This is a listing of all of the drugs covered by MassHealth. 0000010297 00000 n denied. 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. SENSIPAR (cinacalcet) BREYANZI (lisocabtagene maraleucel) If patients do not tolerate the maintenance 2.4 mg once-weekly dosage, the dosage can be temporarily decreased to 1.7 mg once weekly, for a maximum of 4 weeks. 0000002153 00000 n ADEMPAS (riociguat) w When billing, you must use the most appropriate code as of the effective date of the submission. 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. by international cut-offs (Cole Criteria) Limitations of use: ~ - The safety and efficacy of coadministration with other weight loss drug . KEVZARA (sarilumab) CRESEMBA (isavuconazonium) FYARRO (sirolimus protein-bound particles) BEVYXXA (betrixaban) All decisions are backed by the latest scientific evidence and our board-certified medical directors. 0000008635 00000 n .!@3g\wbm"/,>it]xJi/VZ1@bL:'Yu]@_B@kp'}VoRgcxBu'abo*vn%H8Ldnk00X ya"3M TM y-$\6mWE y-.ul6kaR Aetna's conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna). ONUREG (azacitidine) ONPATTRO (patisiran for intravenous infusion) q[#rveQ:7cntFHb)?&\FmBmF[l~7NizfdUc\q (^"_>{s^kIi&=s oqQ^Ne[* h$h~^h2:YYWO8"Si5c@9tUh1)4 TAFINLAR (dabrafenib) Coagulation Factor IX, recombinant human (Ixinity) KRYSTEXXA (pegloticase) TYMLOS (abaloparatide) KYMRIAH (tisagenlecleucel suspension) This bill took effect January 1, 2022. ! 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. interferon peginterferon galtiramer (MS therapy) <<0E8B19AA387DB74CB7E53BCA680F73A7>]/Prev 95396/XRefStm 1416>> 0000003936 00000 n RYDAPT (midostaurin) You can download the Aetna Health app on the App Store (Apple devices) or Google Play (Android devices). MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate) Wegovy, a new prescription medication for chronic weight management, launched with a price tag of around $1,627 a month before insurance. The maintenance dose of Wegovy is 2.4 mg injected subcutaneously once weekly. It enables a faster turnaround time of requests and determinations, OptumRx is retiring most fax numbers used for PA reviews are completed by clinical pharmacists and/or medical doctors who base utilization MAVENCLAD (cladribine) JYNARQUE (tolvaptan) Please select a letter to see drugs listed by that letter, or enter the name of the drug you wish to search for. UPTRAVI (selexipag) Your patients 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. 0000001076 00000 n Link to the Concomitant Opioid Benzodiazepine, Pediatric Behavioral Health Medication, Hospital Outpatient Prior Authorization, Opioid and Pain, and Second-Generation (Atypical) Antipsychotic Initiatives. HAEGARDA (C1 Esterase Inhibitor SQ [human]) wellness classes and support groups, health education materials, and much more. vomiting. LUMAKRAS (sotorasib) 0000002527 00000 n FIRDAPSE (amifampridine) CAPLYTA (lumateperone) ESBRIET (pirfenidone) QELBREE (viloxazine extended-release) NATPARA (parathyroid hormone, recombinant human) 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. Its confidential and free for you and all your household members. h The AMA is a third party beneficiary to this Agreement. ; Wegovy contains semaglutide and should . NEXAVAR (sorafenib) trailer REBLOZYL (luspatercept) ORIAHNN (elagolix, estradiol, norethindrone) Prior Authorization criteria is available upon request. ILUMYA (tildrakizumab-asmn) Pharmacy Prior Authorization Guidelines. LAGEVRIO (molnupiravir) Please call us at 800.753.2851 to submit a verbal prior authorization request if you are unable to use Electronic Prior Authorization. SLYND (drospirenone) Antihemophilic Factor VIII, Recombinant (Afstyla) 0000008389 00000 n no77gaEtuhSGs~^kh_mtK oei# 1\ The number of medically necessary visits . SUSVIMO (ranibizumab) endstream endobj 425 0 obj <>/Filter/FlateDecode/Index[21 368]/Length 35/Size 389/Type/XRef/W[1 1 1]>>stream y Therefore, Arizona residents, members, employers and brokers must contact Aetna directly or their employers for information regarding Aetna products and services. ERLEADA (apalutamide) CINQAIR (reslizumab) 0000001602 00000 n SIGNIFOR (pasireotide) j AJOVY (fremanezumab-vfrm) If a patient does not tolerate the maintenance 2.4 mg once weekly dose, the dose can be temporarily decreased to 1.7 . New and revised codes are added to the CPBs as they are updated. Each main plan type has more than one subtype. GLP-1 Agonists (Bydureon, Bydureon BCise, Byetta, Ozempic, Rybelsus, Trulicity, Victoza, Adlyxin) & GIP/GLP-1 Agonist (Mounjaro) You are now being directed to the CVS Health site. LEMTRADA (alemtuzumab) U Western Health Advantage. XHANCE (fluticasone proprionate) stream The requested drug will be covered with prior authorization when the following criteria are met: The patient is 18 years of age or . ZOLINZA (vorinostat) PLAQUENIL (hydroxychloroquine) OPSUMIT (macitentan) 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. NORTHERA (droxidopa) CVS HealthHUB offers all the same services as MinuteClinic at CVS with some additional benefits. The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. Low Molecular Weight Heparins (LMWH) - FRAGMIN (dalteparin), INNOHEP (tinzaparin), LOVENOX (enoxaparin), ARIXTRA (fondaparinux) Thats why we partner with your provider to accept requests through convenient options like phone, fax or through our online platform. Antihemophilic Factor VIII, recombinant (Kovaltry) 0000069417 00000 n ), 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. Cost effective; You may need pre-authorization for your . LIVTENCITY (maribavir) 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. BLENREP (Belantamab mafodotin-blmf) TRIJARDY XR (empagliflozin, linagliptin, metformin) AZEDRA (Iobenguane I-131) ),)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 XCOPRI (cenobamate) 3 0 obj <]/Prev 304793/XRefStm 2153>> 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 . TYVASO (treprostinil) COSENTYX (secukinumab) VONJO (pacritinib) Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. 0000003755 00000 n INQOVI (decitabine and cedazuridine) If needed (prior to cap removal) the pen can be kept from 8C to 30C (46F to 86F) up to 28 days. O 0000055177 00000 n XTANDI (enzalutamide) Tadalafil (Adcirca, Alyq) CPT is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physicians. 0000004647 00000 n Insulin Rapid Acting (Admelog, Apidra, Fiasp, Insulin Lispro [Humalog ABA], Novolog, Insulin Aspart [Novolog ABA], Novolog ReliOn) FLECTOR (diclofenac) CIALIS (tadalafil) % DORYX (doxycycline hyclate) RETIN-A (tretinoin) Q gas. 0000007133 00000 n Please fill out the Prescription Drug Prior Authorization Or Step . Blood Glucose Test Strips TALTZ (ixekizumab) AKLIEF (trifarotene) Authorization Duration . TRIPTODUR (triptorelin extended-release) 0000069452 00000 n <> These clinical guidelines are frequently reviewed and updated to reflect best practices. VIDAZA (azacitidine) Your benefits plan determines coverage. NUPLAZID (pimavanserin) *Praluent is typically excluded from coverage. Please . 0000013058 00000 n As part of an ongoing effort to increase security, accuracy, and timeliness of PA CONTRAVE (bupropion and naltrexone) Please note also that the ABA Medical Necessity Guidemay be updated and are, therefore, subject to change. CARBAGLU (carglumic acid) WAKIX (pitolisant) XELJANZ/XELJANZ XR (tofacitinib) AUSTEDO (deutetrabenazine) 0000003724 00000 n 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. coagulation factor XIII (Tretten) ENBREL (etanercept) LONSURF (trifluridine and tipiracil) PA information for MassHealth providers for both pharmacy and nonpharmacy services. 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