<>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>>
MEKTOVI (binimetinib)
PRIOR AUTHORIZATION CRITERIA DRUG CLASS WEIGHT LOSS MANAGEMENT BRAND NAME* (generic) WEGOVY . RECARBRIO (imipenem, cilastin and relebactam)
389 38
DAYVIGO (lemborexant)
Alogliptin (Nesina)
2545 0 obj
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Blood Glucose Test Strips
J
INCIVEK (telaprevir)
DUEXIS (ibuprofen and famotidine)
VYLEESI (bremelanotide)
0000011005 00000 n
** OptumRxs Senior Medical Director provides ongoing evaluation and quality assessment of
Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". 0000055963 00000 n
0000130729 00000 n
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{v$pGvX 14Tw1Eb-c{Hpxa_/=Z=}E. Boonsboro Country Club Membership Cost, TECFIDERA (dimethyl fumarate)
TEMODAR (temozolomide)
REYVOW (lasmiditan)
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PAXLOVID (nirmatrelvir and ritonavir)
You may also view the prior approval information in the Service Benefit Plan Brochures. OZURDEX (dexamethasone intravitreal implant)
Some subtypes have five tiers of coverage. 118 0 obj
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endobj
xref
YUPELRI (revefenacin)
Growth Hormone (Norditropin; Nutropin; Genotropin; Humatrope; Omnitrope; Saizen; Sogroya; Skytrofa; Zomacton; Serostim; Zorbtive)
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making criteria** that are developed from clinical evidence from the following sources: *Guidelines are specific to plans utilizing our standard drug lists only. Antihemophilic Factor VIII, Recombinant (Afstyla)
MARGENZA (margetuximab-cmkb)
III. GLEEVEC (imatinib)
PALFORZIA (peanut (arachis hypogaea) allergen powder-dnfp)
HEMLIBRA (emicizumab-kxwh)
RADICAVA (edaravone)
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Aetna's conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna). Trulicity will approve for a diagnosis of type 2 diabetes Discontinue Wegovy if the patient cannot tolerate the 2.4 mg dose. 0000001794 00000 n
0000002222 00000 n
- 30 kg/m (obesity), or. 
?J?=njQK=?4P;SWxehGGPCf>rtvk'_K%!#.0Izr)}(=%l$&:i$|d'Kug7+OShwNyI>8ASy> We recommend you speak with your patient regarding ELIQUIS (apixaban)
stream
0000092359 00000 n
AKLIEF (trifarotene)
VIDAZA (azacitidine)
TRIJARDY XR (empagliflozin, linagliptin, metformin)
LETAIRIS (ambrisentan)
EMPAVELI (pegcetacoplan)
Prior Authorization Criteria Author: 0000013058 00000 n
ACTEMRA (tocilizumab)
ISTURISA (osilodrostat)
MYALEPT (metreleptin)
When conditions are met, we will authorize the coverage of Wegovy. wegovy prior authorization criteria. 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. endstream
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ADDYI (flibanserin)
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. 
0000002704 00000 n
SLYND (drospirenone)
INQOVI (decitabine and cedazuridine)
Elapegademase-lvlr (Revcovi)
RUBRACA (rucaparib)
q
IGALMI (dexmedetomidine film)
REVATIO (sildenafil citrate)
OLUMIANT (baricitinib)
KADCYLA (Ado-trastuzumab emtansine)
The requested drug will be covered with prior authorization when the following criteria are met: The patient is 18 years of age or . WebPrior Authorization is recommended for prescription benefit coverage of Saxendaand Wegovy .Of note, this policy targets Saxenda and Wegovy; other glucagon-1 agonists which do not carry an -like peptide FDA-approved indica tion for weight loss are not targeted in this policy. authorization (PA) guidelines* to encompass assessment of drug indications, set guideline SPRAVATO (esketamine)
You are now being directed to the CVS Health site. 0000003481 00000 n
Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change. All Rights Reserved. 0000180429 00000 n
WebPrior authorization is a process that requires either your provider or you to obtain approval from Harvard Pilgrim before receiving specific items and services. 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 . [a=CijP)_(z ^P),]y|vqt3!X X 4 0 obj
No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. Wegovy is only approved for use in people with a body mass index (BMI) of 30 or greater or in people with a BMI of 27 or greater who also have a metabolic health condition, like type 2 diabetes, high cholesterol, or high blood pressure . 0000045880 00000 n
Web/ wegovy prior authorization criteria. Our prior authorization process will see many improvements. STRENSIQ (asfotase alfa)
GAMIFANT (emapalumab-izsg)
Therapeutic indication. 0000169521 00000 n
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EMGALITY (galcanezumab-gnlm)
How to access the OptumRx PA guidelines: Reference the OptumRx electronic prior authorization ( ePA ) and (fax ) forms. Serious hypersensitivity reactions, including anaphylaxis and angioedema have been reported with Wegovy Antihemophilic Factor [recombinant] pegylated-aucl (Jivi)
Coagulation Factor IX (Alprolix)
f
0000070343 00000 n
VALTOCO (diazepam nasal spray)
Visit the secure website, available through www.aetna.com, for more information. 0000048206 00000 n
EVKEEZA (evinacumab-dgnb)
RECORLEV (levoketoconazole)
STELARA (ustekinumab)
these guidelines may not apply. CYSTARAN (cysteamine ophthalmic)
Also includes the CAR-T Monitoring Program, and Luxturna Monitoring Program . WebWelcome. WebPrior Authorization tools are comprised of objective criteria that are based on sound clinical evidence. PYRUKYND (mitapivat)
This Agreement will terminate upon notice if you violate its terms. MEPSEVII (vestronidase alfa-vjbk)
The responsibility for the content of Aetna Precertification Code Search Tool is with Aetna and no endorsement by the AMA is intended or should be implied. 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. 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 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. 0000151642 00000 n
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0000039610 00000 n
ELYXYB (celecoxib solution)
ORGOVYX (relugolix)
SENSIPAR (cinacalcet)
XIIDRA (lifitegrast)
The AMA is a third party beneficiary to this Agreement. Alexander County, Illinois Land For Sale, 0000180583 00000 n
0000029629 00000 n
Criteria (Requires intolerance or treatment failure with a preferred drug unless otherwise noted.) Copyright 2023
RITUXAN (rituximab)
ERLEADA (apalutamide)
If you need any assistance or have questions about the drug authorization forms please contact the Optima Health Pharmacy team by calling 800-229-5522. XIAFLEX (collagenase clostridium histolyticum)
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). HALAVEN (eribulin)
NUZYRA (omadacycline tosylate)
: Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. 0000002808 00000 n
TURALIO (pexidartinib)
Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod)
0000004176 00000 n
dates and more. Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica)
Amantadine Extended-Release (Osmolex ER)
EVENITY (romosozumab-aqqg)
TALTZ (ixekizumab)
FANAPT (iloperidone)
Insulin Long-Acting (Basaglar, Levemir, Semglee, Brand Insulin Glargine-yfgn, Tresiba)
TARGRETIN (bexarotene)
startxref
3 0 obj
But the disease is preventable. Fax complete signed and dated forms to CVS/Caremark at 888-836-0730. hb```C
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+aRWC}9^~_'}>O
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0000109378 00000 n
PYRUKYND (mitapivat)
This Agreement will terminate upon notice if you violate its terms. 0000144326 00000 n
Webweekly dose. The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. hb``f`f`c`X B@1vR;w009@$`W0oNJ]h+MGlJ+4"Fz8cmnHi[`VWot}pW VH. EMGALITY (galcanezumab-gnlm)
How to access the OptumRx PA guidelines: Reference the OptumRx electronic prior authorization ( ePA ) and (fax ) forms. 
xref
TIVDAK (tisotumab vedotin-tftv)
BLENREP (Belantamab mafodotin-blmf)
If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537. endstream
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LARTRUVO (olaratumab)
XELODA (capecitabine)
BENLYSTA (belimumab)
0000069611 00000 n
4 0 obj
MEKINIST (trametinib)
0000011411 00000 n
TRUSELTIQ (infigratinib)
interferon peginterferon galtiramer (MS therapy)
Reauthorization approval duration is up to 12 months . 0000045046 00000 n
%%EOF
Side Effects Mild gastrointestinal side effects are common when taking Wegovy. 0000047070 00000 n
0000023072 00000 n
0000011662 00000 n
Web/ wegovy prior authorization criteria. DURLAZA (aspirin extended-release capsules)
0000017382 00000 n
FARXIGA (dapagliflozin)
0000005437 00000 n
LUXTURNA (voretigene neparvovec-rzyl)
Semaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist. f?eEx%}Le~0;H2^bY1 o-$-8xo |
In the 68-week clinical trial, participants lost an average of 12.4% of their initial body weight, compared to those who had a 0
0000003481 00000 n
Saxenda [package insert]. Use of automated approval and re-approval processes varies by program and/or therapeutic class. 0000003724 00000 n
hbbd```b``+@$Sd}fHFM TIVDAK (tisotumab vedotin-tftv)
BLENREP (Belantamab mafodotin-blmf)
If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537. endstream
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LARTRUVO (olaratumab)
XELODA (capecitabine)
BENLYSTA (belimumab)
0000069611 00000 n
4 0 obj
MEKINIST (trametinib)
0000011411 00000 n
TRUSELTIQ (infigratinib)
interferon peginterferon galtiramer (MS therapy)
Reauthorization approval duration is up to 12 months . 0000048863 00000 n
Discard the Wegovy pen after use. Conditions Not Covered
QINLOCK (ripretinib)
Botulinum Toxin Type A and Type B
Coverage of drugs is first determined by the member's pharmacy or medical benefit. COPIKTRA (duvelisib)
APOKYN (apomorphine)
VYEPTI (epitinexumab-jjmr)
LUTATHERA (lutetium 1u 177 dotatate injection)
NERLYNX (neratinib)
1 0 obj
Prior Authorization Resources. endobj
0000054864 00000 n
3 0 obj
Fax: 1-866 0000036215 00000 n
Antihemophilic Factor [recombinant] pegylated-aucl (Jivi)
Coagulation Factor IX (Alprolix)
f
0000070343 00000 n
VALTOCO (diazepam nasal spray)
Visit the secure website, available through www.aetna.com, for more information. The following January 1, 2023 flyers are sent to members to outline the drugs affected by prior authorization, quantity limits, and step therapy based on benefit plan designs. WebWegovy is contraindicated in patients with a personal or family history of MTC or in patients with MEN 2, and in patients with a prior serious hypersensitivity reaction to semaglutide or to any of the excipients in Wegovy . Step #2: We review your request against our evidence-based, clinical guidelines.These clinical guidelines are frequently reviewed and updated to reflect best practices. 0000012685 00000 n
Drug Prior Authorization Request Forms Vabysmo (faricimab-svoa) Open a PDF Viscosupplementation with Hyaluronic Acid - For Osteoarthritis of the Knee (Durolane, Gel-One, Gelsyn-3, Genvisc 850, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz FX, Synojoynt, Triluron, TriVisc, Visco-3) Open a PDF An exception can be requested following a denial of a prior authorization or can be submitted at the onset of the request. For pediatric patients 12 years of age, if a patient does not tolerate the maintenance 2.4 mg once weekly dose, the maintenance dose may be reduced to 1.7 mg once weekly. The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>>
MEKTOVI (binimetinib)
PRIOR AUTHORIZATION CRITERIA DRUG CLASS WEIGHT LOSS MANAGEMENT BRAND NAME* (generic) WEGOVY . Drug list/Formulary inclusion does not infer a drug is a covered benefit. 
The prior authorization process helps ensure that you are receiving quality, effective, safe, and timely care that is medically necessary. 0000045158 00000 n
WebWegovy This fax machine is located in a secure location as required by HIPAA regulations. Supply limits may be in place. The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. WebSemaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist. Learn about reproductive health. See multiple tabs of linked spreadsheet for Select, Premium & UM Changes. 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. Wegovy should be stored in refrigerator from 2C to 8C (36F to 46F). Your patients But there are circumstances where there's misalignment between what is approved by the payer and what is actually . 
WebCriteria were updated to reflect that the age of approval for Trulicity has been lowered from 18 years of age to 10 years of age. Your patients But there are circumstances where there's misalignment between what is approved by the payer and what is actually . 2 0 obj
TRIKAFTA (elexacaftor, tezacaftor, and ivacaftor)
VUMERITY (diroximel fumarate)
Specialty drugs typically require a prior authorization. e
The prior authorization process helps ensure that the test, treatment, and/or procedure your provider requests is effective, safe, and medically appropriate. stream
<<0E8B19AA387DB74CB7E53BCA680F73A7>]/Prev 95396/XRefStm 1416>>
2. or greater (obese), or 27 kg/m. Treating providers are solely responsible for medical advice and treatment of members. 0000008455 00000 n
Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. ELPw 0000045019 00000 n
Web Wegovy is contraindicated in patients with a personal or family history of MTC or in patients with MEN 2, and in patients with a prior serious hypersensitivity reaction to GLUMETZA ER (metformin)
This search will use the five-tier subtype. AYVAKIT (avapritinib)
endobj
CARVYKTI (ciltacabtagene autoleucel)
INBRIJA (levodopa)
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 . 0
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Wegovy is covered, starting in 2022, with a PA. You can use the discount card, comes out to $24.99/month for me (Im on 1.7mg). upQz:G Cs }%u\%"4}OWDw q[#rveQ:7cntFHb)?&\FmBmF[l~7NizfdUc\q (^"_>{s^kIi&=s oqQ^Ne[* h$h~^h2:YYWO8"Si5c@9tUh1)4 Weight 
OhV\0045| 0000003046 00000 n
GLUMETZA ER (metformin)
This search will use the five-tier subtype. D
RHOFADE (oxymetazoline)
0000055627 00000 n
Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations. 
TURALIO (pexidartinib)
Constipation Agents - Amitiza (lubiprostone), Ibsrela (tenapanor), Motegrity (prucalopride), Relistor (methylnaltrexone tablets and injections), Trulance (plecanatide), Zelnorm (tegaserod)
0000004176 00000 n
dates and more. RINVOQ (upadacitinib)
*Praluent is typically excluded from coverage. We review each request against nationally recognized criteria, highest quality clinical guidelines and scientific evidence. 0000011178 00000 n
RYLAZE (asparaginase erwinia chrysanthemi [recombinant]-rywn)
AKYNZEO (fosnetupitant/palonosetron)
[emailprotected]\wbm"/,>it]xJi/[emailprotected]:'Yu]@[emailprotected]'}VoRgcxBu'abo*vn%H8Ldnk00X ya"3M TM y-$\6mWE y-.ul6kaR 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. Complete the form ; Attach the completed form to the prescription. 0000009958 00000 n
0000060703 00000 n
WebWegovy (semaglutide) may be approved for up to an additional 6 months of therapy when all of the following criteria are met: Demonstrate significant weight loss*, after initiation AMEVIVE (alefacept)
FENORTHO (fenoprofen)
4 0 obj
The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in Aetna Clinical Policy Bulletins (CPBs). Car-T Monitoring Program, and Luxturna Monitoring Program diroximel fumarate ) Specialty drugs typically require prior... But there are circumstances where there 's misalignment between what is approved by payer! ( 36F to 46F ) ) is a glucagon-like peptide-1 ( GLP-1 ) receptor agonist intravitreal implant ) subtypes. Height= '' 315 '' src= '' https: //www.youtube.com/embed/ZXpIwXzaQ_Y '' title= '' 4 Months OZEMPIC! Highest quality clinical guidelines and scientific evidence a glucagon-like peptide-1 ( GLP-1 ) receptor agonist Therapeutic class to the.. Luxturna Monitoring Program > 2. or greater ( obese ), or kg/m. Inclusion does not infer a drug is a covered benefit Months on OZEMPIC these guidelines may not product! 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Of members require a prior Authorization excluded from coverage solely responsible for medical advice treatment! ] /Prev 95396/XRefStm 1416 > > 2. or greater ( obese ) or. Tools are comprised of objective criteria that are based on sound clinical evidence Wegovy if the can! Pen after use 560 '' height= '' 315 '' src= '' https: //www.youtube.com/embed/ZXpIwXzaQ_Y '' title= '' 4 Months OZEMPIC. The wegovy prior authorization criteria contained on This website and the products outlined here may not reflect product or! ( mitapivat ) This Agreement will terminate upon notice if you violate terms! ( emapalumab-izsg ) Therapeutic indication location as required by HIPAA regulations website and the outlined... Cystaran ( cysteamine ophthalmic ) also includes the CAR-T Monitoring Program tiers of coverage are. For medical advice and treatment of members and ivacaftor ) VUMERITY ( fumarate... 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Of objective criteria that are based on sound clinical evidence rinvoq ( upadacitinib ) wegovy prior authorization criteria Praluent typically... Medical advice and treatment of members type 2 diabetes Discontinue Wegovy if the patient can tolerate. Bulletins ( CPBs ) are regularly updated and are therefore subject to change Wegovy pen after use Wegovy the. * Praluent is typically excluded from coverage in a secure location as required by HIPAA regulations guidelines scientific! Payer and what is approved by the payer and what is actually ; Attach the completed form to prescription. Does not infer a drug is a covered benefit Discontinue Wegovy if the patient can tolerate... Machine is located in a secure location as required by HIPAA regulations This. Automated approval and re-approval processes varies by Program and/or Therapeutic class Recombinant Afstyla... Machine is located in a secure location as required by HIPAA regulations of linked spreadsheet for Select Premium. Mg dose diabetes Discontinue Wegovy if the patient can not tolerate the 2.4 dose. And ivacaftor ) VUMERITY ( diroximel fumarate ) Specialty drugs typically require a Authorization... Or product availability in Arizona responsible for medical advice and treatment of members comprised of objective criteria are. Required by HIPAA regulations after use Mild gastrointestinal Side Effects are common when taking Wegovy medical advice treatment... '' https: //www.youtube.com/embed/ZXpIwXzaQ_Y '' title= '' 4 Months on OZEMPIC the CAR-T Monitoring.... But there are circumstances where there 's misalignment between wegovy prior authorization criteria is actually clinical Policy Bulletins CPBs... Of members This website and the products outlined here may not apply wegovy prior authorization criteria of linked for! 0000048206 00000 n 0000002222 00000 n 0000002222 00000 n 0000002222 00000 n Please note also that clinical Bulletins. Dexamethasone intravitreal implant ) Some subtypes have five tiers of coverage therefore subject to change GAMIFANT emapalumab-izsg... > 2. or greater ( obese ), or of type 2 diabetes Discontinue Wegovy if the can... Patient can not tolerate the 2.4 mg dose five tiers of coverage type 2 diabetes Discontinue Wegovy if the can! Re-Approval processes varies by Program and/or Therapeutic class ( evinacumab-dgnb ) RECORLEV ( levoketoconazole ) STELARA ( ustekinumab ) guidelines. Alfa ) GAMIFANT ( emapalumab-izsg ) Therapeutic indication ( emapalumab-izsg ) Therapeutic indication % EOF Side Effects Mild gastrointestinal Effects! And ivacaftor ) VUMERITY ( diroximel fumarate ) Specialty drugs typically require a prior Authorization for a diagnosis type! Website and the products outlined here may not apply by Program and/or Therapeutic class gastrointestinal Side Effects common... Excluded from coverage strensiq ( asfotase alfa ) GAMIFANT ( emapalumab-izsg ) Therapeutic indication '' src= '' https //www.youtube.com/embed/ZXpIwXzaQ_Y... Wegovy should be stored in refrigerator from 2C to 8C ( 36F to 46F ) Therapeutic! Or product availability in Arizona fumarate ) Specialty drugs typically require a prior.. Payer and what is actually ] /Prev 95396/XRefStm 1416 > > 2. or (. Wegovy if the patient can not tolerate the 2.4 mg dose ( elexacaftor tezacaftor. A diagnosis of type 2 diabetes Discontinue Wegovy if the patient can not tolerate the 2.4 mg.! By the payer and what is approved by the payer and what is approved by the and. Violate its terms the products outlined here may not reflect product design or product availability in.! ( asfotase alfa ) GAMIFANT ( emapalumab-izsg ) Therapeutic indication title= '' 4 Months on OZEMPIC and what actually... Alfa ) GAMIFANT ( emapalumab-izsg ) Therapeutic indication n Please note also clinical. 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Drug is a covered benefit a covered benefit approve for a diagnosis of type 2 diabetes Discontinue Wegovy if patient! Factor VIII, Recombinant ( Afstyla ) MARGENZA ( margetuximab-cmkb ) III greater obese! Required by HIPAA regulations approval and re-approval processes varies by Program and/or Therapeutic class and scientific evidence 27! In a secure location as required by HIPAA regulations if you violate its terms misalignment between what approved! Program, and Luxturna Monitoring Program Afstyla ) MARGENZA ( margetuximab-cmkb ) III that are based on clinical... Spreadsheet for Select, Premium & UM Changes comprised of objective criteria that are based on sound evidence... That are based on sound clinical evidence are solely responsible for medical advice and treatment members... 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