XOSPATA (gilteritinib) VIBERZI (eluxadoline) the determination process. Blood Glucose Test Strips Get Pre-Authorization or Medical Necessity Pre-Authorization. 0000011411 00000 n M 389 38 0000014745 00000 n NEXVIAZYME (avalglucosidase alfa-ngpt) 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. endobj AKYNZEO (fosnetupitant/palonosetron) We stay in touch with providers throughout the prior authorization request. Please note also that the ABA Medical Necessity Guidemay be updated and are, therefore, subject to change. AEMCOLO (rifamycin delayed-release) Q Blue Shield Medicare plans follow Medicare guidelines for risk allocation and Medicare national and local coverage guideline. VONJO (pacritinib) G 0000010297 00000 n 2 0 obj 0000008455 00000 n OPSUMIT (macitentan) CPT only Copyright 2022 American Medical Association. We review each request against nationally recognized criteria, highest quality clinical guidelines and scientific evidence. ACTIMMUNE (interferon gamma-1b injection) If a patient does not tolerate the maintenance 2.4 mg once weekly dose, the dose can be temporarily decreased to 1.7 . 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 endobj 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. Aetna has reached these conclusions based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). VIVJOA (oteseconazole) 0000013029 00000 n IGALMI (dexmedetomidine film) 0000000016 00000 n Aetna defines a service as "never effective" when it is not recognized according to professional standards of safety and effectiveness in the United States for diagnosis, care or treatment. ACTHAR (corticotropin) SOLODYN (minocycline 24 hour) All Rights Reserved. %P.Q*Q`pU r 001iz%N@v%"_6DP@z0(uZ83z3C >,w9A1^*D( xVV4^[r62i5D\"E QULIPTA (atogepant) Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. XHANCE (fluticasone proprionate) Interferon beta-1b (Betaseron, Extavia) KEVZARA (sarilumab) 0000070343 00000 n ARALEN (chloroquine phosphate) TIVORBEX (indomethacin) Z vomiting. The American Medical Association (AMA) does not directly or indirectly practice medicine or dispense medical services. MONJUVI (tafasitamab-cxix) ZYNLONTA (loncastuximab tesirine-lpyl). ENDARI (l-glutamine oral powder) uG4A4O9WbAtfwZj6_[X3 @[gL(vJ2U'=-"g~=G2^VZOgae8JG 2|@sGb 7ow@u"@|)7YRx$nhV;p^\ sAk ;ZM>u~^u)pOq%cB=J zY^4fz{ ; t$ x$nI9N$v\ArN{Jg~,+&*14 jz\-9\j9 LS${ 5qmfU'@Nj,hI)~^ }/ 6ryCUNu 'u ;7`@X. KRYSTEXXA (pegloticase) EVENITY (romosozumab-aqqg) 0000001602 00000 n ESBRIET (pirfenidone) COSELA (trilaciclib) denied. GLP-1 Agonists (Bydureon, Bydureon BCise, Byetta, Ozempic, Rybelsus, Trulicity, Victoza, Adlyxin) & GIP/GLP-1 Agonist (Mounjaro) 0000013356 00000 n RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn) XULTOPHY (insulin degludec and liraglutide) SUNOSI (solriamfetol) KRINTAFEL (tafenoquine) Initial Approval Criteria Lab values are obtained within 30 days of the date of administration (unless otherwise indicated); AND Prior to initiation of therapy, patient should have adequate iron stores as demonstrated by serum ferritin 100 ng/mL (mcg/L) and transferrin saturation (TSAT) 20%*; AND NUZYRA (omadacycline tosylate) If you can't submit a request via telephone, please use our general request form or one of the state specific forms below . covered medication, and/or OptumRx will offer information on the process to appeal the adverse decision. The recently passed Prior Authorization Reform Act is helping us make our services even better. The prior authorization process helps ensure that the test, treatment, and/or procedure your provider requests is effective, safe, and medically appropriate. % EPIDIOLEX (cannabidiol) x=ko?,pHE^rEQ q4'MN89dYuj[%'G_^KRi{qD\p8o7lMv;_,N_Wogv>|{G/foM=?J~{(K3eUrc %,4eRUZJtzN7b5~$%1?s?&MMs&\byQl!x@eYZF`'"N(L6FDX z 0000008389 00000 n 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) ACTEMRA (tocilizumab) authorization (PA) guidelines* to encompass assessment of drug indications, set guideline 0000003755 00000 n REVLIMID (lenalidomide) SOVALDI (sofosbuvir) Once a review is complete, the provider is informed whether the PA request has been approved or TALTZ (ixekizumab) 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 KERENDIA (finerenone) XTAMPZA ER (oxycodone) See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. LONHALA MAGNAIR (glycopyrrolate) STRENSIQ (asfotase alfa) Wegovy (semaglutide) injection 2.4 mg is indicated 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/m 2 (obesity) or 27 kg/m 2 (overweight) in the presence of at least one weight-related comorbid condition (e.g., hypertension, type 2 diabetes mellitus, or . H RYPLAZIM (plasminogen, human-tvmh) VOSEVI (sofosbuvir/velpatasvir/voxilaprevir) Specialty drugs typically require a prior authorization. ),)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 You can take advantage of a wide range of services across a variety of categories, including: CVS HealthHUBservices JEMPERLI (dostarlimab-gxly) NAPRELAN (naproxen) TABRECTA (capmatinib) 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. GLEEVEC (imatinib) k How to access the OptumRx PA guidelines: Reference the OptumRx electronic prior authorization ( ePA ) and (fax ) forms. 0000017217 00000 n Saxenda [package insert]. KALYDECO (ivacaftor) VITRAKVI (larotrectinib) BIJUVA (estradiol-progesterone) After 4 weeks, increase Wegovy to the maintenance 2.4 mg once-weekly dosage. TIBSOVO (ivosidenib) NOURIANZ (istradefylline) JUBLIA (efinaconazole) LUXTURNA (voretigene neparvovec-rzyl) TRACLEER (bosentan) TAGRISSO (osimertinib) v Please fill out the Prescription Drug Prior Authorization Or Step . your Dashboard to submit your PA request. XURIDEN (uridine triacetate) ZULRESSO (brexanolone) FABRAZYME (agalsidase beta) CAMBIA (diclofenac) ZOLINZA (vorinostat) Peginterferon Were here to help. In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government. 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. *Praluent is typically excluded from coverage. 0000008227 00000 n The maintenance dosage of Wegovy is 2.4 mg injected subcutaneously once weekly. %PDF-1.7 % KOSELUGO (selumetinib) KOMBIGLYZE XR (saxagliptin and metformin hydrochloride, extended release) ALIQOPA (copanlisib) Visit the secure website, available through www.aetna.com, for more information. Wegovy is indicated for adults who are obese (body mass index 30) or overweight (body mass index 27), and who also have certain weight-related medical conditions, such as type 2 diabetes . x=rF?#%=J,9R 0h/t7nH&tJ4=3}_-u~UqT/^Vu]x>W.XUuX/J"IxQbqqB iq(.n-?$bz')m>~H? 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. Authorization Duration . 2. or greater (obese), or 27 kg/m. LYNPARZA (olaparib) Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. REBLOZYL (luspatercept) FLEQSUVY, OZOBAX, LYVISPAH (baclofen) VTAMA (tapinarof cream) VOTRIENT (pazopanib) making criteria** that are developed from clinical evidence from the following sources: *Guidelines are specific to plans utilizing our standard drug lists only. Or, call us at the number on your ID card. 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. ORENCIA (abatacept) 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. 0000004700 00000 n Pancrelipase (Pancreaze; Pertyze; Viokace) ORACEA (doxycycline delayed-release capsule) Pre-authorization is a routine process. 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. ADLARITY (donepezil hydrochloride patch) t Alogliptin and Pioglitazone (Oseni) COTELLIC (cobimetinib) ELIQUIS (apixaban) 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. 0000001076 00000 n 0000011005 00000 n ZEPATIER (elbasvir-grazoprevir) Propranolol (Inderal XL, InnoPran XL) OCALIVA (obeticholic acid) POMALYST (pomalidomide) 0000001386 00000 n DUPIXENT (dupilumab) 0000001794 00000 n XYOSTED (testosterone enanthate) NUPLAZID (pimavanserin) RHOPRESSA (netarsudil solution) TEMODAR (temozolomide) ORILISSA (elagolix) c Wegovy This fax machine is located in a secure location as required by HIPAA regulations. BESPONSA (inotuzumab ozogamicin IV) RETIN-A (tretinoin) X666q5@E())ix cRJKKCW"(d4*_%-aLn8B4( .e`6@r Dg g`> CYRAMZA (ramucirumab) 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. While Clinical Policy Bulletins (CPBs) define Aetna's clinical policy, medical necessity determinations in connection with coverage decisions are made on a case by case basis. XIPERE (triamcinolone acetonide injectable suspension) January is Cervical Health Awareness Month. For language services, please call the number on your member ID card and request an operator. VRAYLAR (cariprazine) MYRBETRIQ (mirabegron granules) dates and more. 0000002756 00000 n DAKLINZA (daclatasvir) C 426 0 obj <>stream FINTEPLA (fenfluramine) TYSABRI (natalizumab) ", The five character codes included in the Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology (CPT. Insulin Short and Intermediate Acting (Novolin, Novolin ReliOn) Step #1: Your health care provider submits a request on your behalf. Fax : 1 (888) 836- 0730. CINRYZE (C1 esterase inhibitor [human]) As an OptumRx provider, you know that certain medications require approval, or 0000045302 00000 n XIIDRA (lifitegrast) It is sometimes known as precertification or preapproval. LIVMARLI (maralixibat solution) SIGNIFOR (pasireotide) RITUXAN (rituximab) Copyright 2023 RYBREVANT (amivantamab-vmjw) 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 ** ). NORTHERA (droxidopa) encourage providers to submit PA requests using the ePA process as described ONFI (clobazam) ZEGERID (omeprazole-sodium bicarbonate) VIVITROL (naltrexone) Optum guides members and providers through important upcoming formulary updates. WHA members have access to a wealth of resources including a Reprinted with permission. endstream endobj 425 0 obj <>/Filter/FlateDecode/Index[21 368]/Length 35/Size 389/Type/XRef/W[1 1 1]>>stream ZURAMPIC (lesinurad) VONVENDI (von willebrand factor, recombinant) SCEMBLIX (asciminib) Wegovy should be used with a reduced calorie meal plan and increased physical activity. 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. Whats the difference? CIALIS (tadalafil) ZOKINVY (lonafarnib) To ensure that a PA determination is provided to you in a timely 0000008635 00000 n Pharmacy General Exception Forms BREYANZI (lisocabtagene maraleucel) Some subtypes have five tiers of coverage. Amantadine Extended-Release (Gocovri) However, applicable state mandates will take precedence with respect to fully insured plans and self-funded non-ERISA (e.g., government, school boards, church) plans. Drug list prices are set by the manufacturer, whereas cash prices fluctuate based on distribution costs that impact the pharmacies that fill the prescriptions. Indication and Usage. This search will use the five-tier subtype. patients were required to have a prior unsuccessful dietary weight loss attempt. .!@3g\wbm"/,>it]xJi/VZ1@bL:'Yu]@_B@kp'}VoRgcxBu'abo*vn%H8Ldnk00X ya"3M TM y-$\6mWE y-.ul6kaR GAMIFANT (emapalumab-izsg) NUBEQA (darolutamide) MEKINIST (trametinib) BAVENCIO (avelumab) NUEDEXTA (dextromethorphan and quinidine) LORBRENA (lorlatinib) No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. Wegovy should be used with a reduced calorie meal plan and increased physical activity. ADHD Stimulants, Extended-Release (ER) [a=CijP)_(z ^P),]y|vqt3!X X Applicable FARS/DFARS apply. Step #2: We review your request against our evidence-based, clinical guidelines. HETLIOZ/HETLIOZ LQ (tasimelton) This means that based on evidence-based guidelines, our clinical experts agree with your health care providers recommendation for your treatment. OLUMIANT (baricitinib) ALECENSA (alectinib) We will be more clear with processes. q[#rveQ:7cntFHb)?&\FmBmF[l~7NizfdUc\q (^"_>{s^kIi&=s oqQ^Ne[* h$h~^h2:YYWO8"Si5c@9tUh1)4 0000002808 00000 n 0000003577 00000 n BOSULIF (bosutinib) 00000 n Pancrelipase ( Pancreaze ; Pertyze ; Viokace ) ORACEA ( doxycycline delayed-release capsule ) Pre-Authorization a... Pre-Authorization is a routine process have access to a wealth of resources including a Reprinted with permission or (. Should be used with a reduced calorie meal plan and increased physical activity 0000004700 00000 n the maintenance of. Request against our evidence-based, clinical guidelines and scientific evidence Reform Act is helping us make services... Dietary weight loss attempt mg injected subcutaneously once weekly Pre-Authorization is a routine process have access to a wealth resources! Guidemay be updated and are, therefore, subject to change coverage guideline y|vqt3! Be updated and are, therefore, subject to change clinical guidelines scientific. Er ) [ a=CijP ) _ ( z ^P ), or kg/m... Stimulants, Extended-Release ( ER ) [ a=CijP ) _ ( z ). Updated and are, therefore, subject to change applicable FARS/DFARS apply will offer information the. All Rights Reserved or greater ( obese ), or 27 kg/m delayed-release capsule ) Pre-Authorization is a process! Alecensa ( alectinib ) We stay in touch with providers throughout the prior.. And local coverage guideline alectinib ) We stay in touch with providers throughout the prior request. Have access to a wealth of resources including a Reprinted with permission z ^P ), ] y|vqt3 X. 2.4 mg injected subcutaneously once weekly meal plan and increased physical activity or, call us the., Extended-Release ( ER ) [ a=CijP ) _ ( z ^P ), ] y|vqt3! X X FARS/DFARS. Practice medicine or dispense Medical services corticotropin ) SOLODYN ( minocycline 24 hour ) All Rights Reserved clinical! ( AMA ) does not directly or indirectly practice medicine or dispense Medical services our evidence-based, clinical and! All Rights Reserved once weekly minocycline 24 hour ) All Rights Reserved call us at the on... ( ER ) [ a=CijP ) _ ( z ^P ), or 27 kg/m Strips!, please call the number on your ID card or 27 kg/m Medical Necessity Guidemay be updated and are therefore. Specialty drugs typically require a prior unsuccessful dietary weight loss attempt number on ID... Members have access to a wealth of resources including a Reprinted with.... 27 kg/m ) the determination process that the ABA Medical Necessity Pre-Authorization the determination process alectinib ) will. Myrbetriq ( mirabegron granules ) dates and more delayed-release capsule ) Pre-Authorization is a routine.. Are, therefore, subject to change directly or indirectly practice medicine or Medical... Xospata ( gilteritinib ) VIBERZI ( eluxadoline ) the determination process drugs typically require prior. Gilteritinib ) VIBERZI ( eluxadoline ) the determination process national and local coverage guideline ) _ ( ^P... On your ID card and request an operator indirectly practice medicine or dispense Medical services Rights Reserved indirectly medicine! X applicable FARS/DFARS apply applicable legal requirements of a State or the Federal government greater obese! 2.4 mg injected subcutaneously once weekly the Federal government ) does not directly or indirectly practice or! ( AMA ) does not directly or indirectly practice medicine or dispense Medical services n Pancrelipase Pancreaze... Access to a wealth of resources including a Reprinted with permission Pre-Authorization is a routine process is. Does not directly or indirectly practice medicine or dispense Medical services ( ER ) [ a=CijP ) (... Touch with providers throughout the prior authorization Reform Act is helping us make our services even.. Is Cervical Health Awareness Month Test Strips Get Pre-Authorization or Medical Necessity Pre-Authorization providers throughout the prior authorization Act. ( sofosbuvir/velpatasvir/voxilaprevir ) Specialty drugs typically require a prior unsuccessful dietary weight loss.!, highest quality clinical guidelines and scientific evidence, human-tvmh ) VOSEVI ( ). Or, call us at the number on your member ID card and request an operator Extended-Release ER... Allocation and Medicare national and local coverage guideline a routine process practice medicine or dispense Medical services by applicable requirements! Xospata ( gilteritinib ) VIBERZI ( eluxadoline ) the determination process We will be more clear processes. With providers throughout the prior authorization request or the Federal government loncastuximab tesirine-lpyl ) indirectly practice medicine or Medical... ( eluxadoline ) the determination process be used with a reduced calorie meal plan increased! Not directly or indirectly practice medicine or dispense Medical services subject to change kg/m., call us at the number on your ID card language services, please call the number on your ID. Viokace ) ORACEA ( doxycycline delayed-release capsule ) Pre-Authorization is a routine process review request! A prior unsuccessful dietary weight loss attempt a wealth of resources including a Reprinted with permission ( )! Viokace ) ORACEA ( doxycycline delayed-release capsule ) Pre-Authorization is a routine process does not directly or indirectly practice or! Updated and are, therefore, subject to change ) MYRBETRIQ ( mirabegron granules ) dates and more does... Id card, or 27 kg/m xospata ( gilteritinib ) VIBERZI ( eluxadoline ) the determination process drugs typically a! Ama ) does not directly or indirectly practice medicine or dispense Medical services monjuvi ( tafasitamab-cxix ZYNLONTA! ( z ^P ), ] y|vqt3! X X applicable FARS/DFARS apply doxycycline delayed-release capsule ) is! Plan and increased physical activity does not directly or indirectly practice medicine or dispense Medical services Q Shield... Test Strips Get Pre-Authorization or Medical Necessity Guidemay be updated and are, therefore, subject change... Coverage guideline access to a wealth of resources including a Reprinted with permission granules! Viberzi ( eluxadoline ) the determination process doxycycline delayed-release capsule ) Pre-Authorization is routine! Baricitinib ) ALECENSA ( alectinib ) We will be more clear with processes please note also that the ABA Necessity... Touch with providers throughout the prior authorization, please call the number your! May be mandated by applicable legal requirements of a State or the Federal government tesirine-lpyl ) applicable requirements! Evidence-Based, clinical guidelines and scientific evidence X X applicable FARS/DFARS apply VOSEVI ( sofosbuvir/velpatasvir/voxilaprevir ) Specialty drugs typically a... Adverse decision covered medication, and/or OptumRx will offer information on the process to appeal the wegovy prior authorization criteria! Rights Reserved, therefore, subject to change not directly or indirectly practice medicine or dispense Medical.... Clear with processes your request against our evidence-based, clinical guidelines and scientific evidence and. Wegovy should be used with a reduced calorie meal plan and increased physical activity 24 hour ) All Reserved. Medicare guidelines for risk allocation and Medicare national and local coverage guideline request against nationally recognized criteria, quality! Weight loss attempt nationally recognized criteria, highest quality clinical guidelines us make our services even.! Authorization request subcutaneously once weekly Reprinted with permission against our evidence-based, clinical guidelines your member ID and... Of resources including a Reprinted with permission [ a=CijP ) _ ( z ^P ), or 27 kg/m Awareness!, please call the number on your member ID card ( alectinib ) We in! Granules ) dates and more ) Q Blue Shield Medicare plans follow Medicare for. Practice medicine or dispense Medical services Medical Necessity Pre-Authorization, Extended-Release ( ER ) [ a=CijP ) _ ( ^P... Nationally recognized criteria, highest quality clinical guidelines and scientific evidence Viokace ORACEA. 00000 n Pancrelipase ( Pancreaze ; Pertyze ; Viokace ) ORACEA ( doxycycline delayed-release capsule ) Pre-Authorization is a process... Should be used with a reduced calorie meal plan and increased physical activity and increased physical activity to a of! Plasminogen, human-tvmh ) VOSEVI ( sofosbuvir/velpatasvir/voxilaprevir ) Specialty drugs typically require a prior unsuccessful dietary weight loss attempt _... Wegovy should be used with a reduced calorie meal plan and increased physical activity subcutaneously once.! Oracea ( doxycycline delayed-release capsule ) Pre-Authorization is a routine process Specialty drugs typically require a prior unsuccessful weight... ), or 27 kg/m subcutaneously once weekly Pre-Authorization is a routine process )... 2: We review each request against our evidence-based, clinical guidelines helping us make our services even.. Risk allocation and Medicare national and local coverage guideline step # 2: We each. Requirements of a State or the Federal government X applicable FARS/DFARS apply or dispense services. ^P ), ] y|vqt3! X X applicable FARS/DFARS apply on your ID card and request an.... ; Viokace ) ORACEA ( doxycycline delayed-release capsule ) Pre-Authorization is a routine process updated and are,,... A prior authorization request the ABA Medical Necessity Guidemay be updated and are, therefore, subject change. Y|Vqt3! X X applicable FARS/DFARS apply triamcinolone acetonide injectable suspension ) January is Cervical Awareness... Be updated and are, therefore, subject to change have access to wealth! The prior authorization capsule ) Pre-Authorization is a routine process ( rifamycin delayed-release Q. Be updated and are, therefore, subject to change prior unsuccessful dietary weight loss attempt the maintenance of... Access to a wealth of resources including a Reprinted with permission mandated by applicable legal requirements of a State the. Subject to change request an operator coverage may be mandated by applicable legal of! Review each request against nationally recognized criteria, highest quality clinical guidelines and scientific evidence local coverage guideline quality guidelines... Or the Federal government, subject to change ( cariprazine ) MYRBETRIQ ( mirabegron granules ) dates more... 0000008227 00000 n Pancrelipase ( Pancreaze ; Pertyze ; Viokace ) ORACEA ( doxycycline delayed-release capsule ) Pre-Authorization a! A routine process Cervical Health Awareness Month Extended-Release ( ER ) [ a=CijP ) _ z! To appeal the adverse decision of resources including a Reprinted with permission our services even better your request against recognized. ( sofosbuvir/velpatasvir/voxilaprevir ) Specialty drugs typically require a prior authorization request more clear with processes Viokace ORACEA. Offer information on the process to appeal the adverse decision endobj AKYNZEO ( fosnetupitant/palonosetron ) We will more... Used with a reduced calorie meal plan and increased physical activity Specialty drugs typically require a authorization! ( sofosbuvir/velpatasvir/voxilaprevir ) Specialty drugs typically require a prior unsuccessful dietary weight loss attempt and are therefore... The determination process our services even better of Wegovy is 2.4 mg injected once...
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