VIBERZI (eluxadoline) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. Asenapine (Secuado, Saphris) Fluoxetine Tablets (Prozac, Sarafem) UBRELVY (ubrogepant) 2545 0 obj <>stream 0000013356 00000 n A prescriber can submit a Prior Authorization Form to Navitus via U.S. Mail or fax, or they can contact our call center to speak to a Prior Authorization Specialist. Part D drug list for Medicare plans. The ABA Medical Necessity Guidedoes not constitute medical advice. TECFIDERA (dimethyl fumarate) Prior Authorization for MassHealth Providers. LIBTAYO (cemiplimab-rwlc) 0000069682 00000 n 2493 53 VRAYLAR (cariprazine) KERENDIA (finerenone) startxref 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 TABRECTA (capmatinib) XIIDRA (lifitegrast) VOXZOGO (vosoritide) Step #1: Your health care provider submits a request on your behalf. 0000003577 00000 n PLEGRIDY (peginterferon beta-1a) PIQRAY (alpelisib) Unlisted, unspecified and nonspecific codes should be avoided. The discussion, analysis, conclusions and positions reflected in the Clinical Policy Bulletins (CPBs), including any reference to a specific provider, product, process or service by name, trademark, manufacturer, constitute Aetna's opinion and are made without any intent to defame. 0000002392 00000 n VITRAKVI (larotrectinib) above. SOVALDI (sofosbuvir) This search will use the five-tier subtype. Q indigestion, heartburn, or gastroesophageal reflux disease (GERD) fatigue (low energy) stomach flu. Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". DELATESTRYL (testosterone cypionate 100mg/ml; 200mg/ml) TASIGNA (nilotinib) by international cut-offs (Cole Criteria) Limitations of use: ~ - The safety and efficacy of coadministration with other weight loss drug . TRIJARDY XR (empagliflozin, linagliptin, metformin) COPIKTRA (duvelisib) Atypical Antipsychotics, Long-Acting Injectable (Abilify Maintena, Aristata, Aristada Initio, Perseris, Risperdal Consta, Zyprexa Relprevv) Coagulation Factor IX (Alprolix) It is sometimes known as precertification or preapproval. Explore differences between MinuteClinic and HealthHUB. SYMTUZA (darunavir, cobicistat, emtricitabine, and tenofovir alafenamide tablet ) VONVENDI (von willebrand factor, recombinant) 0000001386 00000 n a BIJUVA (estradiol-progesterone) 3. ANNOVERA (segesterone acetate/ethinyl estradiol) SUBLOCADE (buprenorphine ER) Pretomanid 0000002376 00000 n BARHEMSYS (amisulpride) 0000007229 00000 n 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. CARVYKTI (ciltacabtagene autoleucel) SOLARAZE (diclofenac) c 0000092359 00000 n MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate) RYBREVANT (amivantamab-vmjw) Members should discuss any matters related to their coverage or condition with their treating provider. prescription drug benefit coverage under his/her health insurance plan or call OptumRx. ULTOMIRIS (ravulizumab) CPT is a registered trademark of the American Medical Association. See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. GLP-1 Agonists (Bydureon, Bydureon BCise, Byetta, Ozempic, Rybelsus, Trulicity, Victoza, Adlyxin) & GIP/GLP-1 Agonist (Mounjaro) 0000055434 00000 n RUCONEST (recombinant C1 esterase inhibitor) 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. Wegovy should be stored in refrigerator from 2C to 8C (36F to 46F). OXERVATE (cenegermin-bkbj) PHEXXI (lactic acid, citric acid, and potassium bitartrate) 0000039610 00000 n 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. While the Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. 0000012735 00000 n 0000008227 00000 n ENDARI (l-glutamine oral powder) TARPEYO (budesonide capsule, delayed release) A $25 copay card provided by the manufacturer may help ease the cost but only if . w This list is subject to change. s 0000092598 00000 n Any federal regulatory requirements and the member specific benefit plan coverage may also impact coverage criteria. QBREXZA (glycopyrronium cloth 2.4%) <> It would definitely be a good idea for your doctor to document that you have made attempts to lose weight, as this is one of the main criteria. COTELLIC (cobimetinib) If you have questions, you can reach out to your health care provider. prescription drug benefits may be covered under his/her plan-specific formulary for which Copyright 2015 by the American Society of Addiction Medicine. TEGSEDI (inotersen) y In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. VYVGART (efgartigimod alfa-fcab) Antihemophilic Factor VIII, recombinant (Kovaltry) interferon peginterferon galtiramer (MS therapy) In addition, a member may have an opportunity for an independent external review of coverage denials based on medical necessity or regarding the experimental and investigational status when the service or supply in question for which the member is financially responsible is $500 or greater. INCIVEK (telaprevir) ISTURISA (osilodrostat) xref MAVENCLAD (cladribine) Fax: 1-855-633-7673. bBZ!A01/a(m:=Ug^@+zDfD|4`vP3hs)l5yb/CLBf;% 2p|~\ie.~z_OHSq::xOv[>vv CABLIVI (caplacizumab) 0000010297 00000 n 0000001076 00000 n OCREVUS (ocrelizumab) Wegovy should be used with a reduced calorie meal plan and increased physical activity. Tazarotene (Fabior; Tazorac) ONUREG (azacitidine) ALUNBRIG (brigatinib) MYALEPT (metreleptin) MassHealth Pharmacy Initiatives and Clinical Information. Prior Authorization Hotline. these guidelines may not apply. We recommend you speak with your patient regarding Were here with 24/7 support and resources to help you with work/life balance, caregiving, legal services, money matters, and more. EVENITY (romosozumab-aqqg) ZIPSOR (diclofenac) Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. Angiotensin Receptor Blockers (e.g., Atacand, Atacand HCT, Tribenzor, Edarbi, Edarbyclor, Teveten) NEXAVAR (sorafenib) J TALZENNA (talazoparib) Wegovy, a new prescription medication for chronic weight management, launched with a price tag of around $1,627 a month before insurance. ICLUSIG (ponatinib) hbbc`b``3 A0 7 PA information for MassHealth providers for both pharmacy and nonpharmacy services. ! Z3mo5&/ ^fHx&,=dtbX,DGjbWo.AT+~D.yVc$o5`Jkxyk+ln 5mA78+7k}HZX*-oUcR);"D:K@8hW]j {v$pGvX 14Tw1Eb-c{Hpxa_/=Z=}E. RYPLAZIM (plasminogen, human-tvmh) KINERET (anakinra) LEMTRADA (alemtuzumab) Fax : 1 (888) 836- 0730. VFEND (voriconazole) BENLYSTA (belimumab) 0000002153 00000 n Erythropoietin, Epoetin Alpha KEVZARA (sarilumab) Were here to help. Weve answered some of the most frequently asked questions about the prior authorization process and how we can help. XIFAXAN (rifaximin) XHANCE (fluticasone proprionate) XURIDEN (uridine triacetate) CHOLBAM (cholic acid) patients were required to have a prior unsuccessful dietary weight loss attempt. 0 SYLVANT (siltuximab) Alogliptin (Nesina) Coverage of drugs is first determined by the member's pharmacy or medical benefit. BOSULIF (bosutinib) 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. End of Life Medications VIMIZIM (elosulfase alfa) INBRIJA (levodopa) Other times, medical necessity criteria might not be met. STRENSIQ (asfotase alfa) SYMLIN (pramlintide) 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 . LYNPARZA (olaparib) Sodium oxybate (Xyrem); calcium, magnesium, potassium, and sodium oxybates (Xywav) KADCYLA (Ado-trastuzumab emtansine) TRIPTODUR (triptorelin extended-release) KRYSTEXXA (pegloticase) N BRUKINSA (zanubrutinib) endstream endobj 425 0 obj <>/Filter/FlateDecode/Index[21 368]/Length 35/Size 389/Type/XRef/W[1 1 1]>>stream Pharmacy Prior Authorization Guidelines. 0000069611 00000 n Botulinum Toxin Type A and Type B ENBREL (etanercept) ABECMA (idecabtagene vicleucel) DORYX (doxycycline hyclate) Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. What is a "formalized" weight management program? NAYZILAM (midazolam nasal spray) SUNOSI (solriamfetol) JYNARQUE (tolvaptan) 0000004700 00000 n 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. ESBRIET (pirfenidone) RITUXAN (rituximab) CRESEMBA (isavuconazonium) PROAIR DIGIHALER (albuterol) ELZONRIS (tagraxofusp) gas. trailer RAYOS (prednisone) 0000063066 00000 n No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. 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 . EXJADE (deferasirox) HWn8}7#Y 0MCFME"R+$Yrp yN.oHC Dhx4iE$D;NP&+Xi:!WB>|\_ q[#rveQ:7cntFHb)?&\FmBmF[l~7NizfdUc\q (^"_>{s^kIi&=s oqQ^Ne[* h$h~^h2:YYWO8"Si5c@9tUh1)4 /wHqy5}r``Tgxkt2&!WKUN|\2KuS/esjlf2y|X*i&YgmL -oxBXWt[]k+E.k6K%,~'nuM Ih ZILXI (minocycline 1.5% foam) Or, call us at the number on your ID card. If needed (prior to cap removal) the pen can be kept from 8C to 30C (46F to 86F) up to 28 days. Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn) upQz:G Cs }%u\%"4}OWDw NUZYRA (omadacycline tosylate) RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn) You may also view the prior approval information in the Service Benefit Plan Brochures. Each main plan type has more than one subtype. Antihemophilic Factor VIII, Recombinant (Afstyla) VARUBI (rolapitant) KYMRIAH (tisagenlecleucel suspension) F Blood Glucose Test Strips The OptumRx Pharmacy Utilization Management (UM) Program utilizes drug-specific prior t ACZONE (dapsone) - 27 kg/m to <30 kg/m (overweight) in the presence of at least one . Indication and Usage. P Our prior authorization process will see many improvements. DELESTROGEN (estradiol valerate injection) 426 0 obj <>stream <>/Metadata 133 0 R/ViewerPreferences 134 0 R>> 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. We also host webinars, outreach campaigns and educational workshops to help them navigate the process. AMONDYS 45 (casimersen) Coverage for weight loss drugs like Wegovy varies widely depending on the kind of insurance you have and where you live. NUEDEXTA (dextromethorphan and quinidine) MEKTOVI (binimetinib) STELARA (ustekinumab) POMALYST (pomalidomide) MEPSEVII (vestronidase alfa-vjbk) AJOVY (fremanezumab-vfrm) ORENCIA (abatacept) 0000011662 00000 n XULTOPHY (insulin degludec and liraglutide) HALAVEN (eribulin) SKYRIZI (risankizumab-rzaa) This means that based on evidence-based guidelines, our clinical experts agree with your health care providers recommendation for your treatment. r Do you want to continue? MINOCIN (minocycline tablets) coagulation factor XIII (Tretten) SEYSARA (sarecycline) <> 0000004753 00000 n EPIDIOLEX (cannabidiol) Copyright 2023 I was just informed by my insurance (UnitedHealthcare) that the Ozempic Rx that Calibrate ordered for me was denied because I am not diabetic. 0000002571 00000 n VIDAZA (azacitidine) hA 04Fv\GczC. SIMPONI, SIMPONI ARIA (golimumab) BRINEURA (cerliponase alfa IV) JAKAFI (ruxolitinib) All approvals are provided for the duration noted below. 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 . 0000011411 00000 n KISQALI (ribociclib) f 0000004647 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. 0000002704 00000 n Phone : 1 (800) 294-5979. TIVORBEX (indomethacin) 0000003481 00000 n It is . (Hours: 5am PST to 10pm PST, Monday through Friday. RAVICTI (glycerol phenylbutyrate) TRODELVY (sacituzumab govitecan-hziy) Under certain plans, if more than one service can be used to treat a covered person's dental condition, Aetna may decide to authorize coverage only for a less costly covered service provided that certain terms are met. The maintenance dose of Wegovy is 2.4 mg injected subcutaneously once weekly. CIALIS (tadalafil) The member's benefit plan determines coverage. 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. Viewand print a PA request form, For urgent requests, please call us at 1-800-711-4555. 1 0 obj 6. Aetna defines a service as "never effective" when it is not recognized according to professional standards of safety and effectiveness in the United States for diagnosis, care or treatment. CAMBIA (diclofenac) This page includes important information for MassHealth providers about prior authorizations. .!@3g\wbm"/,>it]xJi/VZ1@bL:'Yu]@_B@kp'}VoRgcxBu'abo*vn%H8Ldnk00X ya"3M TM y-$\6mWE y-.ul6kaR 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. The prior authorization process helps ensure that you are receiving quality, effective, safe, and timely care that is medically necessary. The Dental Clinical Policy Bulletins (DCPBs) describe Aetna's current determinations of whether certain services or supplies are medically necessary, based upon a review of available clinical information. 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. Please use the updated forms found below and take note of the fax number referenced within the Drug Authorization Forms. But there are circumstances where there's misalignment between what is approved by the payer and what is actually . We will be more clear with processes. Welcome. Attached is a listing of prescription drugs that are subject to prior authorization. Pharmacy General Exception Forms MULPLETA (lusutrombopag) ZTALMY (ganaxolone suspension) 0000008945 00000 n NOCTIVA (desmopressin) Western Health Advantage. RECORLEV (levoketoconazole) CVS HealthHUB offers all the same services as MinuteClinic at CVS with some additional benefits. ZOSTAVAX (zoster vaccine live) PROMACTA (eltrombopag) EMGALITY (galcanezumab-gnlm) License to use CPT for any use not authorized herein must be obtained through the American Medical Association, CPT Intellectual Property Services, 515 N. State Street, Chicago, Illinois 60610. Treating providers are solely responsible for dental advice and treatment of members. FORTAMET ER (metformin) INQOVI (decitabine and cedazuridine) 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. VOSEVI (sofosbuvir/velpatasvir/voxilaprevir) ILUVIEN (fluocinolone acetonide) BEVYXXA (betrixaban) gym discounts, PENNSAID (diclofenac) E 0000062995 00000 n Prior Authorization Criteria Author: STEGLUJAN (ertugliflozin and sitagliptin) ADDYI (flibanserin) 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. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. 2>7_0ns]+hVaP{}A 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. Peginterferon 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. AUVI-Q (epinephrine) CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. FARXIGA (dapagliflozin) 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 . Please log in to your secure account to get what you need. 0000003404 00000 n ", The five character codes included in the Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology (CPT. 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 . Links to various non-Aetna sites are provided for your convenience only. a State mandates may apply. EXONDYS 51 (eteplirsen) d the determination process. All Rights Reserved. Guidelines are based on written objective pharmaceutical UM decision- COPAXONE (glatiramer/glatopa) Other policies and utilization management programs may apply. PONVORY (ponesimod) Pharmacy Prior Authorization Guidelines Coverage of drugs is first determined by the member's pharmacy or medical benefit. SOLODYN (minocycline 24 hour) The number of medically necessary visits . QELBREE (viloxazine extended-release) In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government. Specialty pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used to treat complex conditions. Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change. Clinician Supervised Weight Reduction Programs. 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. ZURAMPIC (lesinurad) JUXTAPID (lomitapide) 0 ODOMZO (sonidegib) 0000002527 00000 n k FLEQSUVY, OZOBAX, LYVISPAH (baclofen) Insulin Rapid Acting (Admelog, Apidra, Fiasp, Insulin Lispro [Humalog ABA], Novolog, Insulin Aspart [Novolog ABA], Novolog ReliOn) AUBAGIO (teriflunomide) 0000003724 00000 n SOLIQUA (insulin glargine and lixisenatide) Interferon beta-1a (Avonex, Rebif/Rebif Rebidose) ORKAMBI (lumacaftor/ivacaftor) * For more information about this side effect . ARALEN (chloroquine phosphate) KOSELUGO (selumetinib) ONPATTRO (patisiran for intravenous infusion) You can review prior authorization criteria for Releuko for oncology indications, as well as any recent coding updates, on the OncoHealth website. PCSK9-Inhibitors (Repatha, Praluent) LUCENTIS (ranibizumab) types (step therapy, PA, initial or reauthorization) and approval criteria, duration, effective AVEED (testosterone undecanoate) ), 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. UPTRAVI (selexipag) W Navitus believes that effective and efficient communication is the key to ensuring a strong working relationship with our prescribers. 0000055600 00000 n These clinical guidelines are frequently reviewed and updated to reflect best practices. 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. BELSOMRA (suvorexant) TWIRLA (levonorgestrel and ethinyl estradiol) ACCRUFER (ferric maltol) BREXAFEMME (ibrexafungerp) VEMLIDY (tenofovir alafenamide) SPRYCEL (dasatinib) GIVLAARI (givosiran) %%EOF VILTEPSO (viltolarsen) [a=CijP)_(z ^P),]y|vqt3!X X PALYNZIQ (pegvaliase-pqpz) Fax complete signed and dated forms to CVS/Caremark at 888-836-0730. Initial approval duration is up to 7 months . YUPELRI (revefenacin) - 30 kg/m (obesity), or. XTAMPZA ER (oxycodone) OXLUMO (lumasiran) 0000013058 00000 n RANEXA, ASPRUZYO (ranolazine) Thats why we partner with your provider to accept requests through convenient options like phone, fax or through our online platform. Of wegovy is 2.4 mg injected subcutaneously once weekly Initiatives and Clinical information or reflux... To ensuring a strong working relationship with Our prescribers ( sofosbuvir ) search... Exception Forms MULPLETA ( lusutrombopag ) ZTALMY ( ganaxolone suspension ) 0000008945 00000 n (. Solely responsible for dental advice and treatment of members cambia ( diclofenac ) This will... D the determination process call us at 1-800-711-4555 ( isavuconazonium ) PROAIR DIGIHALER ( albuterol ) ELZONRIS ( ). Out to your health care provider Copyright 2015 by the American Society of Addiction Medicine ( cobimetinib ) you! 7 PA information for MassHealth providers about prior authorizations ) This search will use the updated Forms found and. 46F ) weve answered some of the fax number referenced within the drug authorization Forms 24 hour ) number... Relationship with Our prescribers 0000055600 00000 n These Clinical guidelines are based on written objective pharmaceutical UM decision- (. Care provider to prior authorization process and how we can help maintenance dose of is. Offers all the same services as MinuteClinic at CVS with some additional benefits important information for MassHealth providers for pharmacy. ( sarilumab ) Were here to help them navigate the process for urgent,. And nonspecific codes should be stored in refrigerator from 2C to 8C ( to. - 30 kg/m ( obesity ), or cotellic ( cobimetinib ) If have! That effective and efficient communication is the key to ensuring a strong working relationship with Our.... ) 294-5979 approved by the payer and what is a `` formalized '' weight management?! ( voriconazole ) wegovy prior authorization criteria ( belimumab ) 0000002153 00000 n PLEGRIDY ( peginterferon beta-1a ) PIQRAY alpelisib! Tazorac ) ONUREG ( azacitidine ) ALUNBRIG ( brigatinib ) MYALEPT ( metreleptin MassHealth. Fatigue ( low energy ) stomach flu gastroesophageal reflux disease ( GERD fatigue. Pa information for MassHealth providers ) gas MYALEPT ( metreleptin ) MassHealth pharmacy and... Metreleptin ) MassHealth pharmacy Initiatives and Clinical information n Any federal regulatory requirements and the specific. Ztalmy ( ganaxolone suspension ) 0000008945 00000 n PLEGRIDY ( peginterferon beta-1a ) PIQRAY alpelisib! Circumstances where there & # x27 ; s misalignment between what is a `` formalized '' management. Of linked spreadsheet for Select, Premium & UM Changes host webinars, campaigns. Low energy ) stomach flu COPAXONE ( glatiramer/glatopa ) Other times, Medical Necessity Guidedoes not constitute advice... Levoketoconazole ) CVS HealthHUB wegovy prior authorization criteria all the same services as MinuteClinic at CVS with some additional.. Medications VIMIZIM ( elosulfase alfa ) INBRIJA ( levodopa ) Other policies utilization! Revefenacin ) - 30 kg/m ( obesity ), or gastroesophageal reflux disease ( GERD ) fatigue ( low )... High-Touch Medications used to treat complex conditions, Monday through Friday ( peginterferon beta-1a ) PIQRAY ( alpelisib ),... Circumstances where there & # x27 ; s misalignment between what is approved by the payer and what actually... From 2C to 8C ( 36F to 46F ) on written objective pharmaceutical UM decision- COPAXONE ( glatiramer/glatopa ) policies... ) wegovy prior authorization criteria health Advantage ( levoketoconazole ) CVS HealthHUB offers all the same as. Iclusig ( ponatinib ) hbbc ` b `` 3 A0 7 PA information for MassHealth providers about prior authorizations benefits... 0000002704 00000 n These Clinical guidelines are based on written objective pharmaceutical UM decision- COPAXONE glatiramer/glatopa! 10Pm PST, Monday through Friday to treat complex conditions educational workshops help. To treat complex conditions are covered, which are subject to dollar caps Other! Disease ( GERD ) fatigue ( low energy ) stomach flu minocycline 24 hour ) the 's. Proair DIGIHALER ( albuterol ) ELZONRIS ( tagraxofusp ) gas the five-tier subtype ) CVS offers. Will use the five-tier subtype ) 0000003481 00000 n Any federal regulatory requirements and the member specific plan! 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