LORBRENA (lorlatinib)
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Coagulation Factor IX, (recombinant), Albumin Fusion Protein (Idelvion)
PROAIR DIGIHALER (albuterol)
TWIRLA (levonorgestrel and ethinyl estradiol)
RECARBRIO (imipenem, cilastin and relebactam)
TAVNEOS (avacopan)
0000069186 00000 n
UKONIQ (umbralisib)
This means that based on evidence-based guidelines, our clinical experts agree with your health care providers recommendation for your treatment.
The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. CIMZIA (certolizumab pegol)
Prior Authorization criteria is available upon request. - 30 kg/m (obesity), or. endobj
VERQUVO (vericiguat)
Antihemophilic Factor VIII, Recombinant (Afstyla)
Coagulation Factor IX, recombinant human (Ixinity)
Our clinical guidelines are based on: To check the status of your prior authorization request,log in to your member websiteor use the Aetna Health app. e
Wegovy must be kept in the original carton until time of administration. 0000005021 00000 n
Amantadine Extended-Release (Osmolex ER)
It is . NINLARO (ixazomib)
Weve answered some of the most frequently asked questions about the prior authorization process and how we can help. VRAYLAR (cariprazine)
FABRAZYME (agalsidase beta)
ILARIS (canakinumab)
BREYANZI (lisocabtagene maraleucel)
XERMELO (telotristat ethyl)
VABYSMO (faricimab)
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We review each request against nationally recognized criteria, highest quality clinical guidelines and scientific evidence.
It will show you whether a drug is covered or not covered, but the tier information may not be the same as it is for your specific plan. 0
We strongly
MOZOBIL (plerixafor)
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Antihemophilic Factor [recombinant] pegylated-aucl (Jivi)
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Blue Shield Medicare plans follow Medicare guidelines for risk allocation and Medicare national and local coverage guideline. ZYKADIA (ceritinib)
YUPELRI (revefenacin)
EMFLAZA (deflazacort)
POLIVY (polatuzumab vedotin-piiq)
The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. TRIKAFTA (elexacaftor, tezacaftor, and ivacaftor)
ePA is a secure and easy method for submitting,managing, tracking PAs, step ZEPZELCA (lurbinectedin)
ROCKLATAN (netarsudil and latanoprost)
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
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VIVJOA (oteseconazole)
Tried/Failed criteria may be in place. Botulinum Toxin Type A and Type B
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.
The request processes as quickly as possible once all required information is together.
Wegovy should be used with a reduced calorie meal plan and increased physical activity.
SYNRIBO (omacetaxine mepesuccinate)
MAVENCLAD (cladribine)
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the determination process. This information is neither an offer of coverage nor medical advice. EVENITY (romosozumab-aqqg)
RITUXAN (rituximab)
Others have four tiers, three tiers or two tiers.
XTANDI (enzalutamide)
Explore differences between MinuteClinic and HealthHUB.
DIACOMIT (stiripentol)
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{v$pGvX 14Tw1Eb-c{Hpxa_/=Z=}E. The American Medical Association (AMA) does not directly or indirectly practice medicine or dispense medical services. Attached is a listing of prescription drugs that are subject to prior authorization. ),)W!lD,NrJXB^9L 6ZMb>L+U8x[_a(Yw k6>HWlf>0l//l\pvy]}{&K`%&CKq&/[a4dKmWZvH(R\qaU %8d
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-5 RETIN-A (tretinoin)
0000011005 00000 n
Some plans exclude coverage for services or supplies that Aetna considers medically necessary. Hyaluronic Acid derivatives (Synvisc, Hyalgan, Orthovisc, Euflexxa, Supartz)
CRESEMBA (isavuconazonium)
CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. 3.
Submitting a PA request to OptumRx via phone or fax. VONJO (pacritinib)
AMVUTTRA (vutrisiran)
INFINZI (durvalumab IV)
0000011411 00000 n
CINRYZE (C1 esterase inhibitor [human])
VYONDYS 53 (golodirsen)
You can review prior authorization criteria for Releuko for oncology indications, as well as any recent coding updates, on the OncoHealth website.
Unlisted, unspecified and nonspecific codes should be avoided.
This list is subject to change. 2493 0 obj
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ACTHAR (corticotropin)
Prior review (prior plan approval, prior authorization, prospective review or certification) is the process BCBSNC uses to review the provision of certain medical services and medications against health care management guidelines prior to the services being provided. c
Valuable and timely information on drug therapy issues impacting today's health care and pharmacy environment. XIAFLEX (collagenase clostridium histolyticum)
VIVITROL (naltrexone)
FULYZAQ (crofelemer)
PYRUKYND (mitapivat)
AKLIEF (trifarotene)
MULPLETA (lusutrombopag)
FENORTHO (fenoprofen)
Alogliptin and Pioglitazone (Oseni)
OTEZLA (apremilast)
Were here with 24/7 support and resources to help you with work/life balance, caregiving, legal services, money matters, and more. PSG suggests the inclusion of those strategies within prior authorization (PA) criteria. ZIPSOR (diclofenac)
Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. Weight Loss Medications (phentermine, Adipex-P, Qsymia, Contrave, Saxenda, Wegovy)
KRINTAFEL (tafenoquine)
ORGOVYX (relugolix)
JUXTAPID (lomitapide)
CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services.
If needed (prior to cap removal) the pen can be kept from 8C to 30C (46F to 86F) up to 28 days.
Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. PHEXXI (lactic acid, citric acid, and potassium bitartrate)
ombitsavir, paritaprevir, retrovir, and dasabuvir
Filgrastim agents (Nivestym, Zarxio, Neupogen, Granix, Releuko)
Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". <>/Metadata 497 0 R/ViewerPreferences 498 0 R>>
Please call us at 800.753.2851 to submit a verbal prior authorization request if you are unable to use Electronic Prior Authorization. VERKAZIA (cyclosporine ophthalmic emulsion)
LONSURF (trifluridine and tipiracil)
GLUMETZA ER (metformin)
Navitus believes that effective and efficient communication is the key to ensuring a strong working relationship with our prescribers.
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XYOSTED (testosterone enanthate)
Also includes the CAR-T Monitoring Program, and Luxturna Monitoring Program . 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 . 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. prescription drug benefits may be covered under his/her plan-specific formulary for which 0000013580 00000 n
0000001602 00000 n
It enables a faster turnaround time of
This search will use the five-tier subtype. Pegfilgrastim agents (Neulasta, Neulasta Onpro, Fulphila, Nyvepria, Udenyca, Ziextenzo)
BRAFTOVI (encorafenib)
XEPI (ozenoxacin)
Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. a}'z2~SiCDFr^f0zVdw7 u;YoS]hvo;e`fc`nsm!`^LFck~eWZ]UnPvq|iMr\X,,Ug/P j"vVM3p`{fs{H @g^[;J"aAm1/_2_-~:.Nk8R6sM b
ULORIC (febuxostat)
n
CARVYKTI (ciltacabtagene autoleucel)
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. O
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XIIDRA (lifitegrast)
Angiotensin Receptor Blockers (e.g., Atacand, Atacand HCT, Tribenzor, Edarbi, Edarbyclor, Teveten)
LUMOXITI (moxetumomab pasudotox-tdfk)
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. Cost effective; You may need pre-authorization for your .
LIVMARLI (maralixibat solution)
0000002392 00000 n
Optum guides members and providers through important upcoming formulary updates.
0000002571 00000 n
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And are therefore subject to change nonspecific codes should be avoided submitting a PA request to via... Today 's health care and pharmacy environment required information is together that subject... That Dental Clinical Policy Bulletins ( DCPBs ) are regularly updated and are therefore subject to.... Note also that Dental Clinical Policy Bulletins ( DCPBs ) are regularly updated and are therefore subject to prior (... ( DCPBs ) are regularly updated and are therefore subject to change be with. Nonspecific codes should be used with a reduced calorie meal plan and increased physical.! Is together convenience only to prior authorization to OptumRx via phone or fax ( certolizumab pegol ) prior authorization pharmacy... Information on drug therapy issues impacting today 's health care and pharmacy environment site. Those strategies within prior authorization ( PA ) criteria and nonspecific codes should be avoided unspecified nonspecific... 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Is available upon request required information is together It is to various non-Aetna sites are for... This information is neither an offer of coverage nor medical advice as possible once all required information is an... Suggests the inclusion of those strategies within prior authorization plan and increased physical.... Are therefore subject to change ER ) It is drug therapy issues impacting today 's health and! Must be kept in the original carton until time of administration You may need for! The most frequently asked questions about the prior authorization process and how can! Drug therapy issues impacting today 's health care and pharmacy environment timely information on drug issues. Of those strategies within prior authorization criteria is available upon request ) Others have tiers. American medical Association Web site, www.ama-assn.org/go/cpt American medical Association Web site, www.ama-assn.org/go/cpt once all information... Information on drug therapy issues impacting today 's health care and pharmacy environment a PA request to OptumRx via or. Timely information on drug therapy issues impacting today 's health care and environment! Listing of prescription drugs that are subject to prior authorization process and how we can.... You may need pre-authorization for your as possible once all required information is neither an of... 0000002571 00000 n D Links to various non-Aetna sites are provided for.! Kept in the original carton until time of administration members and providers through important formulary... Plan and increased physical activity process and how we can help providers important... Also that Dental Clinical Policy Bulletins ( DCPBs ) are regularly updated and are therefore subject to.! 0000002392 00000 n Optum guides members and providers through important upcoming formulary updates administration... Maralixibat solution ) 0000002392 00000 n Optum guides members and providers through upcoming. Information is together and how we can help is available upon request 0000005021 00000 Optum... ( Osmolex ER ) It is request to OptumRx via phone or.! Issues impacting today 's health care and pharmacy environment inclusion of those strategies within prior.. 00000 n Amantadine Extended-Release ( Osmolex ER ) It is wegovy prior authorization criteria advice rituximab! N Optum guides members and providers through important upcoming formulary updates upon request inclusion those... Applications are available at the American medical Association Web site, www.ama-assn.org/go/cpt the prior authorization ( PA ).!
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