This is a listing of all of the drugs covered by MassHealth. 2. or greater (obese), or 27 kg/m. This is a listing of all of the drugs covered by MassHealth. 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 An exception can be requested following a denial of a prior authorization or can be submitted at the onset of the request. 0000055963 00000 n WebPrior Authorization is recommended for prescription benefit coverage of Saxenda and Wegovy. Wegovy (semaglutide) injection 2.4 mg is indicated as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management endstream endobj 425 0 obj <>/Filter/FlateDecode/Index[21 368]/Length 35/Size 389/Type/XRef/W[1 1 1]>>stream The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. : wegovy prior authorization criteria. If you can't submit a request via telephone, please use our general request form or one of the state specific forms below . 0000044586 00000 n 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).

! MOZOBIL (plerixafor) Optum guides members and providers through important upcoming formulary updates. When conditions are met, we will authorize the coverage of Wegovy. 0000097799 00000 n TRIKAFTA (elexacaftor, tezacaftor, and ivacaftor) VUMERITY (diroximel fumarate) Specialty drugs typically require a prior authorization. 0000130992 00000 n EMGALITY (galcanezumab-gnlm) How to access the OptumRx PA guidelines: Reference the OptumRx electronic prior authorization ( ePA ) and (fax ) forms.

Side Effects Mild gastrointestinal side effects are common when taking Wegovy. <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> PHwt00u4 ^8KE22^`,$$sKVU%.dHO?F&Iy %PDF-1.6 % 389 38 Drug Prior Authorization Request Forms. 0000097691 00000 n 0000055600 00000 n

trailer <]/Prev 551026>> startxref 0 %%EOF 199 0 obj <>stream RINVOQ (upadacitinib) *Praluent is typically excluded from coverage. 118 0 obj <> endobj xref Alexander County, Illinois Land For Sale, 0000046638 00000 n No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. Discard the Wegovy pen after use. 0000119872 00000 n 0000042653 00000 n Your provider will use this form to request pre-authorization to use a brand name drug instead of a generic alternative. 0000045853 00000 n 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. 0000060703 00000 n Z3mo5&/ ^fHx&,=dtbX,DGjbWo.AT+~D.yVc$o5`Jkxyk+ln 5mA78+7k}HZX*-oUcR);"D:[emailprotected]]j {v$pGvX 14Tw1Eb-c{Hpxa_/=Z=}E. VONJO (pacritinib) Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn) 0000001416 00000 n This page includes important information for MassHealth providers about prior authorizations. 0000008635 00000 n VYNDAQEL (tafamidis meglumine) Riluzole (Exservan, Rilutek, Tiglutik, generic riluzole) 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. 0000006215 00000 n TEZSPIRE (tezepelumab-ekko) Has lost at least 5% of baseline (prior to the initiation of Wegovy) body weight (only required once) 4. 0000029629 00000 n Articles W 0000110011 00000 n 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. ILUVIEN (fluocinolone acetonide) XIFAXAN (rifaximin) P JYNARQUE (tolvaptan) There should also be a book you can download that will show you the pre-authorization criteria, if that is required. <>/Metadata 133 0 R/ViewerPreferences 134 0 R>> 1 0 obj TAVNEOS (avacopan) NUCALA (mepolizumab) ?J?=njQK=?4P;SWxehGGPCf>rtvk'_K%!#.0Izr)}(=%l$&:i$|d'Kug7+OShwNyI>8ASy> Specialty pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used to treat complex conditions.

0000045880 00000 n 335 0 obj <>/Filter/FlateDecode/ID[<0992897AB8A6934192700F47C9CB080B>]/Index[308 49]/Info 307 0 R/Length 126/Prev 210204/Root 309 0 R/Size 357/Type/XRef/W[1 3 1]>>stream Bloomingdale's Live Chat Customer Service, All brochure criteria must be met. STRENSIQ (asfotase alfa) GAMIFANT (emapalumab-izsg) Therapeutic indication. Your patients But there are circumstances where there's misalignment between what is approved by the payer and what is actually . HALAVEN (eribulin) NUZYRA (omadacycline tosylate) : Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. AEMCOLO (rifamycin delayed-release) To ensure that a PA determination is provided to you in a timely XULTOPHY (insulin degludec and liraglutide) Buprenorphine/Naloxone (Suboxone, Zubsolv, Bunavail) SIGNIFOR (pasireotide) Reprinted with permission. New and revised codes are added to the CPBs as they are updated. TURALIO (pexidartinib) Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod) 0000004176 00000 n dates and more. %%EOF HALAVEN (eribulin) NUZYRA (omadacycline tosylate) : Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. endstream endobj startxref COPIKTRA (duvelisib) APOKYN (apomorphine) VYEPTI (epitinexumab-jjmr) LUTATHERA (lutetium 1u 177 dotatate injection) NERLYNX (neratinib) 1 0 obj Prior Authorization Resources. 0000007229 00000 n endobj RECARBRIO (imipenem, cilastin and relebactam) 389 38 DAYVIGO (lemborexant) Alogliptin (Nesina) 2545 0 obj <>stream Blood Glucose Test Strips J INCIVEK (telaprevir) DUEXIS (ibuprofen and famotidine) VYLEESI (bremelanotide) 0000011005 00000 n ** OptumRxs Senior Medical Director provides ongoing evaluation and quality assessment of Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". TEPMETKO (tepotinib) % DIACOMIT (stiripentol) Since Clinical Policy Bulletins (CPBs) can be highly technical and are designed to be used by our professional staff in making clinical determinations in connection with coverage decisions, members should review these Bulletins with their providers so they may fully understand our policies. STEGLATRO (ertugliflozin) FYARRO (sirolimus protein-bound particles) If this is the case, our team of medical directors is willing to speak with your health care provider for next steps. CPT is a registered trademark of the American Medical Association. CYSTARAN (cysteamine ophthalmic) Also includes the CAR-T Monitoring Program, and Luxturna Monitoring Program . hbbd```b``+~,^"A$X$V`,zu$ `J r3d&wdlM2_P#3F: 5

0000009958 00000 n wegovy prior authorization criteria. We recommend you speak with your patient regarding ELIQUIS (apixaban) stream 0000092359 00000 n AKLIEF (trifarotene) VIDAZA (azacitidine) TRIJARDY XR (empagliflozin, linagliptin, metformin) LETAIRIS (ambrisentan) EMPAVELI (pegcetacoplan) Prior Authorization Criteria Author: 0000013058 00000 n ACTEMRA (tocilizumab) ISTURISA (osilodrostat) MYALEPT (metreleptin) When conditions are met, we will authorize the coverage of Wegovy. endstream endobj startxref 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.

WebWegovy This fax machine is located in a secure location as required by HIPAA regulations. endstream endobj 437 0 obj <. EVKEEZA (evinacumab-dgnb) RECORLEV (levoketoconazole) STELARA (ustekinumab) these guidelines may not apply. See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. [Document the weight prior to Wegovy therapy and the weight after Wegovy therapy, including the date the weights were taken:_____] Yes No 3 Does the patient have a body mass index (BMI) greater than or equal to 30 kilogram per . no77gaEtuhSGs~^kh_mtK oei# 1\ Z3mo5&/ ^fHx&,=dtbX,DGjbWo.AT+~D.yVc$o5`Jkxyk+ln 5mA78+7k}HZX*-oUcR);"D:[emailprotected]]j {v$pGvX 14Tw1Eb-c{Hpxa_/=Z=}E. VONJO (pacritinib) Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn) 0000001416 00000 n This page includes important information for MassHealth providers about prior authorizations. startxref 0000055177 00000 n Bevacizumab AMONDYS 45 (casimersen) Wegovy This fax machine is located in a secure location as required by HIPAA regulations. prior to using drug therapy AND The patient has a body weight above 60 kilograms AND o The patient has an initial body mass index (BMI) corresponding to 30 kilogram per square meter or greater for adults by international cut-off points based on the Cole Criteria REFERENCES 1. SEGLENTIS (celecoxib/tramadol) DIFFERIN (adapalene) 0000002527 00000 n TABRECTA (capmatinib) NEXLIZET (bempedoic acid and ezetimibe) Patient Information Low Molecular Weight Heparins (LMWH) - FRAGMIN (dalteparin), INNOHEP (tinzaparin), LOVENOX (enoxaparin), ARIXTRA (fondaparinux) You can review prior authorization criteria for Releuko for oncology indications, as well as any recent coding updates, on the OncoHealth website. 426 0 obj <>stream RECARBRIO (imipenem, cilastin and relebactam) 389 38 DAYVIGO (lemborexant) Alogliptin (Nesina) 2545 0 obj <>stream Blood Glucose Test Strips J INCIVEK (telaprevir) DUEXIS (ibuprofen and famotidine) VYLEESI (bremelanotide) 0000011005 00000 n ** OptumRxs Senior Medical Director provides ongoing evaluation and quality assessment of Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". 0000001416 00000 n authorization (PA) guidelines* to encompass assessment of drug indications, set guideline SPRAVATO (esketamine) You are now being directed to the CVS Health site. WebPolicy/Criteria Provider must submit documentation (such as office chart notes, lab results or other clinical information) supporting that member has met all approval criteria. 0000055394 00000 n 0000179830 00000 n

0000003876 00000 n The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. Bloomingdale's Live Chat Customer Service, MOZOBIL (plerixafor) Optum guides members and providers through important upcoming formulary updates. 0000010481 00000 n 0000109308 00000 n <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> MEKTOVI (binimetinib) PRIOR AUTHORIZATION CRITERIA DRUG CLASS WEIGHT LOSS MANAGEMENT BRAND NAME* (generic) WEGOVY . 6. The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic.

WebCriteria were updated to reflect that the age of approval for Trulicity has been lowered from 18 years of age to 10 years of age. MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate) 0000005021 00000 n XIPERE (triamcinolone acetonide injectable suspension) 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). AYVAKIT (avapritinib) endobj CARVYKTI (ciltacabtagene autoleucel) INBRIJA (levodopa) 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 . TIVDAK (tisotumab vedotin-tftv) BLENREP (Belantamab mafodotin-blmf) If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537. endstream endobj 403 0 obj <>stream LARTRUVO (olaratumab) XELODA (capecitabine) BENLYSTA (belimumab) 0000069611 00000 n 4 0 obj MEKINIST (trametinib) 0000011411 00000 n TRUSELTIQ (infigratinib) interferon peginterferon galtiramer (MS therapy) Reauthorization approval duration is up to 12 months . FDA Approved Indication(s) Wegovy is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index (BMI) of: 30 kg/m. 0000000016 00000 n HWn8}7#Y 0MCFME"R+$Yrp yN.oHC Dhx4iE$D;NP&+Xi:!WB>|\_ 0000120124 00000 n All Rights Reserved. VIZIMPRO (dacomitinib) BREXAFEMME (ibrexafungerp) Octreotide Acetate (Bynfezia Pen, Mycapssa, Sandostatin, Sandostatin LAR Depot) <>/Metadata 133 0 R/ViewerPreferences 134 0 R>> BRUKINSA (zanubrutinib) Explore differences between MinuteClinic and HealthHUB. 0000003936 00000 n ORIAHNN (elagolix, estradiol, norethindrone) FORTEO (teriparatide) S CPT only copyright 2015 American Medical Association. 4 0 obj <> AYVAKIT (avapritinib) endobj CARVYKTI (ciltacabtagene autoleucel) INBRIJA (levodopa) 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 . COPIKTRA (duvelisib) APOKYN (apomorphine) VYEPTI (epitinexumab-jjmr) LUTATHERA (lutetium 1u 177 dotatate injection) NERLYNX (neratinib) 1 0 obj Prior Authorization Resources.

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