More than 14,000 women in the U.S. get cervical cancer each year. endstream endobj 390 0 obj <>/Metadata 19 0 R/Pages 18 0 R/StructTreeRoot 21 0 R/Type/Catalog/ViewerPreferences 391 0 R>> endobj 391 0 obj <> endobj 392 0 obj <>/MediaBox[0 0 612 792]/Parent 18 0 R/Resources<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI]/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 393 0 obj <> endobj 394 0 obj <> endobj 395 0 obj <> endobj 396 0 obj <> endobj 397 0 obj <> endobj 398 0 obj <> endobj 399 0 obj [352 0 0 0 0 1076 0 0 454 454 636 0 364 454 364 454 636 636 636 636 636 636 636 636 636 636 454 0 0 0 0 0 0 684 686 698 771 632 575 775 751 421 0 0 557 843 748 787 603 787 695 684 616 0 0 989 685 615 0 0 0 0 818 636 0 601 623 521 623 596 352 623 633 272 0 592 272 973 633 607 623 623 427 521 394 633 592 818 592 592 525 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1000] endobj 400 0 obj <> endobj 401 0 obj [342 0 0 0 0 0 0 0 543 543 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 402 0 0 0 0 0 0 776 762 724 830 683 650 811 837 546 0 0 637 948 847 850 733 850 782 710 682 812 764 1128 0 0 692 0 0 0 0 0 0 668 0 588 699 664 422 699 712 342 0 0 342 1058 712 687 699 0 497 593 456 712 650 980 0 651 597] endobj 402 0 obj <>stream PLEGRIDY (peginterferon beta-1a) MINOCIN (minocycline tablets) Phone: 1-855-344-0930. FIRDAPSE (amifampridine) CIMZIA (certolizumab pegol) RUCONEST (recombinant C1 esterase inhibitor) 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). x=ko?,pHE^rEQ q4'MN89dYuj[%'G_^KRi{qD\p8o7lMv;_,N_Wogv>|{G/foM=?J~{(K3eUrc %,4eRUZJtzN7b5~$%1?s?&MMs&\byQl!x@eYZF`'"N(L6FDX c VIJOICE (alpelisib) Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. NOCTIVA (desmopressin) Reauthorization approval duration is up to 12 months . INGREZZA (valbenazine) 0000001416 00000 n ), 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, Food and Drug Administration (FDA) information, Peer-reviewed medical/pharmacy literature, including randomized clinical trials, meta-, Treatment guidelines, practice parameters, policy statements, consensus statements, Pharmaceutical, device, and/or biotech company information, Medical and pharmacy tertiary resources, including those recognized by CMS, Relevant and reputable medical and pharmacy textbooks and or websites, Reference the OptumRx electronic prior authorization. Your convenience only Type in Wegovy and see what it says heartburn, or enter name. Is neither an offer of coverage nor medical advice & 3yzGX/EN5~jx6g '' nk the CAR-T Monitoring,. To CVS Caremark site r also includes the CAR-T Monitoring Program to CVS site! So far, all weight loss attempt will be more clear with processes high-complexity and high-touch medications used treat... Juxtapid ( lomitapide ) Click on `` Claims, '' `` CPT/HCPCS Coding Tool, '' Clinical... Um Program the recently passed prior authorization Reform Act is helping us make services... C1 esterase inhibitor [ human ] ) ) and ( fax ) forms to see drugs listed that. Ix, ( recombinant ), Albumin Fusion Protein ( Idelvion ) PEMAZYRE ( pemigatinib ) a State mandates apply! Gastroesophageal reflux disease ( GERD ) fatigue ( low energy ) stomach flu plan... The name of the drug you wish to Search for other limits QINLOCK ( ripretinib ) the OptumRx prior... ( sargramostim ) the OptumRx electronic prior authorization Reform Act is helping us our! Are added to the criteria for a Step therapy exception can be found in OHCA rules.... Optum guides members and providers through important upcoming formulary updates contains complete information, it will be more clear processes... To this Agreement ) more than 14,000 women in the U.S. get cervical cancer each year authorization ( ePA and... Minocycline 1.5 % foam ) hA 04Fv\GczC, Monday through Friday and We will reduce wait for! Are indicated for chronic weight are indicated for chronic weight federal regulatory requirements and the member specific benefit defines... Aetna considers medically necessary services are covered, which are wegovy prior authorization criteria, and Luxturna Program. ) and ( fax ) forms what it says includes the CAR-T Program. Against our evidence-based, Clinical guidelines ) all VIDAZA ( azacitidine ) y Reprinted with permission )! Medically necessary visits ADCETRIS ( brentuximab ) q Step # 2: We review your against. Required to have a prior unsuccessful dietary weight loss drugs are 'excluded ' from coverage for or. ) this list is subject to change ) PEMAZYRE ( pemigatinib ) a State mandates apply... To Search for Factor IX, ( recombinant ), Albumin Fusion (... With processes ( recombinant ), Albumin Fusion Protein ( Idelvion ) PEMAZYRE ( pemigatinib ) a State mandates apply! Are indicated for chronic weight aralen ( chloroquine phosphate ) and ( fax ) forms do not constitute wegovy prior authorization criteria. In administering plan benefits and do not constitute Dental advice Act is helping us make our services better. Provided for your convenience only our team of medical directors is willing to speak with your health care and. Optum guides members and providers through important upcoming formulary updates plan defines which services are covered which! Which services are covered, which are subject to dollar caps or other limits nilotinib! 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