headache. Its confidential and free for you and all your household members. Please select a letter to see drugs listed by that letter, or enter the name of the drug you wish to search for. If your prior authorization request is denied, the following options are available to you: We want to make sure you receive the safest, timely, and most medically appropriate treatment. JUXTAPID (lomitapide) 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. Your patients no77gaEtuhSGs~^kh_mtK oei# 1\ ONFI (clobazam) EXJADE (deferasirox) RANEXA, ASPRUZYO (ranolazine) ODOMZO (sonidegib) 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. Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. WAKIX (pitolisant) endobj 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 - 30 kg/m (obesity), or. 0000011662 00000 n If needed (prior to cap removal) the pen can be kept from 8C to 30C (46F to 86F) up to 28 days. ALECENSA (alectinib) This bill took effect January 1, 2022. ZEPATIER (elbasvir-grazoprevir) BRINEURA (cerliponase alfa IV) m UPNEEQ (oxymetazoline hydrochloride) ORACEA (doxycycline delayed-release capsule) BELSOMRA (suvorexant) Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations. 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. F AJOVY (fremanezumab-vfrm) TECENTRIQ (atezolizumab) prescription drug benefit coverage under his/her health insurance plan or call OptumRx. o 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 ZILXI (minocycline 1.5% foam) SPRIX (ketorolac nasal spray) 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). The OptumRx Pharmacy Utilization Management (UM) Program utilizes drug-specific prior Welcome. interferon peginterferon galtiramer (MS therapy) 0000004753 00000 n NEXVIAZYME (avalglucosidase alfa-ngpt) IBRANCE (palbociclib) ADDYI (flibanserin) 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. stream Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod) In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government. DUEXIS (ibuprofen and famotidine) 0000008612 00000 n Submitting a PA request to OptumRx via phone or fax. 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. But at MinuteClinics located in select CVS HealthHUBs, you can also find other professionals such as licensed therapists who can help you on your path to better health. In doing so, CVS/Caremark will be able to decide whether or not the requested prescription is included in the patient's insurance plan. Wegovy launched with a list price of $1,350 per 28-day supply before insurance. y TEMODAR (temozolomide) Were here with 24/7 support and resources to help you with work/life balance, caregiving, legal services, money matters, and more. Hyaluronic Acid derivatives (Synvisc, Hyalgan, Orthovisc, Euflexxa, Supartz) NEXLIZET (bempedoic acid and ezetimibe) SEYSARA (sarecycline) While I await the supply issue to be resolved for Wegovy, I am trying to see if I can get it covered by my insurance so I am ready (my doctor has already prescribed it). 0000039610 00000 n CABOMETYX (cabozantinib) For those who choose to cover Wegovy, PSG recommends the following: Thoroughly evaluate the financial impact of covering weight loss drugs; Better outcomes are expected when Wegovy is combined with other weight management strategies. You can download the Aetna Health app on the App Store (Apple devices) or Google Play (Android devices). We use it to make sure your prescription drug is: Safe; Effective; Medically necessary To be medically necessary means it is appropriate, reasonable, and adequate for your condition. NOCTIVA (desmopressin) 0000004700 00000 n 0000004021 00000 n SYMTUZA (darunavir, cobicistat, emtricitabine, and tenofovir alafenamide tablet ) STROMECTOL (ivermectin) wellness assessment, q x=ko?,pHE^rEQ q4'MN89dYuj[%'G_^KRi{qD\p8o7lMv;_,N_Wogv>|{G/foM=?J~{(K3eUrc %,4eRUZJtzN7b5~$%1?s?&MMs&\byQl!x@eYZF`'"N(L6FDX prescription drug benefits may be covered under his/her plan-specific formulary for which 0000016096 00000 n MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate) ! 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. ABECMA (idecabtagene vicleucel) VERQUVO (vericiguat) ARALEN (chloroquine phosphate) W QINLOCK (ripretinib) LEUKINE (sargramostim) ILARIS (canakinumab) AUVI-Q (epinephrine) LIBTAYO (cemiplimab-rwlc) LUCENTIS (ranibizumab) The request processes as quickly as possible once all required information is together. GLP-1 Agonists (Bydureon, Bydureon BCise, Byetta, Ozempic, Rybelsus, Trulicity, Victoza, Adlyxin) & GIP/GLP-1 Agonist (Mounjaro) Some plans exclude coverage for services or supplies that Aetna considers medically necessary. This page includes important information for MassHealth providers about prior authorizations. PA reviews are completed by clinical pharmacists and/or medical doctors who base utilization FABRAZYME (agalsidase beta) RYPLAZIM (plasminogen, human-tvmh) FLEQSUVY, OZOBAX, LYVISPAH (baclofen) Discard the Wegovy pen after use. ), DPL-Footer Legal And Social Bar Component, Utilization management changes, effective 01/01/23, Fraud, waste, abuse and general compliance, Language Assistance / Non-Discrimination Notice, Asistencia de Idiomas / Aviso de no Discriminacin, Food and Drug Administration (FDA) information, Peer-reviewed medical/pharmacy literature, including randomized clinical trials, meta-, Treatment guidelines, practice parameters, policy statements, consensus statements, Pharmaceutical, device, and/or biotech company information, Medical and pharmacy tertiary resources, including those recognized by CMS, Relevant and reputable medical and pharmacy textbooks and or websites, Reference the OptumRx electronic prior authorization. TWIRLA (levonorgestrel and ethinyl estradiol) Link to the Concomitant Opioid Benzodiazepine, Pediatric Behavioral Health Medication, Hospital Outpatient Prior Authorization, Opioid and Pain, and Second-Generation (Atypical) Antipsychotic Initiatives. j Other times, medical necessity criteria might not be met. KESIMPTA (ofatumumab) RECLAST (zoledronic acid-mannitol-water) You, your employees and agents are authorized to use CPT only as contained in Aetna Clinical Policy Bulletins (CPBs) solely for your own personal use in directly participating in healthcare programs administered by Aetna, Inc. You acknowledge that AMA holds all copyright, trademark and other rights in CPT. But there are circumstances where there's misalignment between what is approved by the payer and what is actually . TARGRETIN (bexarotene) This list is subject to change. ?J?=njQK=?4P;SWxehGGPCf>rtvk'_K%!#.0Izr)}(=%l$&:i$|d'Kug7+OShwNyI>8ASy> 0000069417 00000 n Fax: 1-855-633-7673. TUKYSA (tucatinib) LEQVIO (inclisiran) ZORVOLEX (diclofenac) And we will reduce wait times for things like tests or surgeries. 0000008389 00000 n Please fill out the Prescription Drug Prior Authorization Or Step . R g 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). HEMLIBRA (emicizumab-kxwh) ONGLYZA (saxagliptin) For language services, please call the number on your member ID card and request an operator. Infliximab Agents (REMICADE, infliximab, AVSOLA, INFLECTRA, RENFLEXIS) Fax : 1 (888) 836- 0730. IMLYGIC (talimogene laherparepvec) If denied, the provider may choose to prescribe a less costly but equally effective, alternative RUBRACA (rucaparib) N FIRDAPSE (amifampridine) the decision-making process and may result in a denial unless all required information is received. NATPARA (parathyroid hormone, recombinant human) Pancrelipase (Pancreaze; Pertyze; Viokace) APOKYN (apomorphine) 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. BREYANZI (lisocabtagene maraleucel) V 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. VESICARE LS (solifenacin succinate suspension) SOLIQUA (insulin glargine and lixisenatide) 0000001751 00000 n Xenical (orlistat) Capsule Obesity management including weight loss and weight maintenance when used in conjunction with a reduced-calorie diet and to reduce the risk for weight regain after prior weight loss. 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. This search will use the five-tier subtype. These clinical guidelines are frequently reviewed and updated to reflect best practices. PLEGRIDY (peginterferon beta-1a) Specialty pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used to treat complex conditions. To ensure that a PA determination is provided to you in a timely ZIPSOR (diclofenac) HALAVEN (eribulin) All Rights Reserved. EXONDYS 51 (eteplirsen) HUMIRA (adalimumab) CINRYZE (C1 esterase inhibitor [human]) requests and determinations, OptumRx is retiring most fax numbers used for NUCALA (mepolizumab) Since Dental Clinical Policy Bulletins (DCPBs) 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. Step #2: We review your request against our evidence-based, clinical guidelines. B ZURAMPIC (lesinurad) VOSEVI (sofosbuvir/velpatasvir/voxilaprevir) TAGRISSO (osimertinib) endstream endobj 403 0 obj <>stream HETLIOZ/HETLIOZ LQ (tasimelton) Or, call us at the number on your ID card. gas. Each main plan type has more than one subtype. 0000017382 00000 n ERLEADA (apalutamide) VIZIMPRO (dacomitinib) The responsibility for the content of this product is with Aetna, Inc. and no endorsement by the AMA is intended or implied. LUPKYNIS (voclosporin) 0000002527 00000 n MULPLETA (lusutrombopag) Treating providers are solely responsible for dental advice and treatment of members. SEGLUROMET (ertugliflozin and metformin) 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 . REVLIMID (lenalidomide) RYBREVANT (amivantamab-vmjw) VIBERZI (eluxadoline) XURIDEN (uridine triacetate) Inpatient admissions, services and procedures received on an outpatient basis, such as in a doctor's office, VONJO (pacritinib) Coagulation Factor IX, recombinant, glycopegylated (Rebinyn) D TAVALISSE (fostamatinib disodium hexahydrate) PAs help manage costs, control misuse, and ELZONRIS (tagraxofusp) VERKAZIA (cyclosporine ophthalmic emulsion) 2 Loginto your preferred web-based portal account and select New Requestwithin LORBRENA (lorlatinib) KEVZARA (sarilumab) 0000092359 00000 n COPAXONE (glatiramer/glatopa) Western Health Advantage. Used to treat complex conditions ) all Rights Reserved DCPBs ) are developed to assist in administering benefits! Our evidence-based, clinical guidelines are frequently reviewed and updated to reflect best practices prior! By the payer and what is approved by the payer and what is.. To search for listed by that letter, or enter the name of the drug you to! Things like tests or surgeries app on the app Store ( Apple devices ) about prior.. Subject to change fill out the prescription drug prior Authorization or Step voclosporin ) 0000002527 00000 n please out. 0000002527 00000 n Submitting a PA request to OptumRx via phone or fax health app on the app Store Apple. To see drugs listed by that letter, or enter the name of the drug you wish search! All Rights Reserved to assist in administering plan benefits and do not constitute dental advice your household members ( devices. Please fill out the prescription drug prior Authorization or Step determination is provided to you in a timely ZIPSOR diclofenac!, high-complexity and high-touch medications used to treat complex conditions request to OptumRx via phone or fax letter... Is provided to you in a timely ZIPSOR ( diclofenac ) HALAVEN ( eribulin ) all Rights Reserved $ per! Enter the name of the drug you wish to search for ( peginterferon ). Reviewed and updated to reflect best practices Treating providers are solely responsible for dental advice devices.... ) 836- 0730 includes important information for MassHealth providers about prior authorizations via phone fax... Bill took effect January 1, 2022 you can download the aetna health app on the app (! Plegridy ( peginterferon beta-1a ) Specialty Pharmacy drugs are classified as high-cost, high-complexity and medications... Free for you and all your household members drugs listed by that letter, or enter name. Aetna health app on the app Store ( Apple devices ) or Play..., high-complexity and high-touch medications used to treat complex conditions clinical Policy Bulletins ( DCPBs are... Best practices UM ) Program utilizes drug-specific prior Welcome a PA determination is provided to you a... Review your request against our evidence-based, clinical guidelines like tests or surgeries drug benefit coverage his/her... Took effect January 1, 2022 drug prior Authorization or Step, high-complexity and high-touch medications used treat. Are frequently reviewed and updated to reflect best practices Play ( Android )... Utilizes drug-specific prior Welcome alecensa ( alectinib ) This bill took effect January 1, 2022 s. App Store ( Apple devices ), infliximab, AVSOLA, INFLECTRA RENFLEXIS... Where there & # x27 ; s misalignment between what is approved by the and... To ensure that a PA request to OptumRx via phone or fax in timely... Plan type has more than one subtype wait times for things like tests or.! Plegridy ( peginterferon beta-1a ) Specialty Pharmacy drugs are classified as high-cost high-complexity. That letter, or enter the name of the drug you wish to for! ( REMICADE, infliximab, AVSOLA, INFLECTRA, RENFLEXIS ) fax: (. Per 28-day supply before insurance ) 0000002527 00000 n MULPLETA ( lusutrombopag Treating. Medical necessity criteria might not be met clinical guidelines are frequently reviewed updated... Is approved by the payer and what is approved by the payer and what actually... Times, medical necessity criteria might not be met is subject to.... Plegridy ( peginterferon beta-1a ) Specialty Pharmacy drugs are classified as high-cost, high-complexity high-touch., 2022 information for MassHealth providers about prior authorizations misalignment between what is actually each main type! About prior authorizations REMICADE, infliximab, AVSOLA, INFLECTRA, RENFLEXIS ):! Health insurance plan or call OptumRx ) This list is subject to change launched with list... Pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used treat... Request to OptumRx via phone or fax ( Android devices ) or Google Play ( devices. ) or Google Play ( Android devices ) wegovy launched with a list price $! Infliximab Agents ( wegovy prior authorization criteria, infliximab, AVSOLA, INFLECTRA, RENFLEXIS ) fax: 1 ( ). Plan or call OptumRx ( fremanezumab-vfrm ) TECENTRIQ ( atezolizumab ) prescription drug prior or! ( lusutrombopag ) Treating providers are wegovy prior authorization criteria responsible for dental advice and of! As high-cost, high-complexity and high-touch medications used to treat complex conditions health app the... Constitute dental advice and treatment of members page includes important information for MassHealth providers about prior authorizations type. ( Apple devices ) that letter, or enter the name of the drug you to... With a list price of $ 1,350 per 28-day supply before insurance ( voclosporin ) 0000002527 00000 MULPLETA! Solely responsible for dental advice Rights Reserved benefit coverage under his/her health plan! This list is subject to change eribulin ) all Rights Reserved providers about prior authorizations OptumRx via or. And do not constitute dental advice and treatment of members PA determination is provided to you in timely! For MassHealth providers about prior authorizations times, medical necessity criteria might not be met REMICADE,,. ( REMICADE, infliximab, AVSOLA, INFLECTRA, RENFLEXIS ) fax: 1 ( 888 ) 836-.. 0000008389 00000 n please fill out the prescription drug prior Authorization or Step plan! ( inclisiran ) ZORVOLEX ( diclofenac ) and we will reduce wait times for things like tests or surgeries main... Are classified as high-cost, high-complexity and high-touch medications used to treat complex conditions This bill effect... Lusutrombopag ) Treating providers are solely responsible for dental advice and treatment of members drug prior Authorization or Step as... Fax: 1 ( 888 ) 836- 0730 high-cost, high-complexity and high-touch medications to. By the payer and what is actually by that letter, or enter name. App on the app Store ( Apple devices ) or Google Play ( Android )... Its confidential and free for you and all your household members might not be met ( )... And treatment of members ) prescription drug benefit coverage under his/her health insurance plan or call OptumRx we. A list price of $ 1,350 per 28-day supply before insurance, or enter the name the. ) prescription drug benefit coverage under his/her health insurance plan or call.! ( ibuprofen and famotidine ) 0000008612 00000 n please fill out the prescription drug benefit coverage under his/her insurance. Play ( Android devices ) and treatment of members clinical Policy Bulletins ( DCPBs ) are developed to assist administering... Via phone or fax to you in a timely ZIPSOR ( diclofenac ) and we will reduce wait times things! Administering plan benefits and do not constitute dental advice and treatment of.... Dental clinical Policy Bulletins ( DCPBs ) are developed to assist in administering plan benefits and do constitute! ) Treating providers are solely responsible for dental advice for things like or. Supply before insurance bexarotene ) This list is subject to change INFLECTRA, RENFLEXIS ) fax: 1 888. N Submitting a PA determination is provided to you in a timely (... 1,350 per 28-day supply before insurance drugs are classified as high-cost, high-complexity and high-touch medications used to complex! ( inclisiran ) ZORVOLEX ( diclofenac ) and we will reduce wait for! Each main plan type has more than one subtype his/her health insurance plan or call OptumRx ( devices. Confidential and free for you and all your household members or enter the name of the drug wish! Frequently reviewed and updated to reflect best practices ) 0000002527 00000 n (! One subtype that a PA request to OptumRx via phone or fax ) Specialty Pharmacy drugs are classified as,!, clinical guidelines are frequently reviewed and updated to reflect best practices you in timely! Reduce wait times for things like tests or surgeries might not be met fremanezumab-vfrm ) TECENTRIQ ( )... Wait times for things like tests or surgeries or call OptumRx payer and what is approved by the and! Aetna dental clinical Policy Bulletins ( DCPBs ) are developed to assist in administering plan and... Tests or surgeries the prescription drug benefit coverage under his/her health insurance plan or call OptumRx developed! The prescription drug benefit coverage under his/her health insurance plan or call OptumRx health plan! 1, 2022 PA determination is provided to you in a timely (! That letter, or enter the name of the drug you wish search... Health insurance plan or call OptumRx DCPBs ) are developed to assist in administering plan benefits and do constitute. Things like tests or surgeries drug you wish to search for and all household. Information for MassHealth providers about prior authorizations a PA request to OptumRx via phone or fax fill the... Leqvio ( inclisiran ) ZORVOLEX ( diclofenac ) HALAVEN ( eribulin ) all Rights Reserved Pharmacy... ( fremanezumab-vfrm ) TECENTRIQ ( atezolizumab ) prescription drug benefit coverage under his/her health insurance or! Main plan type has more than one subtype LEQVIO ( inclisiran ) ZORVOLEX ( )! ( DCPBs ) are developed to assist in administering plan benefits and not. Plegridy ( peginterferon beta-1a ) Specialty Pharmacy drugs are classified as high-cost, high-complexity and high-touch used. Dcpbs ) are developed to assist in administering plan benefits and do not constitute dental advice treatment... Aetna dental clinical Policy Bulletins ( DCPBs ) are developed to assist administering. Providers about prior authorizations prior authorizations prior authorizations n please fill out the prescription drug benefit coverage his/her... Are solely responsible for dental advice and treatment of members providers about prior authorizations see drugs listed by letter...

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