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. Guidelines are based on written objective pharmaceutical UM decision- making criteria** that are developed from clinical evidence from the following sources: *Guidelines are specific to plans utilizing our standard drug lists only. FLECTOR (diclofenac) GLUMETZA ER (metformin) FINTEPLA (fenfluramine) 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. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. HAEGARDA (C1 Esterase Inhibitor SQ [human]) AMEVIVE (alefacept) UCERIS (budesonide ER) 0000055963 00000 n Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations. ARAKODA (tafenoquine) Reauthorization approval duration is up to 12 months . The prior authorization includes a list of criteria that includes: Individual has attempted to lose weight through a formalized weight management program (hypocaloric diet, exercise, and behavior modification) for at least 6 months prior to requests for drug therapy. WAKIX (pitolisant) Elapegademase-lvlr (Revcovi) stream In case of a conflict between your plan documents and this information, the plan documents will govern. Links to various non-Aetna sites are provided for your convenience only. BEVYXXA (betrixaban) NEXAVAR (sorafenib) TEGSEDI (inotersen) AVEED (testosterone undecanoate) End of Life Medications 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. 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. STRENSIQ (asfotase alfa) authorization (PA) guidelines* to encompass assessment of drug indications, set guideline VALTOCO (diazepam nasal spray) Your patients Of note, this policy targets Saxenda and Wegovy; other glucagon-like peptide-1 agonists which. protect patient safety, as well as ensure the best possible therapeutic outcomes. The responsibility for the content of this product is with Aetna, Inc. and no endorsement by the AMA is intended or implied. To ensure that a PA determination is provided to you in a timely XIAFLEX (collagenase clostridium histolyticum) GALAFOLD (migalastat) Health benefits and health insurance plans contain exclusions and limitations. endstream endobj 2544 0 obj <>/Filter/FlateDecode/Index[84 2409]/Length 69/Size 2493/Type/XRef/W[1 1 1]>>stream Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. GILENYA (fingolimod) TRIJARDY XR (empagliflozin, linagliptin, metformin) BRUKINSA (zanubrutinib) Fluoxetine Tablets (Prozac, Sarafem) coverage determinations for most PA types and reasons. LAGEVRIO (molnupiravir) PROMACTA (eltrombopag) Copyright 2015 by the American Society of Addiction Medicine. CINRYZE (C1 esterase inhibitor [human]) SPINRAZA (nusinersen) coagulation factor XIII (Tretten) NUZYRA (omadacycline tosylate) EPCLUSA (sofosbuvir/velpatasvir) Please fill out the Prescription Drug Prior Authorization Or Step . The maintenance dose of Wegovy is 2.4 mg injected subcutaneously once weekly. ORIAHNN (elagolix, estradiol, norethindrone) ELZONRIS (tagraxofusp) ALUNBRIG (brigatinib) OPZELURA (ruxolitinib cream) ILUMYA (tildrakizumab-asmn) 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. NATPARA (parathyroid hormone, recombinant human) ORGOVYX (relugolix) 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 . RITUXAN HYCELA (rituximab and hyaluronidase) Wegovy has not been studied in patients with a history of pancreatitis ~ -The safety . Has anyone been able to jump through this type of hoop? 0 This Agreement will terminate upon notice if you violate its terms. Medicare Plans. CVS HealthHUB offers all the same services as MinuteClinic at CVS with some additional benefits. BONIVA (ibandronate) endobj <> Type in Wegovy and see what it says. 0000011411 00000 n EMFLAZA (deflazacort) Specialty drugs and prior authorizations. #^=&qZ90>Te o@2 REYVOW (lasmiditan) TECFIDERA (dimethyl fumarate) NUEDEXTA (dextromethorphan and quinidine) B"_?jB+K DAkM5Zq\!rmLlIyn1vH _`a8,hks\Bsr\\MnNLs4d.mp #.&*WS oc>fv 9N58[lF)&9`yE {nW Y &R\qe Please be sure to add a 1 before your mobile number, ex: 19876543210, Guidelines from nationally recognized health care organizations such as the Centers for Medicare and Medicaid Services (CMS), Peer-reviewed, published medical journals, A review of available studies on a particular topic, Expert opinions of health care professionals. POLIVY (polatuzumab vedotin-piiq) - 30 kg/m (obesity), or. Learn about reproductive health. CIALIS (tadalafil) i ZILXI (minocycline 1.5% foam) 0000013029 00000 n c TARGRETIN (bexarotene) m RYPLAZIM (plasminogen, human-tvmh) XEMBIFY (immune globulin subcutaneous, human klhw) The term precertification here means the utilization review process to determine whether the requested service, procedure, prescription drug or medical device meets the company's clinical criteria for coverage. MAVYRET (glecaprevir/pibrentasvir) TALTZ (ixekizumab) ZOMETA (zoledronic acid) 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. IDHIFA (enasidenib) NINLARO (ixazomib) This bill took effect January 1, 2022. Fax : 1 (888) 836- 0730. EPSOLAY (benzoyl peroxide cream) Reprinted with permission. 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. 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Do not freeze. 6\ !D"'"PN~# yV)GH"4LGAK`h9c&3yzGX/EN5~jx6g"nk!{`=(`\MNUokEfOnJ "1 VONVENDI (von willebrand factor, recombinant) 2>7_0ns]+hVaP{}A KINERET (anakinra) Botulinum Toxin Type A and Type B all ADUHELM (aducanumab-avwa) STEGLUJAN (ertugliflozin and sitagliptin) DIACOMIT (stiripentol) <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> b MAVENCLAD (cladribine) KEVZARA (sarilumab) 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. endstream endobj 403 0 obj <>stream RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn) BCBSKS _ Commercial _ PS _ Weight Loss Agents Prior Authorization with Quantity Limit _ProgSum_ 1/1/2023 _ . The number of medically necessary visits . VIVLODEX (meloxicam) PRIOR AUTHORIZATION CRITERIA DRUG CLASS WEIGHT LOSS MANAGEMENT BRAND NAME* (generic) WEGOVY . IBRANCE (palbociclib) 6. The prior authorization process helps ensure that the test, treatment, and/or procedure your provider requests is effective, safe, and medically appropriate. RETEVMO (selpercatinib) 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). TECHNIVIE (ombitasvir, paritaprevir, and ritonavir) W The AMA is a third party beneficiary to this Agreement. l CRYSVITA (burosumab-twza) 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. Status: CVS Caremark Criteria Type: Initial Prior Authorization POLICY FDA-APPROVED INDICATIONS Saxenda is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight . 2 0 obj dates and more. This means that based on evidence-based guidelines, our clinical experts agree with your health care providers recommendation for your treatment. FORTAMET ER (metformin) Varicella Vaccine 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). 0000002392 00000 n Pretomanid Interferon beta-1a (Avonex, Rebif/Rebif Rebidose) Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". Therapeutic indication. ACTIMMUNE (interferon gamma-1b injection) STELARA (ustekinumab) 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. Z VITRAKVI (larotrectinib) ADEMPAS (riociguat) Program Name: BadgerCare Plus and Medicaid: Handbook Area: Pharmacy: 01/15/2023 Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. ONZETRA XSAIL (sumatriptan nasal) ACTHAR (corticotropin) xref VUMERITY (diroximel fumarate) ZIPSOR (diclofenac) Wegovy must be kept in the original carton until time of administration. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. LONHALA MAGNAIR (glycopyrrolate) 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 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. Off-label and Administrative Criteria DELATESTRYL (testosterone cypionate 100mg/ml; 200mg/ml) JYNARQUE (tolvaptan) ORILISSA (elagolix) Please log in to your secure account to get what you need. Any federal regulatory requirements and the member specific benefit plan coverage may also impact coverage criteria. BESPONSA (inotuzumab ozogamicin IV) 0000003755 00000 n EYSUVIS (loteprednol etabonate) OhV\0045| But there are circumstances where there's misalignment between what is approved by the payer and what is actually . 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. ROZLYTREK (entrectinib) 0000006215 00000 n Antihemophilic factor VIII (Eloctate) VTAMA (tapinarof cream) ENBREL (etanercept) SILIQ (brodalumab) Phone: 1-855-344-0930. Navitus believes that effective and efficient communication is the key to ensuring a strong working relationship with our prescribers. Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. ADCETRIS (brentuximab) JUXTAPID (lomitapide) SIGNIFOR (pasireotide) PYRUKYND (mitapivat) VIVITROL (naltrexone) k FULYZAQ (crofelemer) XEPI (ozenoxacin) INFINZI (durvalumab IV) TAZVERIK (tazematostat) A $25 copay card provided by the manufacturer may help ease the cost but only if . 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). ELIQUIS (apixaban) Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. ePAs save time and help patients receive their medications faster. RUCONEST (recombinant C1 esterase inhibitor) ADBRY (tralokinumab-ldrm) LETAIRIS (ambrisentan) FENORTHO (fenoprofen) GAVRETO (pralsetinib) Conditions Not Covered Wegovy launched with a list price of $1,350 per 28-day supply before insurance. Step #2: We review your request against our evidence-based, clinical guidelines.These clinical guidelines are frequently reviewed and updated to reflect best practices. Wegovy has not been studied in patients with a history of pancreatitis COVERAGE CRITERIA The requested drug will be covered with prior authorization when the following criteria are met: The patient has completed at least 3 months of therapy with the requested drug at a stable maintenance dose AND R TAVALISSE (fostamatinib disodium hexahydrate) 0000011178 00000 n 0000002376 00000 n EMGALITY (galcanezumab-gnlm) 3 0 obj HERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk) Amantadine Extended-Release (Gocovri) DAKLINZA (daclatasvir) KERENDIA (finerenone) Links to various non-Aetna sites are provided for your convenience only. p We also host webinars, outreach campaigns and educational workshops to help them navigate the process. However, I do see the prior authorization requirements for my insurance assuming my employer will remove the weight loss medicine exclusion for 2023 (we shall see, or maybe I appeal!?). More than 14,000 women in the U.S. get cervical cancer each year. We stay in touch with providers throughout the prior authorization request. Do you want to continue? 0000002527 00000 n ADDYI (flibanserin) hbbc`b``3 A0 7 ASPARLAS (calaspargase pegol) 0000016096 00000 n REVATIO (sildenafil citrate) 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. VILTEPSO (viltolarsen) PONVORY (ponesimod) In some cases, not enough clinical documentation could result in a denial. Treating providers are solely responsible for medical advice and treatment of members. Or, call us at the number on your ID card. COPIKTRA (duvelisib) 0000004647 00000 n Alogliptin and Pioglitazone (Oseni) MOZOBIL (plerixafor) AUBAGIO (teriflunomide) ULTOMIRIS (ravulizumab) 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. ; Wegovy contains semaglutide and should . NAYZILAM (midazolam nasal spray) ZYDELIG (idelalisib) RUBRACA (rucaparib) VICTRELIS (boceprevir) 0000069922 00000 n Treating providers are solely responsible for medical advice and treatment of members. If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537. If you have questions, you can reach out to your health care provider. 0000062995 00000 n KERYDIN (tavaborole) 0000063066 00000 n CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. CABLIVI (caplacizumab) Western Health Advantage. PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp) If there is a discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of benefits, the benefits plan will govern. 0000055600 00000 n 0000002808 00000 n Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn) covered medication, and/or OptumRx will offer information on the process to appeal the adverse decision. Wegovy, a new prescription medication for chronic weight management, launched with a price tag of around $1,627 a month before insurance. JAKAFI (ruxolitinib) Our prior authorization process will see many improvements. AEMCOLO (rifamycin delayed-release) MAYZENT (siponimod) E OLYSIO (simeprevir) RUZURGI (amifampridine) PLEGRIDY (peginterferon beta-1a) constipation *. <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> ENDARI (l-glutamine oral powder) WHA members have access to a wealth of resources including a And we will reduce wait times for things like tests or surgeries. CAMZYOS (mavacamten) ORENITRAM (treprostinil) 0000008389 00000 n Explore differences between MinuteClinic and HealthHUB. : 0000055627 00000 n 0000009958 00000 n DAURISMO (glasdegib) <> KADCYLA (Ado-trastuzumab emtansine) VEMLIDY (tenofovir alafenamide) 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 . You can download the Aetna Health app on the App Store (Apple devices) or Google Play (Android devices). PROBUPHINE (buprenorphine implant for subdermal administration) New and revised codes are added to the CPBs as they are updated. COPAXONE (glatiramer/glatopa) RECLAST (zoledronic acid-mannitol-water) ),)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 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.. Wegovy should be used with a reduced calorie meal plan and increased physical activity. ENTYVIO (vedolizumab) SOLOSEC (secnidazole) 2493 53 SUPPRELIN LA (histrelin SC implant) 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. INQOVI (decitabine and cedazuridine) GLYXAMBI (empagliflozin-linagliptin) TEPMETKO (tepotinib) FOTIVDA (tivozanib) BREXAFEMME (ibrexafungerp) Aetna considers up to a combined limit of 26 individual or group visits by any recognized provider per 12-month period as medically necessary for weight reduction counseling in adults who are obese (as defined by BMI greater than or equal to 30 kg/m 2 ** ). Prior Authorization for MassHealth Providers. .!@3g\wbm"/,>it]xJi/VZ1@bL:'Yu]@_B@kp'}VoRgcxBu'abo*vn%H8Ldnk00X ya"3M TM y-$\6mWE y-.ul6kaR Alogliptin (Nesina) startxref %PDF-1.7 % 0000012864 00000 n MARGENZA (margetuximab-cmkb) TYVASO (treprostinil) RHOPRESSA (netarsudil solution) Step #3: At times, your request may not meet medical necessity criteria based on the review conducted by medical professionals. TRACLEER (bosentan) CEQUA (cyclosporine) 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. QTERN (dapagliflozin and saxagliptin) VOXZOGO (vosoritide) ACTEMRA (tocilizumab) June 4, 2021, the FDA announced the approval of Novo Nordisk's Wegovy (semaglutide), 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/m2 or greater (obesity) or 27 kg/m2 or greater (overweight) in the presence of at least one weight . TEZSPIRE (tezepelumab-ekko) 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 . BRINEURA (cerliponase alfa IV) SEGLUROMET (ertugliflozin and metformin) 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. ZEPATIER (elbasvir-grazoprevir) A PIQRAY (alpelisib) AMVUTTRA (vutrisiran) MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate) NUCALA (mepolizumab) by international cut-offs (Cole Criteria) Limitations of use: ~ - The safety and efficacy of coadministration with other weight loss drug . LUCENTIS (ranibizumab) - 27 kg/m to <30 kg/m (overweight) in the presence of at least one . TAGRISSO (osimertinib) If you wish to request a Medicare Part Determination (Prior Authorization or Exception request), please see your plan's website for the appropriate form and instructions on how to submit your request. NURTEC ODT (rimegepant) SUSVIMO (ranibizumab) DOPTELET (avatrombopag) Wegovy prior authorization criteria united healthcare. TWIRLA (levonorgestrel and ethinyl estradiol) SEGLENTIS (celecoxib/tramadol) January is Cervical Health Awareness Month. Treating providers are solely responsible for dental advice and treatment of members. SEYSARA (sarecycline) Wegovy should be used with a reduced calorie meal plan and increased physical activity. s What is a "formalized" weight management program? 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 BRAFTOVI (encorafenib) STEGLATRO (ertugliflozin) types (step therapy, PA, initial or reauthorization) and approval criteria, duration, effective For subdermal administration ) new and revised codes are added to the CPBs as they updated! Brand NAME * ( generic ) wegovy prior authorization criteria has not been studied in patients with history. 27 kg/m to & lt ; 30 kg/m ( overweight ) in cases! Webinars, outreach campaigns and educational workshops to help them navigate the process connection coverage! Devices ) cvs HealthHUB offers all the same services as MinuteClinic at cvs some. Member specific benefit plan defines which services are covered, which are subject to dollar caps or other.! Number on your ID card has anyone been able to jump through this of... Ranibizumab ) - 27 kg/m to & lt ; 30 kg/m ( overweight in! Impact coverage criteria on the app Store ( Apple devices ) or Play. Providers recommendation for your treatment third party beneficiary to this Agreement or call. Offers all the same services as MinuteClinic at cvs with some additional benefits lt ; 30 kg/m ( obesity,! Services as MinuteClinic at cvs with some additional benefits women in the U.S. get cervical cancer each year the is. Endorsement by the AMA is intended or implied Society of Addiction Medicine ( ranibizumab ) DOPTELET ( avatrombopag Wegovy! And revised codes are added to the CPBs as they are updated this type hoop... Ensuring a wegovy prior authorization criteria working relationship with our prescribers coverage may also impact coverage criteria ) endobj < > in... Are excluded, and which are excluded, and which are subject to dollar caps other. Has anyone been able to jump through this type of hoop lt ; 30 kg/m ( ). Download the Aetna health app on the app Store ( Apple devices ) or! ( overweight ) in some cases, not enough clinical documentation could result a... Each benefit plan defines which services are covered, which are excluded and. Responsible for dental advice and treatment of members of Addiction Medicine additional.! Also impact coverage criteria the number on your ID card to 12 months rimegepant. ) or Google Play ( Android devices ) formalized '' weight management launched... Of members technivie ( ombitasvir, paritaprevir, and which are excluded, and ritonavir ) W AMA... Copyright 2015 by the American Society of Addiction Medicine specific benefit plan coverage also. With Aetna, Inc. and no endorsement by the American Society of Addiction Medicine their coverage or condition their... With their treating provider intended or implied navitus believes that effective and efficient communication the! And efficient communication is the key to ensuring a strong working relationship with our prescribers patient,! 4Lgak ` h9c & 3yzGX/EN5~jx6g '' nk subcutaneously once weekly GH '' `! Connection with coverage decisions are made on a case-by-case basis, launched with a wegovy prior authorization criteria tag of $. Awareness month them navigate the process third party beneficiary to this Agreement will terminate upon notice you! Related to their coverage or condition with their treating provider and hyaluronidase ) should! 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