Specialty drug coverage

Transcript

1 Specialty drug coverage For members with the Aetna Standard plan 2019 Aetna Specialty Drug List F (01/19)

2 You must fill these drugs at an in-network specialty pharmacy, like Aetna Specialty Pharmacy medicine and support services. Look up your plan documents for specialty drug coverage details. You ll also learn more about the requirements and limitations of your pharmacy benefits and insurance plan. What is a specialty drug? Specialty drugs treat complex, chronic conditions. A nurse or pharmacist will often support their use during treatment. These drugs may be injected, infused or taken by mouth. You may need to refrigerate them. They are often expensive and may not be available at retail pharmacies. Key UPPERCASE lowercase italics Brand-name medicine Generic medicine Acromegaly octreotide acetate (SANDOSTATIN) SANDOSTATIN LAR SOMATULINE DEPOT* SOMAVERT* Alpha-1 Antitrypsin Deficiency ARALAST NP* GLASSIA* ZEMAIRA* Anemia ARANESP EPOGEN PROCRIT RETACRIT Asthma CINQAIR* DUPIXENT FASENRA* NUCALA* XOLAIR* Atopic Dermatitis DUPIXENT Cardiac Disorders dofetilide (TIKOSYN) Coagulation Disorders CEPROTIN* Cryopyrin-Associated Periodic Syndromes ARCALYST* ILARIS* Cystic Fibrosis BETHKIS* PULMOZYME tobramycin nebulizer (TOBI*) KITABIS PAK* TOBI PODHALER* * Aetna Specialty Pharmacy refers to Aetna Specialty Pharmacy, LLC, a subsidiary of Aetna Inc., which is a licensed pharmacy that operates through specialty pharmacy prescription fulfillment. Aetna Pharmacy Management administers, but does not offer, insure or otherwise underwrite the prescription drug benefit portion of your health plan and has no financial responsibility therefor. Aetna Pharmacy Management refers to an internal business unit of Aetna Health Management, LLC. See coverage policy documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. This directory is applicable to both Aetna Commercial and joint venture plans. 2

3 Electrolyte Disorders Gastrointestinal Disorders-Other Gout SAMSCA* GATTEX* OCALIVA* SOLESTA* KRYSTEXXA* Growth Hormone & Related Disorders Growth Hormone Disorders GENOTROPIN HUMATROPE NORDITROPIN NUTROPIN AQ OMNITROPE SAIZEN SEROSTIM* ZOMACTON ZORBTIVE Growth Hormone & Related Disorders INCRELEX* IGF-1 Deficiency Hematopoietics MOZOBIL* Hemophilia, Von Willebrand Disease & Related Bleeding Disorders ADVATE ADYNOVATE AFSTYLA ALPHANATE HEMLIBRA HEMOFIL M HUMATE-P IDELVION NUWIQ OBIZUR* PROFILNINE PROFILNINE SD ALPHANINE SD IXINITY REBINYN ALPROLIX JIVI RECOMBINATE BEBULIN KOATE RIASTAP BENEFIX KOATE-DVI RIXUBIS COAGADEX* KOGENATE FS STIMATE CORIFACT* KOVALTRY TRETTEN* ELOCTATE MONOCLATE-P VONVENDI* FEIBA MONONINE WILATE FIBRYGA NOVOEIGHT* XYNTHA HELIXATE FS NOVOSEVEN RT Hepatitis adefovir dipivoxil (HEPSERA) DAKLINZA entecavir (BARACLUDE) EPCLUSA HARVONI INTRON-A* lamivudine (EPIVIR, EPIVIR HBV) MAVYRET PEGASYS PEGINTRON REBETOL SOLUTION ribasphere RIBATAB ribavirin caps (ribasphere, REBETOL) ribavirin tabs (ribasphere, MODERIBA) sofosbuvir/velpatasvir (EPCLUSA) SOVALDI TECHNIVIE tenofovir disoproxil fumarate (VIREAD) VEMLIDY VIEKIRA PAK VOSEVI ZEPATIER Hereditary Angioedema BERINERT* CINRYZE* FIRAZYR* HAEGARDA* KALBITOR* RUCONEST* TAKHZYRO* 3

4 HIV Medications abacavir tab (ZIAGEN) EGRIFTA* PREZCOBIX abacavir/lamivudine (EPZICOM) abacavir/lamivudine/ zidovudine tab (TRIZIVIR) APTIVUS atazanavir sulfate (REYATAZ) EMTRIVA EVOTAZ fosamprenavir (LEXIVA) FUZEON GENVOYA INTELENCE INVIRASE PREZISTA RESCRIPTOR RETROVIR INJECTABLE ritonavir (NORVIR) SELZENTRY stavudine (ZERIT) STRIBILD ATRIPLA ISENTRESS SYMFI BIKTARVY JULUCA SYMFI LO CIMDUO lamivudine (EPIVIR) SYMTUZA COMPLERA CRIXIVAN DELSTRIGO DESCOVY didanosine (VIDEX, VIDEX EC) EDURANT efavirenz (SUSTIVA) lamivudine/zidovudine (COMBIVIR) LEXIVA lopinavir/ritonavir soln (KALETRA) nevirapine (VIRAMUNE, VIRAMUNE XR) ODEFSEY PIFELTRO tenofovir disoproxil fumarate (VIREAD) TIVICAY TRIUMEQ TRUVADA TYBOST VIDEX SOLUTION VIRACEPT zidovudine (RETROVIR) Hormonal Therapies AVEED* LUPANETA PACK TRELSTAR ELIGARD LUPRON DEPOT VANTAS FIRMAGON NATPARA* ZOLADEX leuprolide acetate (LUPRON) SUPPRELIN LA* Immune Deficiencies & Related Disorders BIVIGAM* CUVITRU GAMMAKED GAMMAPLEX* MICRHOGAM NABI-HB CYTOGAM GAMUNEX C OCTAGAM FLEBOGAMMA DIF HEPAGAM B PANZYGA GAMASTAN HIZENTRA* PRIVIGEN GAMASTAN S/D HYPERHEP B RHOGAM GAMMAGARD LIQUID HYPERRHO S/D RHOPHYLAC GAMMAGARD S/D HYQVIA VARIZIG WINRHO SDF Infectious Disease Other ACTIMMUNE* ALFERON N Infertility BRAVELLE FOLLISTIM AQ NOVAREL CETROTIDE GANIRELIX ACETATE OVIDREL CHORIONIC GONADOTROPIN GONAL-F MENOPUR PREGNYL Inflammatory Bowel Disease CIMZIA ENTYVIO INFLECTRA REMICADE SIMPONI STELARA HUMIRA RENFLEXIS* TYSABRI* XELJANZ 4

5 Iron Overload deferoxamine (DESFERAL) EXJADE* JADENU* Lipid Disorders PCSK9 Inhibitors PRALUENT* REPATHA Lysosomal Storage Disorders ALDURAZYME* CERDELGA* ELELYSO* FABRAZYME* miglustat NAGLAZYME* CEREZYME* KANUMA* VIMIZIM* CYSTAGON* LUMIZYME* VPRIV* ELAPRASE* Movement Disorders APOKYN* NORTHERA* SOLIRIS* AUSTEDO NUPLAZID* RADICAVA* tetrabenazine (XENAZINE*) Multiple Sclerosis AUBAGIO* GILENYA OCREVUS* AVONEX BETASERON dalfampridine ER (AMPYRA*) EXTAVIA glatiramer acetate (COPAXONE, GLATOPA) LEMTRADA* mitoxantrone hcl PLEGRIDY* REBIF TECFIDERA* TYSABRI* Neutropenia FULPHILA NEULASTA UDENYCA GRANIX NEUPOGEN ZARXIO LEUKINE NIVESTYM Ocular Disorders EYLEA* MACUGEN* RETISERT* ILUVIEN* OZURDEX* VISUDYNE* LUCENTIS* Oncology-Injectable ADCETRIS* GAZYVA PROLEUKIN ARZERRA* HALAVEN RITUXAN AVASTIN HERCEPTIN RITUXAN HYCELA* azacitidine (VIDAZA) IMFINZI* ROMIDEPSIN BAVENCIO* INTRON A* SYLATRON* BELEODAQ* ISTODAX* SYLVANT* BENDAMUSTINE HYDROCHLORIDE BENDEKA* BLINCYTO* BORTEZOMIB CYRAMZA* DARZALEX* decitabine (DACOGEN) EMPLICITI* ERBITUX EVOMELA* FOLOTYN FUSILEV IXEMPRA JEVTANA KADCYLA KEYTRUDA* KYPROLIS* LEVOLEUCOVORIN LUMOXITI* mitoxantrone ONCASPAR OPDIVO* PERJETA* PORTRAZZA* POTELIGEO* TECENTRIQ* TEMODAR temsirolimus (TORISEL) TEPADINA THYROGEN* TREANDA VALSTAR VECTIBIX VELCADE XGEVA YERVOY YONDELIS* ZALTRAP* zoledronic acid (ZOMETA) 5

6 Oncology Oral/Topical abiraterone acetate (ZYTIGA*) AFINITOR ALECENSA* ALUNBRIG* bexarotene (TARGRETIN) BOSULIF CABOMETYX* capecitabine (XELODA) COTELLIC* DAURISMO* ERIVEDGE* ERLEADA* FARYDAK* HYCAMTIN IBRANCE* IDHIFA* imatinib mesylate (GLEEVEC) INLYTA* IRESSA* JAKAFI* KISQALI KISQALI FEMARA CO-PACK LONSURF* LORBRENA* LYNPARZA* MEKINIST* MUGARD NERLYNX* NEXAVAR* NINLARO* ODOMZO* POMALYST* PURIXAN* REVLIMID* RUBRACA* RYDAPT SPRYCEL STIVARGA* SUTENT TAFINLAR* TAGRISSO* TALZENNA* TARCEVA* TASIGNA temozolomide (TEMODAR) THALOMID TYKERB* VERZENIO* VITRAKVI* VIZIMPRO* VOTRIENT* XALKORI* XTANDI* YONSA* ZELBORAF* ZOLINZA ZYDELIG* ZYKADIA* Osteoporosis FORTEO PROLIA TYMLOS zoledronic acid (RECLAST) Paroxysmal Nocturnal Hemoglobinuria Phenylketonuria Pre-Term Birth SOLIRIS* KUVAN* hydroxyprogesterone capro (MAKENA*) Psoriasis CIMZIA OTEZLA SILIQ COSENTYX* OTREXUP STELARA ENBREL RASUVO TALTZ* HUMIRA REMICADE TREMFYA ILUMYA* RENFLEXIS* XELJANZ INFLECTRA Pulmonary Arterial Hypertension ADEMPAS* epoprostenol sodium (FLOLAN, VELETRI)* LETAIRIS* OPSUMIT* ORENITRAM* REMODULIN* sildenafil citrate (REVATIO) tadalafil (ADCIRCA) TRACLEER* TYVASO* UPTRAVI* VENTAVIS* Pulmonary Disorders Other ESBRIET* OFEV* Rare Disorders Other CRYSVITA* Renal Disease PARSABIV SENSIPAR 6

7 Respiratory Syncytial Virus SYNAGIS Retinal Disorders EYLEA* LUCENTIS* OZURDEX* ILUVIEN* MACUGEN* RETISERT* VISUDYNE* Rheumatoid Arthritis ACTEMRA* KEVZARA* REMICADE CIMZIA OLUMIANT* RENFLEXIS* ENBREL ORENCIA RITUXAN HUMIRA OTREXUP SIMPONI INFLECTRA RASUVO SIMPONI ARIA XELJANZ Seizure Disorders EPIDIOLEX* SABRIL TABS* vigadrone (SABIL PWD)* H. P. ACTHAR GEL* vigabatrin pwd (SABRILPWD)* Systemic Lupus Erythematosus BENLYSTA* Thrombocytopenia DOPTELET* MULPLETA NPLATE PROMACTA* Transplant ASTAGRAF XL cyclosporine (gengraf, NEORAL, SANDIMMUNE) ENVARSUS XR mycophenolate mofetil (CELLCEPT) mycophenolate sodium DR (MYFORTIC) NULOJIX PROGRAF INJECTABLE RAPAMUNE SOLUTION sirolimus tab (RAPAMUNE) tacrolimus (PROGRAF) ZORTRESS Urea Cycle Disorders RAVICTI* sodium phenylbutyrate (BUPHENYL*) 7

8 Index A abacavir tab (ZIAGEN) abacavir/lamivudine (EPZICOM) abacavir/lamivudine/ zidovudine tab (TRIZIVIR) abiraterone acetate (ZYTIGA) ACTEMRA* ACTHAR H.P. GEL* ACTIMMUNE* ADCETRIS* ADCIRCA adefovir (HEPSERA) ADEMPAS* ADVATE ADYNOVATE AFINITOR AFSTYLA ALDURAZYME* ALECENSA* ALFERON N ALPHANATE ALPHANINE SD ALPROLIX ALUNBRIG* AMPYRA* APOKYN* APTIVUS ARALAST NP* ARANESP ARCALYST* ARZERRA* ASTAGRAF XL atazanavir sulfate (REYATAZ) ATRIPLA AUBAGIO* AUSTEDO AVASTIN AVEED* AVONEX azacitidine (VIDAZA) B BARACLUDE BAVENCIO* BEBULIN BELEODAQ* BENDAMUSTINE HYDROCHLORIDE BENDEKA* BENEFIX BENLYSTA* BERINERT* BETASERON BETHKIS* bexarotene (TARGRETIN) BIKTARVY BIVIGAM* BLINCYTO* BORTEZOMIB BOSULIF BRAVELLE BUPHENYL* C CABOMETYX* capecitabine (XELODA) CELLCEPT CEPROTIN* CERDELGA* CEREZYME* CETROTIDE CHORIONIC GONADOTROPIN CIMDUO CIMZIA CINQAIR* CINRYZE* COAGADEX* COMBIVIR COMPLERA COPAXONE CORIFACT* COSENTYX* COTELLIC* CRIXIVAN CRYSVITA* CUVITRU cyclosporine (gengraf, NEORAL, SANDIMMUNE) CYRAMZA* CYSTAGON* CYTOGAM D DACOGEN DAKLINZA dalfampridine ER (AMPYRA*) DARZALEX* DAURISMO* decitabine (DACOGEN) deferoxamine (DESFERAL) DELSTRIGO DESCOVY DESFERAL didanosine (VIDEX, VIDEX EC) dofetilide (TIKOSYN) DOPTELET* DUPIXENT E EDURANT efavirenz (SUSTIVA) EGRIFTA* ELAPRASE* ELELYSO* ELIGARD ELOCTATE EMPLICITI* EMTRIVA ENBREL entecavir (BARACLUDE) ENTYVIO ENVARSUS XR EPCLUSA EPIDIOLEX* EPIVIR EPIVIR HBV EPOGEN epoprostenol sodium (FLOLAN, VELETRI)* EPZICOM ERBITUX ERIVEDGE* ERLEADA* ESBRIET* EVOMELA* EVOTAZ EXJADE* EXTAVIA EYLEA* F FABRAZYME* FARYDAK* FASENRA* FEIBA FIBRYGA FIRAZYR* FIRMAGON FLEBOGAMMA DIF FLOLAN* FOLLISTIM AQ FOLOTYN FORTEO fosamprenavir (LEXIVA) FULPHILA FUSILEV FUZEON G GAMASTAN GAMASTAN S/D GAMMAGARD LIQUID GAMMAGARD S/D GAMMAKED GAMMAPLEX* GAMUNEX C GANIRELIX ACETATE GATTEX* GAZYVA* gengraf GENOTROPIN GENVOYA GILENYA GLASSIA* glatiramer acetate (COPAXONE, GLATOPA) GLATOPA GLEEVEC GONAL-F GRANIX H H. P. ACTHAR GEL* HAEGARDA* HALAVEN HARVONI HELIXATE FS HEMLIBRA HEMOFIL M HEPAGAM B HEPSERA HERCEPTIN HIZENTRA* HUMATE-P HUMATROPE HUMIRA HYCAMTIN hydroxyprogesterone capro (MAKENA*) HYPERHEP B HYPERRHO S/D HYQVIA I IBRANCE* IDELVION IDHIFA* ILARIS* ILUMYA* ILUVIEN* imatinib mesylate (GLEEVEC) IMFINZI* INCRELEX* INFLECTRA INLYTA* INTELENCE INTRON A* INVIRASE IRESSA* ISENTRESS ISTODAX* IXEMPRA IXINITY J JADENU* JAKAFI* JEVTANA JIVI JULUCA K KADCYLA KALBITOR* KALETRA KANUMA* KEVZARA* KEYTRUDA* KISQALI KISQALI FEMARA CO-PACK KITABIS PAK* KOATE KOATE-DVI KOGENATE FS KOVALTRY KRYSTEXXA* KUVAN* KYPROLIS* L lamivudine (EPIVIR, EPIVIR HBV) lamivudine/zidovudine (COMBIVIR) ledipasvir/sofosbuvir (HARVONI) LEMTRADA* LETAIRIS* LEUKINE leuprolide acetate (LUPRON) LEVOLEUCOVORIN LEXIVA LONSURF* lopinavir/ritonavir soln (KALETRA) LORBRENA* LUCENTIS* LUMIZYME* LUMOXITI* LUPANETA PACK LUPRON LUPRON DEPOT LYNPARZA* M MACUGEN* MAKENA* MAVYRET MEKINIST* MENOPUR MICRHOGAM miglustat 8

9 mitoxantrone MODERIBA MONOCLATE-P MONONINE MOZOBIL* MUGARD MULPLETA mycophenolate mofetil (CELLCEPT) mycophenolic acid dr (MYFORTIC) MYFORTIC N NABI-HB NAGLAZYME* NATPARA* NEORAL NERLYNX* NEULASTA NEUPOGEN nevirapine (VIRAMUNE, VIRAMUNE XR) NEXAVAR* NINLARO* NIVESTYM NORDITROPIN NORTHERA* NORVIR NOVAREL NOVOEIGHT* NOVOSEVEN RT NPLATE NUCALA* NULOJIX NUPLAZID* NUTROPIN NUWIQ O OBIZUR* OCALIVA* OCREVUS* OCTAGAM octreotide acetate (SANDOSTATIN) ODEFSEY ODOMZO* OFEV* OLUMIANT* OMNITROPE ONCASPAR OPDIVO* OPSUMIT* ORENCIA ORENITRAM* OTEZLA OTREXUP OVIDREL OZURDEX* P PANZYGA PARSABIV PEGASYS PEGINTRON PERJETA* PIFELTRO PLEGRIDY* POMALYST* PORTRAZZA* POTELIGEO* PREGNYL PREZCOBIX PREZISTA PRIVIGEN PROCRIT PROFILNINE PROFILNINE SD PROGRAF PROLEUKIN PROLIA PROMACTA* PULMOZYME PURIXAN* R RADICAVA* RAPAMUNE RASUVO RAVICTI* REBETOL REBIF REBINYN RECLAST RECOMBINATE REMICADE REMODULIN* RENFLEXIS* RESCRIPTOR RETACRIT RETISERT* RETROVIR RETROVIR INJ REVATIO REVLIMID* REYATAZ RHOGAM RHOPHYLAC RIASTAP ribasphere RIBATAB ribavirin caps (ribasphere, REBETOL) ribavirin tabs (ribasphere, MODERIBA) ritonavir RITUXAN RITUXAN HYCELA* RIXUBIS ROMIDEPSIN RUBRACA* RUCONEST* RYDAPT S SABRIL PWD* SABRIL TABS* SAIZEN SAMSCA* SANDIMMUNE SANDOSTATIN SANDOSTATIN LAR SELZENTRY SENSIPAR SEROSTIM* sildenafil citrate (REVATIO) SILIQ SIMPONI SIMPONI ARIA sirolimus tab (RAPAMUNE) sodium phenylbutyrate (BUPHENYL*) sofosbuvir/velpatasvir (EPCLUSA) SOLESTA* SOLIRIS* SOMATULINE DEPOT* SOMAVERT* SOVALDI SPRYCEL stavudine (ZERIT) STELARA STIMATE STIVARGA* STRIBILD SUPPRELIN LA* SUSTIVA SUTENT SYLATRON* SYLVANT* SYMFI SYMFI LO SYMTUZA SYNAGIS T tacrolimus (PROGRAF) tadalafil (ADCIRCA) TAFINLAR* TAGRISSO* TAKHZYRO* TALTZ* TALZENNA* TARCEVA* TARGRETIN TASIGNA TECENTRIQ* TECFIDERA* TECHNIVIE TEMODAR temozolomide (TEMODAR) temsirolimus (TORISEL) tenofovir disoproxil fumarate (VIREAD) TEPADINA tetrabenazine (XENAZINE*) THALOMID THYROGEN* TIKOSYN TIVICAY TOBI* TOBI PODHALER* tobramycin nebulizer (TOBI*) TORISEL TRACLEER* TREANDA TRELSTAR TREMFYA TRETTEN* TRIUMEQ TRIZIVIR TRUVADA TYBOST TYKERB* TYMLOS TYSABRI* TYVASO* U UDENYCA UPTRAVI* V VALSTAR VANTAS VARIZIG VECTIBIX VELCADE VELETRI* VEMLIDY VENTAVIS* VERZENIO* VIDAZA VIDEX VIDEX EC VIEKIRA PAK vigabatrin pwd* (SABRIL*) vigadrone (SABRIL*) VIMIZIM* VIRACEPT VIRAMUNE VIRAMUNE XR VIREAD VISUDYNE* VITRAKVI* VIZIMPRO* VONVENDI* VOSEVI VOTRIENT* VPRIV* W WILATE WINRHO SDF X XALKORI* XELJANZ XELODA XENAZINE* XGEVA XOLAIR* XTANDI* XYNTHA Y YERVOY YONDELIS* YONSA* Z ZALTRAP* ZARXIO ZELBORAF* ZEMAIRA* ZEPATIER ZERIT ZIAGEN zidovudine (RETROVIR) ZOLADEX zoledronic acid (RECLAST, ZOMETA) ZOLINZA ZOMACTON ZOMETA ZORBTIVE ZORTRESS ZYDELIG* ZYKADIA* ZYTIGA* 9

10 Limited Distribution* ACTEMRA* ACTHAR H.P. GEL* ACTIMMUNE* ADCETRIS* ADEMPAS* ALDURAZYME* ALECENSA* ALUNBRIG* AMPYRA* APOKYN* ARALAST NP* ARCALYST* ARZERRA* AUBAGIO* AVEED* BAVENCIO* BELEODAQ* BENDEKA* BENLYSTA* BERINERT* BETHKIS* BIVIGAM* BLINCYTO* BUPHENYL* CABOMETYX* CEPROTIN* CERDELGA* CEREZYME* CINQAIR* CINRYZE* COAGADEX* CORIFACT* COSENTYX* COTELLIC* CRYSVITA* CYRAMZA* CYSTAGON* DARZALEX* DAURISMO* DOPTELET* EGRIFTA* ELAPRASE* ELELYSO* EMPLICITI* EPIDIOLEX* epoprostenol sodium (FLOLAN, VELETRI)* ERIVEDGE* ERLEADA* ESBRIET* EVOMELA* EXJADE* EYLEA* FABRAZYME* FARYDAK* FASENRA* FIRAZYR* FLOLAN* GAMMAPLEX* GATTEX* GAZYVA* GLASSIA* H. P. ACTHAR GEL* HAEGARDA* HIZENTRA* IBRANCE* IDHIFA* ILARIS* ILUMYA* ILUVIEN* IMFINZI* INCRELEX* INLYTA* INTRON A* IRESSA* ISTODAX* JADENU* JAKAFI* KALBITOR* KANUMA* KEVZARA* KEYTRUDA* KITABIS PAK* KRYSTEXXA* KUVAN* KYPROLIS* LEMTRADA* LETAIRIS* LONSURF* LORBRENA* LUCENTIS* LUMIZYME* LUMOXITI* LYNPARZA* MACUGEN* MAKENA* MEKINIST* MOZOBIL* NAGLAZYME* NATPARA* NERLYNX* NEXAVAR* NINLARO* NORTHERA* NOVOEIGHT* NUCALA* NUPLAZID* OBIZUR* OCALIVA* OCREVUS* ODOMZO* OFEV* OLUMIANT* OPDIVO* OPSUMIT* ORENITRAM* OZURDEX* PERJETA* PLEGRIDY* POMALYST* PORTRAZZA* POTELIGEO* PROMACTA* PURIXAN* RADICAVA* RAVICTI* REMODULIN* RENFLEXIS* RETISERT* REVLIMID* RITUXAN HYCELA* RUBRACA* RUCONEST* SABRIL POW* SABRIL TABS* SAMSCA* SEROSTIM* SOLESTA* SOLIRIS* SOMATULINE DEPOT* SOMAVERT* STIVARGA* SUPPRELIN LA* SYLATRON* SYLVANT* TAFINLAR* TAGRISSO* TAKHZYRO* TALTZ* TALZENNA* TARCEVA* TECENTRIQ* TECFIDERA* THYROGEN* TOBI* TOBI PODHALER* TRACLEER* TRETTEN* TYKERB* TYSABRI* TYVASO* UPTRAVI* VELETRI* VENTAVIS* VERZENIO* vigabatrin pwd* (SABRIL PWD)* VIMIZIM* VISUDYNE* VITRAKVI* VIZIMPRO* VONVENDI* VOTRIENT* VPRIV* XALKORI* XENAZINE* XOLAIR* XTANDI* YONDELIS* YONSA* ZALTRAP* ZELBORAF* ZEMAIRA* ZYDELIG* ZYKADIA* ZYTIGA* 10

11 Commercial fully insured members in Louisiana and Texas (except Federal Employee Health Benefit Plan members) who have coverage for medications that are added to or removed from the Aetna Specialty Drug list, national precertification list, precertification safety edit list, precertification list, step-therapy list or quantity limit list, or have quantity limits modified, during the plan year will continue to have those medications covered at the same benefits level under their plan prior to the addition, removal or change, until their plan s renewal date. The term precertification means the utilization review process to determine whether the requested service, procedure, prescription drug or medical device meets the company s clinical criteria for coverage. 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. In accordance with state law, fully insured commercial Connecticut PPO members (except Federal Employee Health Benefit Plan members) who are receiving coverage for medications that are added to the precertification or step-therapy lists will continue to have those medications covered for as long as the treating physician prescribes them, provided the drug is medically necessary and more medically beneficial than other covered drugs. Nothing in this section shall preclude the prescribing provider from prescribing another drug covered by the plan that is medically appropriate for the enrollee, nor shall anything in this section be construed to prohibit generic drug substitutions. This material is for information only and is not an offer or invitation to contract. An application must be completed to obtain coverage. Health benefits and health insurance plans contain exclusions and limitations. Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Providers are independent contractors and are not agents of Aetna pharmacy. Provider participation may change without notice. Aetna pharmacy does not provide care or guarantee access to health services. Information is believed to be accurate as of the production date; however, it is subject to change Aetna Inc F (01/19)