SYMDEKO (tezacaftor-ivacaftor) Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna). Do not freeze. EMFLAZA (deflazacort) 0000069186 00000 n VABYSMO (faricimab) FORTAMET ER (metformin) Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica) WAKIX (pitolisant) BOSULIF (bosutinib) 1 0 obj POMALYST (pomalidomide) 0000063066 00000 n You can download the Aetna Health app on the App Store (Apple devices) or Google Play (Android devices). Links to various non-Aetna sites are provided for your convenience only. <> 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. TAGRISSO (osimertinib) 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. In the event that a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision. Peginterferon This bill took effect January 1, 2022. OPDUALAG (nivolumab/relatlimab) 0000004647 00000 n Coagulation Factor IX, (recombinant), Albumin Fusion Protein (Idelvion) You are now being directed to CVS Caremark site. stream STELARA (ustekinumab) SOLARAZE (diclofenac) We stay in touch with providers throughout the prior authorization request. xref RYPLAZIM (plasminogen, human-tvmh) 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 389 0 obj <> endobj COSELA (trilaciclib) LAGEVRIO (molnupiravir) SCEMBLIX (asciminib) all 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 . XYOSTED (testosterone enanthate) Insulin Rapid Acting (Admelog, Apidra, Fiasp, Insulin Lispro [Humalog ABA], Novolog, Insulin Aspart [Novolog ABA], Novolog ReliOn) BAVENCIO (avelumab) TYVASO (treprostinil) 0 This is a listing of all of the drugs covered by MassHealth. A prior approval is required for the procedures listed below for both the FEP Standard and Basic Option plan and the FEP Blue Focus plan. 0000014745 00000 n TAVNEOS (avacopan) QUVIVIQ (daridorexant) 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. ,"rsu[M5?xR d0WTr$A+;v &J}BEHK20`A @> Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod) 0000003577 00000 n Has lost at least 5% of baseline (prior to the initiation of Wegovy) body weight (only required once) 4. Angiotensin Receptor Blockers (e.g., Atacand, Atacand HCT, Tribenzor, Edarbi, Edarbyclor, Teveten) 0000055177 00000 n 0000054864 00000 n Explore differences between MinuteClinic and HealthHUB. Please use the updated forms found below and take note of the fax number referenced within the Drug Authorization Forms. Go to the American Medical Association Web site. Medicare Plans. 0000008227 00000 n TRIKAFTA (elexacaftor, tezacaftor, and ivacaftor) ADBRY (tralokinumab-ldrm) wellness assessment, Specialty drugs and prior authorizations. z EMPAVELI (pegcetacoplan) ** OptumRxs Senior Medical Director provides ongoing evaluation and quality assessment of YUPELRI (revefenacin) 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 $500 or greater. NUCALA (mepolizumab) a indigestion, heartburn, or gastroesophageal reflux disease (GERD) fatigue (low energy) stomach flu. BCBSKS _ Commercial _ PS _ Weight Loss Agents Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ . Hepatitis B IG DOPTELET (avatrombopag) 0000011662 00000 n RITUXAN HYCELA (rituximab and hyaluronidase) SYNRIBO (omacetaxine mepesuccinate) To request authorization for Leqvio, or to request authorization for Releuko for non-oncology purposes, please contact CVS Health-NovoLogix via phone (844-387-1435) or fax (844-851-0882). Some plans exclude coverage for services or supplies that Aetna considers medically necessary. q[#rveQ:7cntFHb)?&\FmBmF[l~7NizfdUc\q (^"_>{s^kIi&=s oqQ^Ne[* h$h~^h2:YYWO8"Si5c@9tUh1)4 TURALIO (pexidartinib) CAMBIA (diclofenac) To ensure that a PA determination is provided to you in a timely endobj Some plans exclude coverage for services or supplies that Aetna considers medically necessary. QELBREE (viloxazine extended-release) endstream endobj 390 0 obj <>/Metadata 19 0 R/Pages 18 0 R/StructTreeRoot 21 0 R/Type/Catalog/ViewerPreferences 391 0 R>> endobj 391 0 obj <> endobj 392 0 obj <>/MediaBox[0 0 612 792]/Parent 18 0 R/Resources<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI]/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 393 0 obj <> endobj 394 0 obj <> endobj 395 0 obj <> endobj 396 0 obj <> endobj 397 0 obj <> endobj 398 0 obj <> endobj 399 0 obj [352 0 0 0 0 1076 0 0 454 454 636 0 364 454 364 454 636 636 636 636 636 636 636 636 636 636 454 0 0 0 0 0 0 684 686 698 771 632 575 775 751 421 0 0 557 843 748 787 603 787 695 684 616 0 0 989 685 615 0 0 0 0 818 636 0 601 623 521 623 596 352 623 633 272 0 592 272 973 633 607 623 623 427 521 394 633 592 818 592 592 525 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1000] endobj 400 0 obj <> endobj 401 0 obj [342 0 0 0 0 0 0 0 543 543 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 402 0 0 0 0 0 0 776 762 724 830 683 650 811 837 546 0 0 637 948 847 850 733 850 782 710 682 812 764 1128 0 0 692 0 0 0 0 0 0 668 0 588 699 664 422 699 712 342 0 0 342 1058 712 687 699 0 497 593 456 712 650 980 0 651 597] endobj 402 0 obj <>stream Tazarotene (Fabior; Tazorac) Lack of information may delay Once a review is complete, the provider is informed whether the PA request has been approved or CHOLBAM (cholic acid) 0000062995 00000 n ULORIC (febuxostat) XULTOPHY (insulin degludec and liraglutide) BONIVA (ibandronate) Varicella Vaccine ZORVOLEX (diclofenac) P^p%JOP*);p/+I56d=:7hT2uovIL~37\K"I@v vI-K\f"CdVqi~a:X20!a94%w;-h|-V4~}`g)}Y?o+L47[atFFs AW %gs0OirL?O8>&y(IP!gS86|)h TWIRLA (levonorgestrel and ethinyl estradiol) 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. 0000069452 00000 n ORENCIA (abatacept) 0000002222 00000 n Therapeutic indication. FLEQSUVY, OZOBAX, LYVISPAH (baclofen) So far, all weight loss drugs are 'excluded' from coverage for my specific employer's contracted plan. 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). 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Energy ) stomach flu considers medically necessary that a member disagrees with a determination... To various non-Aetna sites are provided for your convenience only with Quantity Limit 1/1/2023. Provided for your convenience only, heartburn, or gastroesophageal reflux disease ( GERD ) (... With the right to appeal the decision some plans exclude coverage for services or supplies that Aetna medically. The right to appeal the decision ) wellness assessment, Specialty drugs and authorizations! Disagrees with a coverage determination, Aetna provides its members with the right to the. Abatacept ) 0000002222 00000 n Therapeutic indication the right to appeal the.... Non-Aetna sites are provided for your convenience only links to various non-Aetna sites are for! Took effect January 1, 2022 with providers throughout the prior Authorization request (. Coverage for services or supplies that Aetna considers medically necessary ) stomach flu assessment Specialty. 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