In case of a conflict between your plan documents and this information, the plan documents will govern. protect patient safety, as well as ensure the best possible therapeutic outcomes. The number of medically necessary visits . AUBAGIO (teriflunomide) LEUKINE (sargramostim) What is a "formalized" weight management program? ORKAMBI (lumacaftor/ivacaftor) iMo::>91}h9 But there are circumstances where there's misalignment between what is approved by the payer and what is actually . LONHALA MAGNAIR (glycopyrrolate) COPAXONE (glatiramer/glatopa) III. Aetna makes no representations and accepts no liability with respect to the content of any external information cited or relied upon in the Clinical Policy Bulletins (CPBs). GILENYA (fingolimod) ACTHAR (corticotropin) Step #1: Your health care provider submits a request on your behalf. Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". MAVENCLAD (cladribine) endstream endobj 403 0 obj <>stream OTEZLA (apremilast) NPLATE (romiplostim) TYRVAYA (varenicline) ESBRIET (pirfenidone) MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate) KYLEENA (Levonorgestrel intrauterine device) VONJO (pacritinib) ORENCIA (abatacept) TAZVERIK (tazematostat) In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. rz^6>)@?v": QCd?Pcu EYSUVIS (loteprednol etabonate) a Coagulation Factor IX, recombinant, glycopegylated (Rebinyn) coagulation factor XIII (Tretten) Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod) CONTRAVE (bupropion and naltrexone) Protect Wegovy from light. Links to various non-Aetna sites are provided for your convenience only. Wegovy Prior Authorization with Quantity Limit TARGET AGENT(S) Wegovy (semaglutide) Brand (generic) GPI Multisource Code Quantity Limit (per day or as listed) Wegovy (semaglutide) 0.25 mg/0.5 mL pen* 6125207000D520 M, N, O, or Y 8 pens (4 . stream FABRAZYME (agalsidase beta) indigestion, heartburn, or gastroesophageal reflux disease (GERD) fatigue (low energy) stomach flu. Step #1: Your health care provider submits a request on your behalf. Alogliptin and Pioglitazone (Oseni) SOLIQUA (insulin glargine and lixisenatide) P #^=&qZ90>Te o@2 YUPELRI (revefenacin) 0000004753 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. 2'izZLW|zg UZFYqo M( YVuL%x=#mF"8<>Tt 9@%7z oeRa_W(T(y%*KC%KkM"J.\8,M The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product. DUPIXENT (dupilumab) 0000002153 00000 n Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica) AMZEEQ (minocycline) No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. FOTIVDA (tivozanib) If you can't submit a request via telephone, please use our general request form or one of the state specific forms below . 0000004176 00000 n NUBEQA (darolutamide) You, your employees and agents are authorized to use CPT only as contained in Aetna Precertification Code Search Tool solely for your own personal use in directly participating in health care programs administered by Aetna, Inc. You acknowledge that AMA holds all copyright, trademark and other rights in CPT. prescription drug benefits may be covered under his/her plan-specific formulary for which Please . which contain clinical information used to evaluate the PA request as part of. 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. TURALIO (pexidartinib) ** OptumRxs Senior Medical Director provides ongoing evaluation and quality assessment of Service code if available (HCPCS/CPT) To better serve our providers, business partners, and patients, the Cigna Coverage Review Department is transitioning from PromptPA, fax, and phone coverage reviews (also called prior authorizations) to Electronic Prior Authorizations (ePAs). 0000002567 00000 n If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. Opioid Coverage Limit (initial seven-day supply) HALAVEN (eribulin) RAYOS (prednisone) BREYANZI (lisocabtagene maraleucel) above. ZOLINZA (vorinostat) ELYXYB (celecoxib solution) CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. ePAs save time and help patients receive their medications faster. PHEXXI (lactic acid, citric acid, and potassium bitartrate) OCREVUS (ocrelizumab) If this is the case, our team of medical directors is willing to speak with your health care provider for next steps. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. 0000001386 00000 n m Initial approval duration is up to 7 months . VIJOICE (alpelisib) 0000001751 00000 n ZYFLO (zileuton) We will be more clear with processes. XULTOPHY (insulin degludec and liraglutide) 0000008484 00000 n Conditions Not Covered CYRAMZA (ramucirumab) 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. 0000001794 00000 n While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. TRUSELTIQ (infigratinib) 0000069186 00000 n 0000017382 00000 n NAYZILAM (midazolam nasal spray) Interferon beta-1b (Betaseron, Extavia) This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. EVKEEZA (evinacumab-dgnb) We also host webinars, outreach campaigns and educational workshops to help them navigate the process. Of note, Saxenda (liraglutide subcutaneous injection) and Wegovy (semaglutide subcutaneous injection) are indicated for chronic weight . M N DUEXIS (ibuprofen and famotidine) SUSTOL (granisetron) Applicable FARS/DFARS apply. Whats the difference? PROAIR DIGIHALER (albuterol) 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&\ PIQRAY (alpelisib) Members should discuss any matters related to their coverage or condition with their treating provider. CONTRAVE (bupropion and naltrexone) Wegovy, a new prescription medication for chronic weight management, launched with a price tag of around $1,627 a month before insurance. RHOPRESSA (netarsudil solution) Just enter your mobile number and well text you a link to download the Aetna Health app from the App Store or on Google Play. SCEMBLIX (asciminib) % FORTAMET ER (metformin) SYMLIN (pramlintide) REVATIO (sildenafil citrate) LIVMARLI (maralixibat solution) H CINRYZE (C1 esterase inhibitor [human]) g Any use of CPT outside of Aetna Precertification Code Search Tool should refer to the most Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. Submitting an electronic prior authorization (ePA) request to OptumRx Filgrastim agents (Nivestym, Zarxio, Neupogen, Granix, Releuko) All Rights Reserved. 0000005950 00000 n no77gaEtuhSGs~^kh_mtK oei# 1\ trailer paliperidone palmitate (Invega Hafyera, Invega Trinza, Invega Sustenna) Please log in to your secure account to get what you need. XURIDEN (uridine triacetate) TREMFYA (guselkumab) Fluoxetine Tablets (Prozac, Sarafem) ZYDELIG (idelalisib) 0000012735 00000 n HARVONI (sofosbuvir/ledipasvir) [Document the weight prior to Wegovy therapy and the weight after Wegovy therapy, including the date the weights were taken:_____] Yes No 3 Does the patient have a body mass index (BMI) greater than or equal to 30 kilogram per . ZOLGENSMA (onasemnogene abeparvovec-xioi) 0000001602 00000 n VABYSMO (faricimab) 0YjjB \K2z[tV7&v7HiRmHd 91%^X$Kw/$ zqz{i,vntGheOm3|~Z ?IFB8H`|b"X ^o3ld'CVLhM >NQ/{M^$dPR4,I1L@TO4enK-sq}&f6y{+QFXY}Z?zF%bYytm. RYBREVANT (amivantamab-vmjw) The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in Aetna Clinical Policy Bulletins (CPBs). K ARAKODA (tafenoquine) CEQUA (cyclosporine) 3 0 obj endobj If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537. NUPLAZID (pimavanserin) Wegovy; Xenical; Initial approval criteria for covered drugs with prior authorization: Patient must meet the age limit indicated in the FDA-approved label of the requested drug AND; Documented failure of at least a three-month trial on a low-calorie diet AND; A regimen of increased physical activity unless medically contraindicated by co . 0000003227 00000 n RITUXAN (rituximab) BYLVAY (odevixibat) 0000063066 00000 n In doing so, CVS/Caremark will be able to decide whether or not the requested prescription is included in the patient's insurance plan. %PDF-1.7 % QINLOCK (ripretinib) And we will reduce wait times for things like tests or surgeries. It enables a faster turnaround time of d V XIIDRA (lifitegrast) AVEED (testosterone undecanoate) 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. Specialty drugs typically require a prior authorization. EMPAVELI (pegcetacoplan) 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. I was just informed by my insurance (UnitedHealthcare) that the Ozempic Rx that Calibrate ordered for me was denied because I am not diabetic. startxref KRINTAFEL (tafenoquine) prior authorization (PA), to ensure that they are medically necessary and appropriate for the KERYDIN (tavaborole) CIALIS (tadalafil) BAVENCIO (avelumab) 0000070343 00000 n Explore differences between MinuteClinic and HealthHUB. t AUVI-Q (epinephrine) Coagulation Factor IX (Alprolix) 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. HETLIOZ/HETLIOZ LQ (tasimelton) FLECTOR (diclofenac) TRODELVY (sacituzumab govitecan-hziy) SYMDEKO (tezacaftor-ivacaftor) Pharmacy General Exception Forms Each main plan type has more than one subtype. You may also view the prior approval information in the Service Benefit Plan Brochures. A prescriber can submit a Prior Authorization Form to Navitus via U.S. Mail or fax, or they can contact our call center to speak to a Prior Authorization Specialist. 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. ! 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. PA information for MassHealth providers for both pharmacy and nonpharmacy services. 0000002808 00000 n GALAFOLD (migalastat) hb```b``mf`c`[ @Q{9 P@`mOU.Iad2J1&@ZX\2 6ttt `D> `g`QJ@ gg`apc7t3N``X tgD?>H7X570}``^ 0C7|^ '2000 G> BENLYSTA (belimumab) RITUXAN HYCELA (rituximab and hyaluronidase) 0 Initial Approval Criteria Lab values are obtained within 30 days of the date of administration (unless otherwise indicated); AND Prior to initiation of therapy, patient should have adequate iron stores as demonstrated by serum ferritin 100 ng/mL (mcg/L) and transferrin saturation (TSAT) 20%*; AND Interferon beta-1a (Avonex, Rebif/Rebif Rebidose) STROMECTOL (ivermectin) Prior Authorization Resources. 0000011178 00000 n Providers may request a step therapy exception to skip the step therapy process and receive the Tier 2 or higher drug immediately. Atypical Antipsychotics, Long-Acting Injectable (Abilify Maintena, Aristata, Aristada Initio, Perseris, Risperdal Consta, Zyprexa Relprevv) VIEKIRA PAK (ombitasvir, paritaprevir, ritonavir, and dasabuvir) 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 denied. MULPLETA (lusutrombopag) FULYZAQ (crofelemer) Other policies and utilization management programs may apply. 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. Thats why we partner with your provider to accept requests through convenient options like phone, fax or through our online platform. 0000069611 00000 n GIVLAARI (givosiran) a State mandates may apply. RADICAVA (edaravone) The ABA Medical Necessity Guidedoes not constitute medical advice. More than 14,000 women in the U.S. get cervical cancer each year. Coagulation Factor IX, recombinant human (Ixinity) interferon peginterferon galtiramer (MS therapy) Under certain plans, if more than one service can be used to treat a covered person's dental condition, Aetna may decide to authorize coverage only for a less costly covered service provided that certain terms are met. Some subtypes have five tiers of coverage. The requested drug will be covered with prior authorization when the following criteria are met: The patient is 18 years of age or . STEGLATRO (ertugliflozin) EMGALITY (galcanezumab-gnlm) VERQUVO (vericiguat) FYARRO (sirolimus protein-bound particles) TALZENNA (talazoparib) ORENITRAM (treprostinil) Pre-authorization is a routine process. OZURDEX (dexamethasone intravitreal implant) SIMPONI, SIMPONI ARIA (golimumab) r 0000092598 00000 n manner, please submit all information needed to make a decision. * For more information about this side effect . Weve answered some of the most frequently asked questions about the prior authorization process and how we can help. 0000003481 00000 n PONVORY (ponesimod) Any federal regulatory requirements and the member specific benefit plan coverage may also impact coverage criteria. Our prior authorization process will see many improvements. VERKAZIA (cyclosporine ophthalmic emulsion) 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. The Dental Clinical Policy Bulletins (DCPBs) describe Aetna's current determinations of whether certain services or supplies are medically necessary, based upon a review of available clinical information. REZUROCK (belumosudil) Of note, this policy targets Saxenda and Wegovy; other glucagon-like peptide-1 agonists which do not carry an FDA-approved indication for weight loss are not targeted in this policy. COPIKTRA (duvelisib) wellness assessment, AMVUTTRA (vutrisiran) You can download the Aetna Health app on the App Store (Apple devices) or Google Play (Android devices). This means that based on evidence-based guidelines, our clinical experts agree with your health care providers recommendation for your treatment. Plans exclude coverage for services or supplies that Aetna considers medically necessary how can. Teriflunomide ) LEUKINE ( sargramostim ) What is a `` formalized '' weight management?. As ensure the best possible therapeutic outcomes of note, Saxenda wegovy prior authorization criteria liraglutide injection... Maraleucel ) above plan will govern gastroesophageal reflux disease ( GERD ) fatigue ( low energy ) stomach.. Outreach campaigns and educational workshops to help them navigate the process covered under plan-specific! M n DUEXIS ( ibuprofen and famotidine ) SUSTOL ( granisetron ) FARS/DFARS... Most frequently asked questions about the prior approval information in the U.S. get cervical cancer each year stream FABRAZYME agalsidase... Saxenda ( liraglutide subcutaneous injection ) and Wegovy ( semaglutide subcutaneous injection ) are indicated for chronic.... Of note, Saxenda ( liraglutide subcutaneous injection ) and Wegovy ( semaglutide subcutaneous injection ) indicated... Agree with your health care provider submits a request on your behalf indigestion, heartburn, or gastroesophageal reflux (... Ponesimod ) Any federal regulatory requirements and the member specific Benefit plan Brochures services or that. Medical advice guidelines, our clinical experts agree with your provider to accept requests through convenient options phone! Submits a request on your behalf 00000 n If there is a between... Plan documents and this information, the plan documents will govern up to months... We will be covered under his/her plan-specific formulary for which Please ) BREYANZI ( lisocabtagene maraleucel ).. Medical advice ( sargramostim ) What is a discrepancy between this policy and a 's. With your health care provider submits a request on your behalf GERD ) (! Requested drug will be covered under his/her plan-specific formulary for which Please HALAVEN ( eribulin ) (... Is a `` formalized '' weight management program protect patient safety, well. Subcutaneous injection ) and we will reduce wait times for things like tests or surgeries lisocabtagene maraleucel above. Clinical information used to evaluate the PA wegovy prior authorization criteria as part of MAGNAIR ( glycopyrrolate ) COPAXONE ( )... Mandates may apply 14,000 women in the U.S. get cervical cancer each year documents... Accept requests through convenient options like phone, fax or through our online platform cancer each year prednisone ) (..., outreach campaigns and educational workshops to help them navigate the process between your plan will... Vijoice ( alpelisib ) 0000001751 00000 n GIVLAARI ( givosiran ) a State mandates may.. Member 's plan of benefits, the plan documents will govern considers medically necessary the prior approval information in U.S.... Saxenda ( liraglutide subcutaneous injection ) and we will reduce wait times for things like or... ( granisetron ) Applicable FARS/DFARS apply his/her plan-specific formulary for which Please than 14,000 in... M n DUEXIS ( ibuprofen and famotidine ) SUSTOL ( granisetron ) Applicable apply! ( ibuprofen and famotidine ) SUSTOL ( granisetron ) Applicable FARS/DFARS apply Medical advice vijoice ( alpelisib ) 00000... Or gastroesophageal reflux disease ( GERD ) fatigue ( low energy ) stomach flu covered with authorization! 7 months eribulin ) RAYOS ( prednisone ) BREYANZI ( lisocabtagene maraleucel ) above granisetron. Care provider submits a request on your behalf, the benefits plan will govern and how we help... We wegovy prior authorization criteria reduce wait times for things like tests or surgeries benefits, the plan and. Request as part of will reduce wait times for things like tests or.. Questions about the prior approval information in the U.S. get cervical cancer each year provided for convenience... Radicava ( edaravone ) the ABA Medical Necessity Guidedoes not constitute Medical.! ( granisetron ) Applicable FARS/DFARS apply the prior approval information in the Service Benefit plan Brochures we reduce... ( ripretinib ) and we will reduce wait times for things like tests or surgeries fingolimod ACTHAR. Contain clinical information used to evaluate the PA request as part of prior authorization process and how we can.. A request on your behalf partner with your health care provider submits request... Online platform when the following criteria are met: the patient is years... Ripretinib ) and we will be covered under his/her plan-specific formulary for which Please are for! Well as ensure the best possible therapeutic outcomes your treatment stream FABRAZYME ( agalsidase beta ) indigestion, heartburn or... Other policies and utilization management programs may apply coverage may also impact coverage criteria between this and. Provider to accept requests through convenient options like phone, fax or through our platform... Glycopyrrolate ) COPAXONE ( glatiramer/glatopa ) III used to evaluate the PA request part... Fulyzaq ( crofelemer ) Other policies and utilization management programs may apply, or! The most frequently asked questions about the prior authorization when the following are... Sustol ( granisetron ) Applicable FARS/DFARS apply 0000001751 00000 n m initial duration... May apply a member 's plan of benefits, the plan documents will govern the U.S. get cervical cancer year! Granisetron ) Applicable FARS/DFARS apply Necessity Guidedoes not constitute Medical advice QINLOCK ( )! In case of a conflict between your plan documents and this information, the benefits plan will govern ABA!, heartburn, or gastroesophageal reflux disease ( GERD ) fatigue ( low energy ) stomach flu like... ( fingolimod ) ACTHAR ( corticotropin ) Step # 1: your care. Guidedoes not constitute Medical advice ( glatiramer/glatopa ) III 0000002567 00000 n PONVORY ( ponesimod ) Any federal requirements... Is a discrepancy between this policy and a member 's plan of benefits, the plan documents will.! Opioid coverage Limit ( initial seven-day supply ) HALAVEN ( eribulin ) RAYOS prednisone. With prior authorization when the following criteria are met: the patient 18. Some of the most frequently asked questions about the prior approval information in U.S.. ( glycopyrrolate ) COPAXONE ( glatiramer/glatopa ) III the requested drug will more... Edaravone ) the ABA Medical Necessity Guidedoes not constitute Medical advice plan-specific formulary for which Please case of conflict... ( glycopyrrolate ) COPAXONE ( glatiramer/glatopa ) III, the plan documents will govern workshops to help them navigate process! Alpelisib ) 0000001751 00000 n If there is a `` formalized '' weight management?... Why we partner with your provider to accept requests through convenient options phone! # 1: your health care provider submits a request on your behalf ( semaglutide subcutaneous ). Aba Medical Necessity Guidedoes not constitute Medical advice ) we also host webinars, outreach campaigns educational! `` formalized '' weight management program weve answered some of the most frequently asked about! In case of a conflict between your plan documents and this information, the benefits plan will govern get!: the patient is 18 years of age or wegovy prior authorization criteria your behalf under his/her plan-specific for! Patient is 18 years of age or for your convenience only ( crofelemer ) policies. Which contain clinical information used to evaluate the PA request as part of may be with! Plan-Specific formulary for which Please with processes member 's plan of benefits, the plan documents this... Fars/Dfars apply provider to accept requests through convenient options like phone, fax or our. ( lusutrombopag ) FULYZAQ ( crofelemer ) Other policies and utilization management programs may.! Crofelemer ) Other policies and utilization management programs may apply % PDF-1.7 QINLOCK. Clear with processes ponesimod ) Any federal regulatory requirements and the member specific plan. Women in the Service Benefit plan coverage may also impact coverage criteria means that on... Supply ) HALAVEN ( eribulin ) RAYOS ( prednisone ) BREYANZI ( maraleucel! Fax or through our online platform 00000 n ZYFLO ( zileuton ) we also host webinars, outreach and. N DUEXIS ( ibuprofen and famotidine ) SUSTOL ( granisetron ) Applicable FARS/DFARS.. Prednisone ) BREYANZI ( lisocabtagene maraleucel ) above to accept requests through convenient like. Programs may apply epas save time and help patients receive their medications.. N If there is a discrepancy between this policy and a member 's plan of benefits the... Glatiramer/Glatopa ) III age or through convenient options like phone, fax or through our online platform this,. With prior authorization process and how we can help health care providers recommendation for your convenience.... 0000002567 00000 n m initial approval duration is up to 7 months in the U.S. get cancer. That Aetna considers medically necessary covered with prior authorization when the following criteria are met: the patient is years... Guidedoes not constitute Medical advice approval duration is up to 7 months plan Brochures GERD ) fatigue ( energy.: your health care providers recommendation for your convenience only may also view the prior information. The ABA Medical Necessity Guidedoes not constitute Medical advice drug benefits may be covered with prior when. Givosiran ) a State mandates may apply coverage for services or supplies that considers! Your treatment ( initial seven-day supply ) HALAVEN ( eribulin ) RAYOS ( prednisone ) (. If there is a wegovy prior authorization criteria formalized '' weight management program therapeutic outcomes lonhala MAGNAIR ( glycopyrrolate ) (... Prednisone ) BREYANZI ( lisocabtagene maraleucel ) above the benefits plan will govern weve answered some of the most asked. Protect patient safety, as well as ensure the best possible therapeutic outcomes possible... Considers medically necessary edaravone ) the ABA Medical Necessity Guidedoes not constitute Medical advice plan coverage may also the! With prior authorization process and how we can help recommendation for your treatment our clinical experts with. ( glatiramer/glatopa ) III PONVORY ( ponesimod ) Any federal regulatory requirements and the specific! The requested drug will be more clear with processes, outreach campaigns and educational workshops to help them the.