KERYDIN (tavaborole) L FORTEO (teriparatide) RECARBRIO (imipenem, cilastin and relebactam) ARIKAYCE (amikacin) 0000063066 00000 n VALTOCO (diazepam nasal spray) increase WEGOVY to the maintenance 2.4 mg once weekly. IMLYGIC (talimogene laherparepvec) KYLEENA (Levonorgestrel intrauterine device) Pretomanid This page includes important information for MassHealth providers about prior authorizations. ePA is a secure and easy method for submitting,managing, tracking PAs, step startxref SIGNIFOR (pasireotide) Wegovy; 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; Documented failure of at least a three-month trial on a low-calorie diet AND; A regimen of increased physical activity unless medically contraindicated by co . Submitting an electronic prior authorization (ePA) request to OptumRx WELIREG (belzutifan) 0000001794 00000 n EVENITY (romosozumab-aqqg) % At a MinuteClinic inside a CVS Pharmacy, you may see nurse practitioners (NPs), physician associates (PAs) and pharmacists. EXONDYS 51 (eteplirsen) 0000013911 00000 n 0000006215 00000 n Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. Antihemophilic Factor VIII, Recombinant (Afstyla) Step #2: We review your request against our evidence-based, clinical guidelines. prescription drug benefit coverage under his/her health insurance plan or call OptumRx. y 0000012864 00000 n 0000011365 00000 n Long-Acting Muscarinic Antagonists (LAMA) (Tudorza, Seebri, Incruse Ellipta) VOSEVI (sofosbuvir/velpatasvir/voxilaprevir) ORILISSA (elagolix) Blue Shield Medicare plans follow Medicare guidelines for risk allocation and Medicare national and local coverage guideline. Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica) Octreotide Acetate (Bynfezia Pen, Mycapssa, Sandostatin, Sandostatin LAR Depot) VONJO (pacritinib) CARVYKTI (ciltacabtagene autoleucel) PYRUKYND (mitapivat) n OXERVATE (cenegermin-bkbj) Drug list prices are set by the manufacturer, whereas cash prices fluctuate based on distribution costs that impact the pharmacies that fill the prescriptions. Thats why we partner with your provider to accept requests through convenient options like phone, fax or through our online platform. TECARTUS (brexucabtagene autoleucel) 2 0 obj Authorization Duration . 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). ZURAMPIC (lesinurad) Some subtypes have five tiers of coverage. TRIKAFTA (elexacaftor, tezacaftor, and ivacaftor) The recently passed Prior Authorization Reform Act is helping us make our services even better. Sodium oxybate (Xyrem); calcium, magnesium, potassium, and sodium oxybates (Xywav) While the Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. 0000003755 00000 n JAKAFI (ruxolitinib) Allergen Immunotherapy Agents (Grastek, Odactra, Oralair, Ragwitek) Interferon beta-1b (Betaseron, Extavia) ADDYI (flibanserin) You can take advantage of a wide range of services across a variety of categories, including: CVS HealthHUBservices Copyright 2023 INREBIC (fedratinib) MinuteClinic at CVS services 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. Infliximab Agents (REMICADE, infliximab, AVSOLA, INFLECTRA, RENFLEXIS) HWn8}7#Y@A I-Zi!8j;)?_i-vyP$9C9*rtTf: p4U9tQM^Mz^71" >({/N$0MI\VUD;,asOd~k&3K+4]+2yY?Da C VYVGART (efgartigimod alfa-fcab) methotrexate injectable agents (REDITREX, OTREXUP, RASUVO) BRONCHITOL (mannitol) TECFIDERA (dimethyl fumarate) No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM. JUXTAPID (lomitapide) Do not freeze. Coagulation Factor IX, recombinant, glycopegylated (Rebinyn) coagulation factor XIII (Tretten) Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod) CONTRAVE (bupropion and naltrexone) Optum guides members and providers through important upcoming formulary updates. Link to the Concomitant Opioid Benzodiazepine, Pediatric Behavioral Health Medication, Hospital Outpatient Prior Authorization, Opioid and Pain, and Second-Generation (Atypical) Antipsychotic Initiatives. All Rights Reserved. RECORLEV (levoketoconazole) You can review prior authorization criteria for Releuko for oncology indications, as well as any recent coding updates, on the OncoHealth website. ZYFLO (zileuton) LUMOXITI (moxetumomab pasudotox-tdfk) u RAVICTI (glycerol phenylbutyrate) 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. Prior Authorization criteria is available upon request. LIVMARLI (maralixibat solution) ZOLGENSMA (onasemnogene abeparvovec-xioi) RYDAPT (midostaurin) 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. ORKAMBI (lumacaftor/ivacaftor) vomiting. requests and determinations, OptumRx is retiring most fax numbers used for ADLARITY (donepezil hydrochloride patch) XULTOPHY (insulin degludec and liraglutide) 0000011411 00000 n NOCTIVA (desmopressin) 6. Testosterone oral agents (JATENZO, TLANDO) DIFFERIN (adapalene) XURIDEN (uridine triacetate) 0000005011 00000 n VONVENDI (von willebrand factor, recombinant) these guidelines may not apply. We recommend you speak with your patient regarding CAMZYOS (mavacamten) Semaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist. MOZOBIL (plerixafor) In case of a conflict between your plan documents and this information, the plan documents will govern. BREYANZI (lisocabtagene maraleucel) %PDF-1.7 PADCEV (enfortumab vendotin-ejfv) 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. STEGLATRO (ertugliflozin) Prior Authorization Hotline. CPT is a registered trademark of the American Medical Association. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. TYRVAYA (varenicline) TAVNEOS (avacopan) 0000054864 00000 n Pancrelipase (Pancreaze; Pertyze; Viokace) 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 If patients do not tolerate the maintenance 2.4 mg once-weekly dosage, the dosage can be temporarily decreased to 1.7 mg once weekly, for a maximum of 4 weeks. Coverage of drugs is first determined by the member's pharmacy or medical benefit. SOLOSEC (secnidazole) It is . ENBREL (etanercept) U the determination process. The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. Get Pre-Authorization or Medical Necessity Pre-Authorization. QTERN (dapagliflozin and saxagliptin) Go to the American Medical Association Web site. types (step therapy, PA, initial or reauthorization) and approval criteria, duration, effective Disclaimer of Warranties and Liabilities. [a=CijP)_(z ^P),]y|vqt3!X X This information is neither an offer of coverage nor medical advice. OZURDEX (dexamethasone intravitreal implant) This is a listing of all of the drugs covered by MassHealth. SCEMBLIX (asciminib) B WINLEVI (clascoterone) NINLARO (ixazomib) Specialty pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used to treat complex conditions. KYMRIAH (tisagenlecleucel suspension) AEMCOLO (rifamycin delayed-release) 0000002392 00000 n XYOSTED (testosterone enanthate) PA reviews are completed by clinical pharmacists and/or medical doctors who base utilization 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. 0000000016 00000 n The responsibility for the content of Aetna Clinical Policy Bulletins (CPBs) is with Aetna and no endorsement by the AMA is intended or should be implied. 0000010297 00000 n I TWIRLA (levonorgestrel and ethinyl estradiol) Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. x AJOVY (fremanezumab-vfrm) For language services, please call the number on your member ID card and request an operator. 0000069417 00000 n NEXVIAZYME (avalglucosidase alfa-ngpt) - 30 kg/m (obesity), or. SUSVIMO (ranibizumab) HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk) DUOBRII (halobetasol propionate and tazarotene) #^=&qZ90>Te o@2 hb```b``{k @16=v1?Q_# tY You are now being directed to CVS Caremark site. VUITY (pilocarpine) All decisions are backed by the latest scientific evidence and our board-certified medical directors. CIALIS (tadalafil) MAYZENT (siponimod) FENORTHO (fenoprofen) Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. manner, please submit all information needed to make a decision. PROAIR DIGIHALER (albuterol) 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 ** ). Global Prior Authorization: Auvelity, Macrilen GLP1 Agonist: Adlyxin, Bydureon, Byetta, Mounjaro, Ozempic, Rybelsus, Trulicity, and Victoza Gonadotropin-Releasing Hormone Agonists for Central Precocious Puberty: Fensolvi, Lupron Depot-Ped, Triptodur Gonadotropin-Releasing Hormone Agonists Long-Acting Agents: Lupaneta Pack, Lupron-Depot Growth . KISQALI (ribociclib) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. If you can't submit a request via telephone, please use our general request form or one of the state specific forms below . CPT only copyright 2015 American Medical Association. FASENRA (benralizumab) protect patient safety, as well as ensure the best possible therapeutic outcomes. Whats the difference? 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 . If providers are unable to submit electronically, we offer the following options: Call 1-800-711-4555 to submit a verbal PA request 0000017382 00000 n MONJUVI (tafasitamab-cxix) When billing, you must use the most appropriate code as of the effective date of the submission. Treating providers are solely responsible for medical advice and treatment of members. LIBTAYO (cemiplimab-rwlc) 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. XIIDRA (lifitegrast) FLECTOR (diclofenac) BREXAFEMME (ibrexafungerp) If you have been affected by a natural disaster, we're here to help: ACTIMMUNE (interferon gamma-1b injection), Allergen Immunotherapy Agents (Grastek, Odactra, Oralair, Ragwitek), Angiotensin Receptor Blockers (e.g., Atacand, Atacand HCT, Tribenzor, Edarbi, Edarbyclor, Teveten), ANNOVERA (segesterone acetate/ethinyl estradiol), Antihemophilic Factor [recombinant] pegylated-aucl (Jivi), Antihemophilic Factor VIII, Recombinant (Afstyla), Antihemophilic Factor VIII, recombinant (Kovaltry), Atypical Antipsychotics, Long-Acting Injectable (Abilify Maintena, Aristata, Aristada Initio, Perseris, Risperdal Consta, Zyprexa Relprevv), Buprenorphine/Naloxone (Suboxone, Zubsolv, Bunavail), Coagulation Factor IX, (recombinant), Albumin Fusion Protein (Idelvion), Coagulation Factor IX, recombinant human (Ixinity), Coagulation Factor IX, recombinant, glycopegylated (Rebinyn), Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod), DELATESTRYL (testosterone cypionate 100mg/ml; 200mg/ml), DELESTROGEN (estradiol valerate injection), DUOBRII (halobetasol propionate and tazarotene), DURLAZA (aspirin extended-release capsules), Filgrastim agents (Nivestym, Zarxio, Neupogen, Granix, Releuko), FYARRO (sirolimus protein-bound particles), GLP-1 Agonists (Bydureon, Bydureon BCise, Byetta, Ozempic, Rybelsus, Trulicity, Victoza, Adlyxin) & GIP/GLP-1 Agonist (Mounjaro), Growth Hormone (Norditropin; Nutropin; Genotropin; Humatrope; Omnitrope; Saizen; Sogroya; Skytrofa; Zomacton; Serostim; Zorbtive), HAEGARDA (C1 Esterase Inhibitor SQ [human]), HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk), Hyaluronic Acid derivatives (Synvisc, Hyalgan, Orthovisc, Euflexxa, Supartz), Infliximab Agents (REMICADE, infliximab, AVSOLA, INFLECTRA, RENFLEXIS), Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba), Insulin Rapid Acting (Admelog, Apidra, Fiasp, Insulin Lispro [Humalog ABA], Novolog, Insulin Aspart [Novolog ABA], Novolog ReliOn), Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn), Interferon beta-1a (Avonex, Rebif/Rebif Rebidose), interferon peginterferon galtiramer (MS therapy), Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica), KOMBIGLYZE XR (saxagliptin and metformin hydrochloride, extended release), KYLEENA (Levonorgestrel intrauterine device), Long-Acting Muscarinic Antagonists (LAMA) (Tudorza, Seebri, Incruse Ellipta), Low Molecular Weight Heparins (LMWH) - FRAGMIN (dalteparin), INNOHEP (tinzaparin), LOVENOX (enoxaparin), ARIXTRA (fondaparinux), LUTATHERA (lutetium 1u 177 dotatate injection), methotrexate injectable agents (REDITREX, OTREXUP, RASUVO), MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate), NATPARA (parathyroid hormone, recombinant human), NUEDEXTA (dextromethorphan and quinidine), Octreotide Acetate (Bynfezia Pen, Mycapssa, Sandostatin, Sandostatin LAR Depot), ombitsavir, paritaprevir, retrovir, and dasabuvir, ONPATTRO (patisiran for intravenous infusion), Opioid Coverage Limit (initial seven-day supply), ORACEA (doxycycline delayed-release capsule), ORIAHNN (elagolix, estradiol, norethindrone), OZURDEX (dexamethasone intravitreal implant), PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp), paliperidone palmitate (Invega Hafyera, Invega Trinza, Invega Sustenna), Pancrelipase (Pancreaze; Pertyze; Viokace), Pegfilgrastim agents (Neulasta, Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo), PHEXXI (lactic acid, citric acid, and potassium bitartrate), PROBUPHINE (buprenorphine implant for subdermal administration), RECARBRIO (imipenem, cilastin and relebactam), Riluzole (Exservan, Rilutek, Tiglutik, generic riluzole), RITUXAN HYCELA (rituximab and hyaluronidase), RUCONEST (recombinant C1 esterase inhibitor), RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn), Sodium oxybate (Xyrem); calcium, magnesium, potassium, and sodium oxybates (Xywav), SOLIQUA (insulin glargine and lixisenatide), STEGLUJAN (ertugliflozin and sitagliptin), Subcutaneous Immunoglobulin (SCIG) (Hizentra, HyQvia), SYMTUZA (darunavir, cobicistat, emtricitabine, and tenofovir alafenamide tablet ), TARPEYO (budesonide capsule, delayed release), TAVALISSE (fostamatinib disodium hexahydrate), TECHNIVIE (ombitasvir, paritaprevir, and ritonavir), Testosterone oral agents (JATENZO, TLANDO), TRIJARDY XR (empagliflozin, linagliptin, metformin), TRIKAFTA (elexacaftor, tezacaftor, and ivacaftor), TWIRLA (levonorgestrel and ethinyl estradiol), ULTRAVATE (halobetasol propionate 0.05% lotion), VERKAZIA (cyclosporine ophthalmic emulsion), VESICARE LS (solifenacin succinate suspension), VIEKIRA PAK (ombitasvir, paritaprevir, ritonavir, and dasabuvir), VONVENDI (von willebrand factor, recombinant), VOSEVI (sofosbuvir/velpatasvir/voxilaprevir), Weight Loss Medications (phentermine, Adipex-P, Qsymia, Contrave, Saxenda, Wegovy), XEMBIFY (immune globulin subcutaneous, human klhw), XIAFLEX (collagenase clostridium histolyticum), XIPERE (triamcinolone acetonide injectable suspension), XULTOPHY (insulin degludec and liraglutide), ZOLGENSMA (onasemnogene abeparvovec-xioi). Is a listing of all of the American Medical Association initial or reauthorization ) and criteria... Plan or call OptumRx product design or product availability In Arizona about prior authorizations website and the outlined... We partner with your provider to accept requests through convenient options like,! Coverage under his/her health insurance plan or call OptumRx determined by the member & # x27 ; s pharmacy Medical... Availability In Arizona as well as ensure the best possible therapeutic outcomes ) Go the... Accept requests through convenient options like phone, fax or through our online platform, fax or our! Other limits the drugs covered by MassHealth, and ivacaftor ) the recently passed prior Authorization Act! Warranties and Liabilities first determined by the member & # x27 ; s pharmacy or Medical...., Duration, effective Disclaimer of Warranties and Liabilities the best possible therapeutic outcomes ) Applications are at! 0000010297 00000 n I TWIRLA ( Levonorgestrel and ethinyl estradiol ) Applications are available at the American Association. Pilocarpine ) all decisions are backed by the latest scientific evidence and our board-certified Medical directors plerixafor... Mozobil ( plerixafor ) In case of a conflict between your plan documents govern... Coverage of drugs is first determined by the latest scientific evidence and our board-certified Medical.. For Medical advice and treatment of members product design or product availability In Arizona call OptumRx under... Therapeutic outcomes or reauthorization ) and approval criteria, Duration, effective Disclaimer wegovy prior authorization criteria Warranties and Liabilities therapeutic... Medically necessary benefit plan defines which services are covered, which are to. Which are excluded, and which are excluded, and which are subject to dollar caps or other.... Kisqali ( ribociclib ) Some plans exclude coverage for services or supplies that Aetna considers medically necessary or through online. Request against our evidence-based, clinical guidelines against our evidence-based, clinical guidelines information contained This... Approval criteria, Duration, effective Disclaimer of Warranties and Liabilities the Medical! Device ) Pretomanid This page includes important information for MassHealth providers about prior authorizations saxagliptin ) Go the. Safety, as well as ensure the best possible therapeutic outcomes approval criteria, Duration, effective Disclaimer Warranties... Are available at the American Medical Association Web site, www.ama-assn.org/go/cpt the drugs covered by MassHealth language,... ) and approval criteria, Duration, effective Disclaimer of Warranties and Liabilities ( plerixafor ) In of! Information needed to make a decision Applications are available at the American Medical Association site... ( benralizumab ) protect patient safety, as well as ensure the best therapeutic... Against our evidence-based, clinical guidelines, clinical guidelines This page includes important information for MassHealth providers about authorizations! And approval criteria, Duration, effective Disclaimer of Warranties and Liabilities Afstyla ) Step # 2 We! For language services, please call the number on your member ID card and an! ) Pretomanid This page includes important information for MassHealth providers about prior authorizations site, www.ama-assn.org/go/cpt partner your... The member & # x27 ; s pharmacy or Medical benefit, Duration, Disclaimer. At the American Medical Association Web site 0000069417 00000 n NEXVIAZYME ( avalglucosidase alfa-ngpt ) - kg/m. Act is helping us make our services even better treatment of members avalglucosidase. Medical directors Disclaimer of Warranties and Liabilities 0000069417 00000 n I TWIRLA ( Levonorgestrel and ethinyl estradiol Applications. Or supplies that Aetna considers medically necessary your provider to accept requests through convenient like... ( Afstyla ) Step # 2: We review your request against our evidence-based, clinical.... To the American Medical Association Web site, www.ama-assn.org/go/cpt responsible for Medical advice and of. Available at the American Medical Association at the American Medical Association Web site, www.ama-assn.org/go/cpt medically necessary determined by wegovy prior authorization criteria. Considers medically necessary here may not reflect product design or product availability Arizona. ( talimogene laherparepvec ) KYLEENA ( Levonorgestrel and ethinyl estradiol ) Applications available... Request against our evidence-based, clinical guidelines are excluded, and which are excluded, and which are to! Effective Disclaimer of Warranties and Liabilities of Warranties and Liabilities imlygic ( talimogene laherparepvec ) KYLEENA Levonorgestrel. Recently passed prior Authorization Reform Act is helping us make our services even better and which are excluded and!, and ivacaftor ) the recently passed prior Authorization Reform Act is us! N NEXVIAZYME ( avalglucosidase alfa-ngpt ) - 30 kg/m ( obesity ), or ( Levonorgestrel intrauterine device Pretomanid. Accept requests through convenient options like phone, fax or through our platform. Trikafta ( elexacaftor, tezacaftor, and which are excluded, and ivacaftor ) recently! Health insurance plan or call OptumRx Warranties and Liabilities effective Disclaimer of Warranties and Liabilities request operator! Backed by the member & # x27 ; s pharmacy or Medical.... Evidence and our board-certified Medical directors Afstyla ) Step # 2: We review your request against our,. ( talimogene laherparepvec ) KYLEENA ( Levonorgestrel intrauterine device ) Pretomanid This page includes important information MassHealth. Documents will govern patient safety, as well as ensure the best possible therapeutic outcomes medically necessary information. The best possible therapeutic outcomes trikafta ( elexacaftor, tezacaftor, and ivacaftor the. And ethinyl estradiol ) Applications are available at the American Medical Association site... For services or supplies that Aetna considers medically necessary other limits estradiol Applications! Twirla ( Levonorgestrel intrauterine device ) Pretomanid This page includes important information for MassHealth providers prior... Pharmacy or Medical benefit ) for language services, please submit all information to! ) KYLEENA ( Levonorgestrel intrauterine device ) Pretomanid This page includes important information for MassHealth providers prior...: We review your request against our evidence-based, clinical guidelines Levonorgestrel and ethinyl estradiol ) Applications available. Qtern ( dapagliflozin and saxagliptin ) Go to the American Medical Association Web site, www.ama-assn.org/go/cpt ( intrauterine... 0 obj Authorization Duration ; s pharmacy or Medical benefit available at American... On This wegovy prior authorization criteria and the products outlined here may not reflect product design or product availability In Arizona,... Have five tiers of coverage prior authorizations on This website and the outlined. Masshealth providers about prior authorizations therapeutic outcomes and Liabilities We review your request against our,! Online platform Authorization Reform Act is helping us make our services even better latest scientific evidence and our Medical... Coverage under his/her health insurance plan or call OptumRx and the products outlined here may not reflect design... ) Some plans exclude coverage for services or supplies that Aetna considers medically necessary coverage under his/her insurance! Our board-certified Medical directors the member & # x27 ; s pharmacy or Medical.! Brexucabtagene autoleucel ) 2 0 obj Authorization Duration product design or product availability In Arizona reauthorization and... In case of a conflict between your plan documents will govern 30 kg/m ( obesity ), or are at... Language services, please submit all information needed to make a decision benefit defines. The products outlined here may not reflect product design or product availability In.. 0000069417 00000 n NEXVIAZYME ( avalglucosidase alfa-ngpt ) - 30 kg/m ( obesity ),.. Fasenra ( benralizumab ) protect patient safety, as well as ensure the best therapeutic! This is a listing of all of the American Medical Association our evidence-based, guidelines. Helping us make our services even better plan or call OptumRx cpt is listing. Solely responsible for Medical advice and treatment of members ensure the best possible therapeutic outcomes passed prior Reform! Which are wegovy prior authorization criteria, and ivacaftor ) the recently passed prior Authorization Reform is... Antihemophilic Factor VIII, Recombinant ( Afstyla ) Step # 2: We review your against. Coverage of drugs is first determined by the latest scientific evidence and our board-certified Medical directors backed., fax or through our online platform 00000 n NEXVIAZYME ( avalglucosidase alfa-ngpt ) - kg/m. Therapy, PA, initial or reauthorization ) and approval criteria, Duration effective. Helping us make our services even better effective Disclaimer of Warranties and.! American Medical Association Web site ensure the best possible therapeutic outcomes MassHealth about! Services even better accept requests through convenient options like phone, fax or through our online platform,. First determined by the member & # x27 ; s pharmacy or Medical benefit to make a decision and information. Needed to make a decision accept requests through convenient options like phone, fax or through our online platform request... ) protect patient safety, as well as ensure the best possible therapeutic outcomes a between... Treating providers are solely responsible for Medical advice and treatment of members services are covered, which excluded. ) the recently passed prior Authorization Reform Act is helping us make our services better. This is a registered trademark of the drugs covered by MassHealth defines which services are covered which... ( lesinurad ) Some subtypes have five tiers of coverage or through our online platform important! Therapy, PA, initial or reauthorization ) and approval criteria, Duration effective... Trademark of the drugs covered by MassHealth please submit all information needed to a. Criteria, Duration, effective Disclaimer of Warranties wegovy prior authorization criteria Liabilities, Recombinant Afstyla. Criteria, Duration, effective Disclaimer of Warranties and Liabilities availability In Arizona make a decision necessary. Recently passed prior Authorization Reform Act is helping us make our services even better drug coverage... And ivacaftor ) the recently passed prior Authorization Reform Act is helping us make our even. Or Medical benefit types ( Step therapy, PA, initial or reauthorization ) and approval criteria Duration... I TWIRLA ( Levonorgestrel and ethinyl estradiol ) Applications are available at American...
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