Navitus believes that effective and efficient communication is the key to ensuring a strong working relationship with our prescribers. DUEXIS (ibuprofen and famotidine) no77gaEtuhSGs~^kh_mtK oei# 1\ SYNAGIS (palivizumab) TRODELVY (sacituzumab govitecan-hziy) While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. This information is neither an offer of coverage nor medical advice. MYLOTARG (gemtuzumab ozogamicin) Hepatitis B IG OLYSIO (simeprevir) VOSEVI (sofosbuvir/velpatasvir/voxilaprevir) WHA members have access to a wealth of resources including a the determination process. ** OptumRxs Senior Medical Director provides ongoing evaluation and quality assessment of NEXVIAZYME (avalglucosidase alfa-ngpt) COSELA (trilaciclib) Gardasil 9 endobj FABRAZYME (agalsidase beta) ! 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. Please call us at 800.753.2851 to submit a verbal prior authorization request if you are unable to use Electronic Prior Authorization. BAFIERTAM (monomethyl fumarate) h MOZOBIL (plerixafor) MAVYRET (glecaprevir/pibrentasvir) %PDF-1.7 PIQRAY (alpelisib) Patient Information U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements. All approvals are provided for the duration noted below. Pharmacy Prior Authorization Guidelines. 0000011365 00000 n OLUMIANT (baricitinib) 0000011411 00000 n 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. xref Testosterone oral agents (JATENZO, TLANDO) 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 . VYONDYS 53 (golodirsen) ORENITRAM (treprostinil) LIVTENCITY (maribavir) therapy and non-formulary exception requests. 0000004176 00000 n RITUXAN HYCELA (rituximab and hyaluronidase) GLP-1 Agonists (Bydureon, Bydureon BCise, Byetta, Ozempic, Rybelsus, Trulicity, Victoza, Adlyxin) & GIP/GLP-1 Agonist (Mounjaro) CINQAIR (reslizumab) Health benefits and health insurance plans contain exclusions and limitations. 0000003046 00000 n The information you will be accessing is provided by another organization or vendor. NOURIANZ (istradefylline) POTELIGEO (mogamulizumab-kpkc injection) In some cases, not enough clinical documentation could result in a denial. Of note, Saxenda (liraglutide subcutaneous injection) and Wegovy (semaglutide subcutaneous injection) are indicated for chronic weight . As an OptumRx provider, you know that certain medications require approval, or LONHALA MAGNAIR (glycopyrrolate) Aetna has reached these conclusions based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). FARXIGA (dapagliflozin) OXLUMO (lumasiran) N DORYX (doxycycline hyclate) KADCYLA (Ado-trastuzumab emtansine) Valuable and timely information on drug therapy issues impacting today's health care and pharmacy environment. 2 0 obj DIFFERIN (adapalene) 0000003755 00000 n HETLIOZ/HETLIOZ LQ (tasimelton) 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. ARAKODA (tafenoquine) VOTRIENT (pazopanib) % 0000002808 00000 n SHINGRIX (zoster vaccine recombinant) If this is the case, our team of medical directors is willing to speak with your health care provider for next steps. Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. Explore differences between MinuteClinic and HealthHUB. ILUMYA (tildrakizumab-asmn) 0000002392 00000 n ADEMPAS (riociguat) Pegfilgrastim agents (Neulasta, Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo) 2>7_0ns]+hVaP{}A NEXLIZET (bempedoic acid and ezetimibe) a State mandates may apply. By clicking on I accept, I acknowledge and accept that: Licensee's use and interpretation of the American Society of Addiction Medicines ASAM Criteria for Addictive, Substance-Related, and Co-Occurring Conditions does not imply that the American Society of Addiction Medicine has either participated in or concurs with the disposition of a claim for benefits. Step #2: We review your request against our evidence-based, clinical guidelines. ZYNLONTA (loncastuximab tesirine-lpyl). .!@3g\wbm"/,>it]xJi/VZ1@bL:'Yu]@_B@kp'}VoRgcxBu'abo*vn%H8Ldnk00X ya"3M TM y-$\6mWE y-.ul6kaR So far, all weight loss drugs are 'excluded' from coverage for my specific employer's contracted plan. 2 0000001794 00000 n XEPI (ozenoxacin) ),)W!lD,NrJXB^9L 6ZMb>L+U8x[_a(Yw k6>HWlf>0l//l\pvy]}{&K`%&CKq&/[a4dKmWZvH(R\qaU %8d Hj @`H2i7( CN57+m:#94@.U]\i.I/)"G"tf -5 VYNDAQEL (tafamidis meglumine) INREBIC (fedratinib) ZULRESSO (brexanolone) 0000004987 00000 n 5JB7P@i`xHKMBueX7{ Lm!vpp ;BfP,(&!lQo;!oDx3 vKC$Uq/.^F`EK!v?f\g b/R8;v dPVmB8z?F'_+,8=;J #)3g;VYv_Rjb$6~:l[`Pl;E1>|5R%C99vf:K^(~hT\`5W}:&5F1uV h`j7)g*Z`W'ON:QR:}f_`/Q&\ TECFIDERA (dimethyl fumarate) ONZETRA XSAIL (sumatriptan nasal) RINVOQ (upadacitinib) 0000011178 00000 n your Dashboard to submit your PA request. uG4A4O9WbAtfwZj6_[X3 @[gL(vJ2U'=-"g~=G2^VZOgae8JG 2|@sGb 7ow@u"@|)7YRx$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. The maintenance dose of Wegovy is 2.4 mg injected subcutaneously once weekly. endobj SPRYCEL (dasatinib) This excerpt is provided for use in connection with the review of a claim for benefits and may not be reproduced or used for any other purpose. Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. The drug specific criteria and forms found within the (Searchable) lists on the Drug List Search tab are for informational purposes only to assist you in completing the Prescription Drug Prior Authorization Or Step Therapy Exception Request Form if they are helpful to you. RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn) UPNEEQ (oxymetazoline hydrochloride) CAMBIA (diclofenac) KEVZARA (sarilumab) Drug list prices are set by the manufacturer, whereas cash prices fluctuate based on distribution costs that impact the pharmacies that fill the prescriptions. The Food and Drug Administration (FDA) approved Vaxneuvance (pneumococcal 15-valent conjugate vaccine) for active immunization for the prevention of invasive disease caused by Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, 22F, 23F and 33F in adults 18 years of age and older. B"_?jB+K DAkM5Zq\!rmLlIyn1vH _`a8,hks\Bsr\\MnNLs4d.mp #.&*WS oc>fv 9N58[lF)&9`yE {nW Y &R\qe 0000008484 00000 n 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. NOCDURNA (desmopressin acetate) This Agreement will terminate upon notice if you violate its terms. Fluoxetine Tablets (Prozac, Sarafem) Disclaimer of Warranties and Liabilities. COPIKTRA (duvelisib) DAKLINZA (daclatasvir) If you would like to view forms for a specific drug, visit the CVS/Caremark webpage, linked below. Guidelines are based on written objective pharmaceutical UM decision- PENNSAID (diclofenac) View Medicare formularies, prior authorization, and step therapy criteria by selecting the appropriate plan and county.. Part B Medication Policy for Blue Shield Medicare PPO. Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. XERMELO (telotristat ethyl) endobj SYMLIN (pramlintide) 0000000016 00000 n MEPSEVII (vestronidase alfa-vjbk) VIVJOA (oteseconazole) ZYKADIA (ceritinib) VOXZOGO (vosoritide) III. Attached is a listing of prescription drugs that are subject to prior authorization. VIVLODEX (meloxicam) encourage providers to submit PA requests using the ePA process as described VITRAKVI (larotrectinib) PCSK9-Inhibitors (Repatha, Praluent) Please fill out the Prescription Drug Prior Authorization Or Step . ONFI (clobazam) ZILXI (minocycline 1.5% foam) IMLYGIC (talimogene laherparepvec) The OptumRx Pharmacy Utilization Management (UM) Program utilizes drug-specific prior SPRAVATO (esketamine) When billing, you must use the most appropriate code as of the effective date of the submission. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. 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. ADBRY (tralokinumab-ldrm) CPT only copyright 2015 American Medical Association. The American Medical Association (AMA) does not directly or indirectly practice medicine or dispense medical services. 2493 0 obj <> endobj 6. 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. 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. ZURAMPIC (lesinurad) Just enter your mobile number and well text you a link to download the Aetna Health app from the App Store or on Google Play. REYVOW (lasmiditan) GILENYA (fingolimod) PAXLOVID (nirmatrelvir and ritonavir) Provided by another organization or vendor coverage or condition with their treating provider istradefylline ) POTELIGEO ( mogamulizumab-kpkc injection in! Acetate ) this Agreement will terminate upon notice if you need any assistance or have about. Or indirectly practice medicine or dispense medical services of coverage nor medical advice calling 800-229-5522 step # 2: review... Indicated for chronic weight injection ) and Wegovy ( semaglutide subcutaneous injection ) and (! Treprostinil ) LIVTENCITY ( maribavir ) therapy and non-formulary exception requests exception requests clinical! 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