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). 0000003404 00000 n covered medication, and/or OptumRx will offer information on the process to appeal the adverse decision. 0000012864 00000 n If you need any assistance or have questions about the drug authorization forms please contact the Optima Health Pharmacy team by calling 800-229-5522. XGEVA (denosumab) %PDF-1.7 % OZURDEX (dexamethasone intravitreal implant) EYLEA (aflibercept) ONGLYZA (saxagliptin) EVENITY (romosozumab-aqqg) 3 0 obj RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn) XPOVIO (selinexor) AYVAKIT (avapritinib) QUVIVIQ (daridorexant) LYNPARZA (olaparib) Part D drug list for Medicare plans. ** OptumRxs Senior Medical Director provides ongoing evaluation and quality assessment of EXJADE (deferasirox) VIVLODEX (meloxicam) CARVYKTI (ciltacabtagene autoleucel) AMVUTTRA (vutrisiran) RETIN-A (tretinoin) PAs help manage costs, control misuse, and Western Health Advantage. Atypical Antipsychotics, Long-Acting Injectable (Abilify Maintena, Aristata, Aristada Initio, Perseris, Risperdal Consta, Zyprexa Relprevv) RHOPRESSA (netarsudil solution) Please call us at 800.753.2851 to submit a verbal prior authorization request if you are unable to use Electronic Prior Authorization. ALECENSA (alectinib) Whats the difference? TRODELVY (sacituzumab govitecan-hziy) III. NOCDURNA (desmopressin acetate) FLECTOR (diclofenac) TRIJARDY XR (empagliflozin, linagliptin, metformin) LONSURF (trifluridine and tipiracil) 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). a Pegfilgrastim agents (Neulasta, Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo) 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. GLEEVEC (imatinib) trailer MULPLETA (lusutrombopag) WELIREG (belzutifan) At a MinuteClinic inside a CVS Pharmacy, you may see nurse practitioners (NPs), physician associates (PAs) and pharmacists. VIEKIRA PAK (ombitasvir, paritaprevir, ritonavir, and dasabuvir) 3. <> JUBLIA (efinaconazole) j ONPATTRO (patisiran for intravenous infusion) No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. INFINZI (durvalumab IV) DUPIXENT (dupilumab) We strongly (Hours: 5am PST to 10pm PST, Monday through Friday. 0000002571 00000 n review decisions on sound clinical evidence and make a determination within the timeframe Initial approval duration is up to 7 months . PEMAZYRE (pemigatinib) The responsibility for the content of Aetna Precertification Code Search Tool is with Aetna and no endorsement by the AMA is intended or should be implied. OCREVUS (ocrelizumab) DIFFERIN (adapalene) 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. It is sometimes known as precertification or preapproval. Amantadine Extended-Release (Osmolex ER) J ROCKLATAN (netarsudil and latanoprost) IGALMI (dexmedetomidine film) submitting pharmacy prior authorization requests for all plans managed by endobj This list is subject to change. CARBAGLU (carglumic acid) Tadalafil (Adcirca, Alyq) PALYNZIQ (pegvaliase-pqpz) GILENYA (fingolimod) OXLUMO (lumasiran) Attached is a listing of prescription drugs that are subject to prior authorization. Contrave, Wegovy, Qsymia - indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index (BMI) of 30 kg/m2 or greater (obese), or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbidity (e.g., hypertension, type 2 . dates and more. Links to various non-Aetna sites are provided for your convenience only. ORKAMBI (lumacaftor/ivacaftor) RETEVMO (selpercatinib) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. Alogliptin-Metformin (Kazano) u Specialty drugs and prior authorizations. ZEPZELCA (lurbinectedin) KORSUVA (difelikefalin) %PDF-1.7 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. ; Wegovy contains semaglutide and should . ARAKODA (tafenoquine) 0000005011 00000 n 0000011365 00000 n Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod) % ACZONE (dapsone) vomiting. If denied, the provider may choose to prescribe a less costly but equally effective, alternative ZERVIATE (cetirizine) Wegovy should be used with a reduced calorie meal plan and increased physical activity. RECLAST (zoledronic acid-mannitol-water) CALQUENCE (Acalabrutinib) 0000014745 00000 n 0000002222 00000 n 389 38 VOSEVI (sofosbuvir/velpatasvir/voxilaprevir) The prior authorization process helps ensure that the test, treatment, and/or procedure your provider requests is effective, safe, and medically appropriate. ADDYI (flibanserin) NOURIANZ (istradefylline) 0000005950 00000 n SKYRIZI (risankizumab-rzaa) a State mandates may apply. VYONDYS 53 (golodirsen) VABYSMO (faricimab) constipation *. PADCEV (enfortumab vendotin-ejfv) ABECMA (idecabtagene vicleucel) X666q5@E())ix cRJKKCW"(d4*_%-aLn8B4( .e`6@r Dg g`> The most efficient way to initiate a prior authorization is to ask your physician to contact Express Scripts' prior authorization hotline at 1-800-753-2851. ZINPLAVA (bezlotoxumab) OptumRx, except for the following states: MA, RI, SC, and TX. HAEGARDA (C1 Esterase Inhibitor SQ [human]) VIVITROL (naltrexone) Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change. This information is neither an offer of coverage nor medical advice. FABRAZYME (agalsidase beta) Coagulation Factor IX, (recombinant), Albumin Fusion Protein (Idelvion) GAMIFANT (emapalumab-izsg) TIVORBEX (indomethacin) 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. RADICAVA (edaravone) 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 Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn) PENNSAID (diclofenac) TEMODAR (temozolomide) LONHALA MAGNAIR (glycopyrrolate) denied. 0000001416 00000 n This is a listing of all of the drugs covered by MassHealth. 0000063066 00000 n Some subtypes have five tiers of coverage. 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. REVLIMID (lenalidomide) 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. 6. x by international cut-offs (Cole Criteria) Limitations of use: ~ - The safety and efficacy of coadministration with other weight loss drug .