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). 0000005021 00000 n
CAMZYOS (mavacamten)
0000007133 00000 n
0000004700 00000 n
ZYKADIA (ceritinib)
AKYNZEO (fosnetupitant/palonosetron)
Coagulation Factor IX, recombinant, glycopegylated (Rebinyn)
APOKYN (apomorphine)
VITRAKVI (larotrectinib)
AYVAKIT (avapritinib)
AIMOVIG (erenumab-aooe)
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. ICLUSIG (ponatinib)
ZYDELIG (idelalisib)
U
LUCENTIS (ranibizumab)
KERYDIN (tavaborole)
PENNSAID (diclofenac)
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. FULYZAQ (crofelemer)
i
EXJADE (deferasirox)
L
Elapegademase-lvlr (Revcovi)
MassHealth Pharmacy Initiatives and Clinical Information. prescription drug benefit coverage under his/her health insurance plan or call OptumRx. DORYX (doxycycline hyclate)
O
u
0000005705 00000 n
ADDYI (flibanserin)
There should also be a book you can download that will show you the pre-authorization criteria, if that is required.
LUCEMYRA (lofexidine)
CONTRAVE (bupropion and naltrexone)
Z
VERQUVO (vericiguat)
*Praluent is typically excluded from coverage.
ZEJULA (niraparib)
The maintenance dosage of Wegovy is 2.4 mg injected subcutaneously once weekly. In doing so, CVS/Caremark will be able to decide whether or not the requested prescription is included in the patient's insurance plan.
MYLOTARG (gemtuzumab ozogamicin)
ZYFLO (zileuton)
ACCRUFER (ferric maltol)
o
0000013356 00000 n
ENBREL (etanercept)
After 4 weeks, increase Wegovy to the maintenance 2.4 mg once-weekly dosage.
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 RINVOQ (upadacitinib)
0000011365 00000 n
Some plans exclude coverage for services or supplies that Aetna considers medically necessary. The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. ORKAMBI (lumacaftor/ivacaftor)
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 .
0000069186 00000 n
NEXLETOL (bempedoic acid)
%
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 . Please . N
DUEXIS (ibuprofen and famotidine)
0000008455 00000 n
DELATESTRYL (testosterone cypionate 100mg/ml; 200mg/ml)
D
VIMIZIM (elosulfase alfa)
All decisions are backed by the latest scientific evidence and our board-certified medical directors.
Guidelines are based on written objective pharmaceutical UM decision- %%EOF
Prior Authorization criteria is available upon request. patients were required to have a prior unsuccessful dietary weight loss attempt. Please contact CVS/Caremark at 855-582-2022 with questions regarding the prior authorization process. VUMERITY (diroximel fumarate)
ZOMETA (zoledronic acid)
Coverage for weight loss drugs like Wegovy varies widely depending on the kind of insurance you have and where you live.
SEGLUROMET (ertugliflozin and metformin)
CPT is a registered trademark of the American Medical Association.
PSG suggests the inclusion of those strategies within prior authorization (PA) criteria. DUPIXENT (dupilumab)
RITUXAN (rituximab)
III.
NAYZILAM (midazolam nasal spray)
ADCETRIS (brentuximab)
KYLEENA (Levonorgestrel intrauterine device)
IMCIVREE (setmelanotide)
FIRDAPSE (amifampridine)
BIJUVA (estradiol-progesterone)
TYMLOS (abaloparatide)
review decisions on sound clinical evidence and make a determination within the timeframe Protect Wegovy from light.
SCEMBLIX (asciminib)
The cash price is even higher, averaging $1,988.22 since August 2021 according to GoodRx . 0000011178 00000 n
VELCADE (bortezomib)
KEVZARA (sarilumab)
0000001794 00000 n
SOLIQUA (insulin glargine and lixisenatide)
%%EOF
BYLVAY (odevixibat)
KRINTAFEL (tafenoquine)
SPRIX (ketorolac nasal spray)
Discontinue WEGOVY if the patient cannot tolerate the 2.4 mg dose. VIJOICE (alpelisib)
0000013058 00000 n
VIBERZI (eluxadoline)
Therapeutic indication. hb```b``{k @16=v1?Q_# tY 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.
Or, call us at the number on your ID card.
NEXVIAZYME (avalglucosidase alfa-ngpt)
Capsaicin Patch
ORENCIA (abatacept)
This page includes important information for MassHealth providers about prior authorizations. Also includes the CAR-T Monitoring Program, and Luxturna Monitoring Program . Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod)
Part D drug list for Medicare plans.
SENSIPAR (cinacalcet)
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). I
BONIVA (ibandronate)
Copyright 2023
I'm assuming this is a fairly common occurrence with Calibrate, as I wouldn't have spent $1500 if I could have easily been prescribed Ozempic by my PCP and have it covered. ULTOMIRIS (ravulizumab)
VYLEESI (bremelanotide)
ZILXI (minocycline 1.5% foam)
0000012864 00000 n
TURALIO (pexidartinib)
NUCALA (mepolizumab)
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 .
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. 0000004987 00000 n
ARIKAYCE (amikacin)
SOLODYN (minocycline 24 hour)
CARBAGLU (carglumic acid)
STRENSIQ (asfotase alfa)
TALTZ (ixekizumab)
It would definitely be a good idea for your doctor to document that you have made attempts to lose weight, as this is one of the main criteria. BARHEMSYS (amisulpride)
Wegovy prior authorization criteria united healthcare.
0000008227 00000 n
Your patients SILIQ (brodalumab)
FLECTOR (diclofenac)
SLYND (drospirenone)
MINOCIN (minocycline tablets)
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UKONIQ (umbralisib)
TYSABRI (natalizumab)
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Some plans exclude coverage for services or supplies that Aetna considers medically necessary.
Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. OXERVATE (cenegermin-bkbj)
The requested drug will be covered with prior authorization when the following criteria are met: The patient is 18 years of age or . NUZYRA (omadacycline tosylate)
CRYSVITA (burosumab-twza)
XCOPRI (cenobamate)
TASIGNA (nilotinib)
3.
Hepatitis C
ISTURISA (osilodrostat)
EUCRISA (crisaborole)
PROMACTA (eltrombopag)
TAKHZYRO (lanadelumab)
r
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(Hours: 5am PST to 10pm PST, Monday through Friday. ILARIS (canakinumab)
If you do not intend to leave our site, close this message. G
0000002567 00000 n
AMVUTTRA (vutrisiran)
CABOMETYX (cabozantinib)
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). Propranolol (Inderal XL, InnoPran XL)
PONVORY (ponesimod)
MAYZENT (siponimod)
VERKAZIA (cyclosporine ophthalmic emulsion)
ONZETRA XSAIL (sumatriptan nasal)
January is Cervical Health Awareness Month. 1 0 obj
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VOXZOGO (vosoritide)
ACTIMMUNE (interferon gamma-1b injection)
AZEDRA (Iobenguane I-131)
If denied, the provider may choose to prescribe a less costly but equally effective, alternative Step #3: At times, your request may not meet medical necessity criteria based on the review conducted by medical professionals. No fee schedules, basic unit, relative values or related listings are included in CPT.
trailer
0000008635 00000 n
0000069611 00000 n
If this is the case, our team of medical directors is willing to speak with your health care provider for next steps.
ADEMPAS (riociguat)
0000055627 00000 n
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.
The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in Aetna Precertification Code Search Tool. VIZIMPRO (dacomitinib)
FABRAZYME (agalsidase beta)
It is .
RYDAPT (midostaurin)
ADUHELM (aducanumab-avwa)
Authorization will be issued for 12 months.
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; Wegovy contains semaglutide and should . You can take advantage of a wide range of services across a variety of categories, including: CVS HealthHUBservices Were here with 24/7 support and resources to help you with work/life balance, caregiving, legal services, money matters, and more. 0000013911 00000 n
KALYDECO (ivacaftor)
We stay in touch with providers throughout the prior authorization request. INQOVI (decitabine and cedazuridine)
GAVRETO (pralsetinib)
ZIPSOR (diclofenac)
Patient Information covered medication, and/or OptumRx will offer information on the process to appeal the adverse decision.
This information is neither an offer of coverage nor medical advice.
ZYNLONTA (loncastuximab tesirine-lpyl). rz^6>)@?v": QCd?Pcu STEGLUJAN (ertugliflozin and sitagliptin)
JAKAFI (ruxolitinib)
LETAIRIS (ambrisentan)
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0000055434 00000 n
T
FORTEO (teriparatide)
.
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xVV4^[r62i5D\"E CARVYKTI (ciltacabtagene autoleucel)
Coagulation Factor IX (Alprolix)
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.
encourage providers to submit PA requests using the ePA process as described RYBREVANT (amivantamab-vmjw)
Low Molecular Weight Heparins (LMWH) - FRAGMIN (dalteparin), INNOHEP (tinzaparin), LOVENOX (enoxaparin), ARIXTRA (fondaparinux)
n
IMLYGIC (talimogene laherparepvec)
How to access the OptumRx PA guidelines: Reference the OptumRx electronic prior authorization ( ePA ) and (fax ) forms.
Testosterone pellets (Testopel)
DOJOLVI (triheptanoin liquid)
Call 1-800-711-4555 to request OptumRx standard drug-specific guideline to be faxed.
Q
OLUMIANT (baricitinib)
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.
UBRELVY (ubrogepant)
PAs help manage costs, control misuse, and by international cut-offs (Cole Criteria) Limitations of use: ~ - The safety and efficacy of coadministration with other weight loss drug .
TIVORBEX (indomethacin)
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Therefore, Arizona residents, members, employers and brokers must contact Aetna directly or their employers for information regarding Aetna products and services. 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. While the Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits.
VALTOCO (diazepam nasal spray)
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.
EVENITY (romosozumab-aqqg)
Visit the secure website, available through www.aetna.com, for more information.
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.
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VYEPTI (epitinexumab-jjmr)
COPIKTRA (duvelisib)
FASENRA (benralizumab)
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. Testosterone oral agents (JATENZO, TLANDO)
Per AACE/ACE obesity guidelines (2016), pharmacotherapy for . [a=CijP)_(z ^P),]y|vqt3!X X 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.
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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. Members should discuss any matters related to their coverage or condition with their treating provider. LIBTAYO (cemiplimab-rwlc)
w
ROCKLATAN (netarsudil and latanoprost)
0000001416 00000 n
AKLIEF (trifarotene)
0000054934 00000 n
All Rights Reserved. DIFFERIN (adapalene)
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.
Health benefits and health insurance plans contain exclusions and limitations. Specialty pharmacy drugs are classified as high-cost, high-complexity and high-touch medications used to treat complex conditions. ORIAHNN (elagolix, estradiol, norethindrone)
4 0 obj
SUPPRELIN LA (histrelin SC implant)
Phone : 1 (800) 294-5979. SOLARAZE (diclofenac)
ONPATTRO (patisiran for intravenous infusion)
a State mandates may apply. If there is a discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of benefits, the benefits plan will govern. MYRBETRIQ (mirabegron granules)
0000008945 00000 n
SUNOSI (solriamfetol)
Erythropoietin, Epoetin Alpha
RETIN-A (tretinoin)
Antihemophilic factor VIII (Eloctate)
3 0 obj
DUOBRII (halobetasol propionate and tazarotene)
constipation *.
SEYSARA (sarecycline)
COSENTYX (secukinumab)
PLEGRIDY (peginterferon beta-1a)
End of Life Medications
TRODELVY (sacituzumab govitecan-hziy)
Wegovy should be stored in refrigerator from 2C to 8C (36F to 46F). TECARTUS (brexucabtagene autoleucel)
VTAMA (tapinarof cream)
6. OCREVUS (ocrelizumab)
See multiple tabs of linked spreadsheet for Select, Premium & UM Changes.
EMGALITY (galcanezumab-gnlm)
TAVNEOS (avacopan)
The Prescriber Portal offers 24/7 access to plan specifications, formulary and prior authorization forms, everything you need to manage your business and provide your patients the best possible care. BREXAFEMME (ibrexafungerp)
DAKLINZA (daclatasvir)
Authorization Duration .
Subcutaneous Immunoglobulin (SCIG) (Hizentra, HyQvia)
ZOKINVY (lonafarnib)
iMo::>91}h9
TREANDA (bendamustine)
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. Whats the difference? TWIRLA (levonorgestrel and ethinyl estradiol)
ZEPATIER (elbasvir-grazoprevir)
STEGLATRO (ertugliflozin)
MONJUVI (tafasitamab-cxix)
HALAVEN (eribulin)
ALUNBRIG (brigatinib)
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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. TEGSEDI (inotersen)
Step #1: Your health care provider submits a request on your behalf. AMPYRA (dalfampridine)
0000002808 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. BRINEURA (cerliponase alfa IV)
BESPONSA (inotuzumab ozogamicin IV)
Off-label and Administrative Criteria
We will be more clear with processes.
0000002571 00000 n
W
headache.
ESBRIET (pirfenidone)
CRESEMBA (isavuconazonium)
KRYSTEXXA (pegloticase)
KESIMPTA (ofatumumab)
TAGRISSO (osimertinib)
June 4, 2021, the FDA announced the approval of Novo Nordisks 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-related comorbid condition (eg, hypertension, type 2 diabetes mellitus [T2DM], or dyslipidemia), 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. KOSELUGO (selumetinib)
Wegovy has not been studied in patients with a history of pancreatitis ~ -The safety . In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members.
GLYXAMBI (empagliflozin-linagliptin)
TECFIDERA (dimethyl fumarate)
It is only a partial, general description of plan or program benefits and does not constitute a contract.
0000092598 00000 n
NATPARA (parathyroid hormone, recombinant human)
Please log in to your secure account to get what you need. 0000003227 00000 n
0000001751 00000 n
LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT"). In case of a conflict between your plan documents and this information, the plan documents will govern. QBREXZA (glycopyrronium cloth 2.4%)
hbbc`b``3
A0 7
SIMPONI, SIMPONI ARIA (golimumab)
Atypical Antipsychotics, Long-Acting Injectable (Abilify Maintena, Aristata, Aristada Initio, Perseris, Risperdal Consta, Zyprexa Relprevv)
WAKIX (pitolisant)
FANAPT (iloperidone)
%PDF-1.7
Some subtypes have five tiers of coverage. This excerpt is provided for use in connection with the review of a claim for benefits and may not be reproduced or used for any other purpose. LONHALA MAGNAIR (glycopyrrolate)
LYBALVI (olanzapine/samidorphan)
DAYVIGO (lemborexant)
TYRVAYA (varenicline)
XERMELO (telotristat ethyl)
BAVENCIO (avelumab)
The request processes as quickly as possible once all required information is together.
0000001076 00000 n
MULPLETA (lusutrombopag)
SYMLIN (pramlintide)
EGRIFTA SV (tesamorelin)
ULTRAVATE (halobetasol propionate 0.05% lotion)
TALZENNA (talazoparib)
ZOLGENSMA (onasemnogene abeparvovec-xioi)
Please select a letter to see drugs listed by that letter, or enter the name of the drug you wish to search for. The most efficient way to initiate a prior authorization is to ask your physician to contact Express Scripts' prior authorization hotline at 1-800-753-2851. REYVOW (lasmiditan)
The ABA Medical Necessity Guidedoes not constitute medical advice. MARGENZA (margetuximab-cmkb)
BENLYSTA (belimumab)
NOCTIVA (desmopressin)
: A $25 copay card provided by the manufacturer may help ease the cost but only if . 0000003755 00000 n
0000062995 00000 n
Do not freeze. Drug list prices are set by the manufacturer, whereas cash prices fluctuate based on distribution costs that impact the pharmacies that fill the prescriptions. LEMTRADA (alemtuzumab)
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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). 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