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Specialty
Drug List
2023 Aetna Specialty Drug List
1011950-01-07 (10/23)
2023 Aetna Specialty Drug List (10/23)
-
How to use this guide
You may fill these drugs at an in-network specialty pharmacy. 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 spe
cialty 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 Brand-name medicine
lowercase italics Generic medicine
Category
Drug class
Analgesics
Viscosupplements DUROLANE
EUFLEXXA
GELSYN-3
SUPARTZ FX
Anti-Infectives
Antiretroviral Agents
Antiretroviral Combinations §
abacavir-lamivudine
efavirenz-emtricitabine-tenofovir
disoproxil fumarate
efavirenz-lamivudine-tenofovir
disoproxil fumarate
emtricitabine-tenofovir disoproxil
fumarate
lamivudine-zidovudine
BIKTARVY
CIMDUO
DESCOVY
DOVATO
EVOTAZ
GENVOYA
ODEFSEY
PREZCOBIX
SYMTUZA
TRIUMEQ
Antiretroviral Agents
Fusion Inhibitors
FUZEON
maraviroc
Antiretroviral Agents
Integrase Inhibitors
ISENTRESS
TIVICAY
Antiretroviral Agents
Non-Nucleoside Reverse Transcriptase Inhibitors §
efavirenz
nevirapine
nevirapine ext-rel
EDURANT
INTELENCE
Antiretroviral Agents
Nucleoside Reverse Transcriptase Inhibitors §
abacavir
lamivudine
stavudine
zidovudine
EMTRIVA
Antiretroviral Agents
Nucleotide Reverse Transcriptase Inhibitors §
tenofovir disoproxil fumarate
Health benefits and health insurance plans are offered, administered and/or underwritten by Aetna Health Inc.,
Aetna Health Insurance Company of New York, Aetna Health Assurance Pennsylvania Inc., Aetna Health
Insurance company and/or Aetna Life Insurance Company (Aetna). In Florida, by Aetna Health Inc. and/or Aetna
Life Insurance Company. In Utah and Wyoming by Aetna Health of Utah Inc. and Aetna Life Insurance Company.
In Maryland, by Aetna Health Inc., 151 Farmington Avenue, Hartford, CT 06156. Each insurer has sole financial
responsibility for its own products. Pharmacy benefits are administered by an affiliated pharmacy benefit
manager, CVS Caremark. Aetna is part of the CVS Health family of companies.
2023 Aetna Specialty Drug List (10/23)
Category
Drug class
Antiretroviral Agents
Protease Inhibitors §
atazanavir
lopinavir-ritonavir solution
NORVIR
PREZISTA
Antivirals
Hepatitis B Agents §
entecavir
lamivudine
tenofovir disoproxil fumarate
Antivirals
Hepatitis C Agents §
ribavirin
EPCLUSA
(genotypes 1, 2, 3, 4, 5, 6)
HARVONI
(genotypes 1, 4, 5, 6)
VOSEVI
2
Antineoplastic Agents
Alkylating Agents § temozolomide
Antimetabolites § capecitabine
LONSURF
Biosimilars KANJINTI
RUXIENCE
TRAZIMERA
ZIRABEV
Hormonal Antineoplastic Agents
Antiandrogens §
abiraterone
ERLEADA
NUBEQA
XTANDI
YONSA
Kinase Inhibitors § erlotinib
everolimus
imatinib mesylate
lapatinib
sunitinib
ALECENSA
ALUNBRIG
BOSULIF
BRAFTOVI
BRUKINSA
CABOMETYX
CALQUENCE
COPIKTRA
COTELLIC
GAVRETO
IBRANCE
IMBRUVICA
INLYTA
IRESSA
KISQALI
KISQALI FEMARA CO-PACK
KOSELUGO
LENVIMA
MEKTOVI
NEXAVAR
RETEVMO
ROZLYTREK
RYDAPT
SPRYCEL
STIVARGA
TAGRISSO
VITRAKVI
XOSPATA
ZELBORAF
ZYDELIG
ZYKADIA
Monoclonal Antibodies PERJETA
PHESGO
Multiple Myeloma
Immunomodulators
REVLIMID
THALOMID
Multiple Myeloma
Proteasome Inhibitors
bortezomib
NINLARO
Miscellaneous § bexarotene capsule
ERIVEDGE
LYNPARZA
LYSODREN
MATULANE
ODOMZO
VISTOGARD
ZEJULA
ZOLINZA
Prostate Cancer
Luteinizing Hormone-Releasing Hormone (LHRH)
Agonists §
leuprolide acetate
ELIGARD
Cardiovascular
2023 Aetna Specialty Drug List (10/23)
Category
Drug class
Antilipemics
PCSK9 Inhibitors
REPATHA
Pulmonary Arterial Hypertension
Endothelin Receptor Antagonists §
ambrisentan
bosentan
OPSUMIT
Pulmonary Arterial Hypertension
Phosphodiesterase Inhibitors §
sildenal
tadalal
Pulmonary Arterial Hypertension
Prostacyclin Receptor Agonists
UPTRAVI
Pulmonary Arterial Hypertension
Prostaglandin Vasodilators
treprostinil
ORENITRAM
Pulmonary Arterial Hypertension
Soluble Guanylate Cyclase Stimulators
ADEMPAS
Central Nervous System
Anticonvulsants § vigabatrin
Antiparkinsonian Agents INBRIJA
KYNMOBI
Movement Disorders § tetrabenazine
AUSTEDO
INGREZZA
Multiple Sclerosis Agents § delayed-rel
dimethyl fumarate
ngolimod
glatiramer
AVONEX
BETASERON
COPAXONE
KESIMPTA
MAYZENT
OCREVUS
REBIF
TYSABRI
VUMERITY
ZEPOSIA
Narcolepsy WAKIX
XYWAV
Endocrine and Metabolic
Acromegaly SOMATULINE DEPOT
Calcium Regulators Antagonists § cinacalcet
Calcium Regulators
Parathyroid Hormones
FORTEO
TYMLOS
Calcium Regulators
Miscellaneous
PROLIA
Central Precosious Puberty FENSOLVI
LUPRON DEPOT-PED
SUPPRELIN LA
TRIPTODUR
Contraceptives
Progestin Intrauterine Devices
KYLEENA
MIRENA
SKYLA
2023 Aetna Specialty Drug List (10/23)
Category
Drug class
Fertility Regulators
GNRH/LHRH Antagonists
CETROTIDE
Fertility Regulators
Ovulation Stimulants, Gonadotropins
GONAL-F
MENOPUR
OVIDREL
Gaucher Disease CERDELGA
CEREZYME
Hereditary Tyrosinemia Type 1 Agents ORFADIN
Human Growth Hormones NORDITROPIN
GENOTROPIN
PHENYLKETONURIA TREATMENT AGENTS § sapropterin
Polyneuropathy TEGSEDI
Urea Cycle Disorders § sodium phenylbutyrate
Miscellaneous betaine
carglumic acid
CYSTAGON
Genitourinary
Miscellaneous § tiopronin
Hematologic
Chelating Agents § deferasirox
deferiprone
deferoxamine
penicillamine capsule
trientine
Hematopoietic Growth Factors ARANESP
NIVESTYM
PROCRIT
RETACRIT
ZIEXTENZO
Hemophilia A Agents ADVATE
ADYNOVATE
AFSTYLA
ELOCATE
ESPERCOT
JIVI
KOGENATE FS
KOVALTRY
NOVOEIGHT
NUWIQ
XYNTHA
Hemophilia B Agents ALPROLIX
REBINYN
Miscellaneous Bleeding Disorders Agents NOVOSEVEN RT
SEVENFACT
Paroxysmal Nocturnal Hemoglobinuria
Hemoglobinuria (PNH) Agents
EMPAVELI
Sickle Cell Disease ENDARI
Thrombocytopenia Agents DOPTELET
PROMACTA
TAVALISSE
* See Table 1 For Indication Based Coverage Details
# After Failure Of Humira
2023 Aetna Specialty Drug List (10/23)
Category
Drug class
Immunologic Agents
Allergenic Extracts ORALAIR
Autoimmune Agents*
(Physician Administered)
ILUMYA
REMICADE
SIMPONI ARIA
SKYRIZI INTRAVENOUS
STELARA INTRAVENOUS
Autoimmune Agents*
(Self-Administered)
See table 1 for indication based coverage details
Autoimmune Agents*
Ankylosing Spondylitis
COSENTYX
ENBREL
HUMIRA
RINVOQ
Autoimmune Agents*
Crohn's Disease
HUMIRA
RINVOQ
SKYRIZI SUBCUTANEOUS
STELARA SUBCUTANEOUS
Autoimmune Agents*
Non-Radiographic Axial Spondyloarthritis
CIMZIA PREFILLED SYRINGE
COSENTYX
RINVOQ
Autoimmune Agents*
Psoriasis
HUMIRA
OTEZLA
SKYRIZI SUBCUTANEOUS
STELARA SUBCUTANEOUS
TA LTZ
TREMFYA
Autoimmune Agents*
Psoriatic Arthritis
COSENTYX
ENBREL
HUMIRA
OTEZLA
RINVOQ
SKYRIZI SUBCUTANEOUS
STELARA SUBCUTANEOUS
TREMFYA
Autoimmune Agents*
Rheumatoid Arthritis
ENBREL
HUMIRA
KEVZARA
ORENCIA CLICKJECT
ORENCIA SUBCUTANEOUS
RINVOQ
XELJANZ
XELJANZ XR
Autoimmune Agents*
Ulcerative Colitis
HUMIRA
RINVOQ
STELARA SUBCUTANEOUS
XELJANZ
XELJANZ XR
ZEPOSIA
Autoimmune Agents*
All Other Conditions
ENBREL
HUMIRA
Disease-Modifying Antirheumatic
Drugs (DMARDs)
RASUVO
Hereditary Angioedema icatibant
ORLADEYO
RUCONEST
TAKHZYRO
Immunomodulators
Immune Globulins
CUTAQUIG
Miscellaneous ILARIS
Immunosuppressants
Antimetabolites §
mycophenolate mofetil
mycophenolate sodium
2023 Aetna Specialty Drug List (10/23)
Category
Drug class
Immunosuppressants
Calcineurin Inhibitors §
cyclosporine
cyclosporine, modied
tacrolimus
Immunosuppressants
Monoclonal Antibodies
ENSPRYNG
Immunosuppressants
Rapamycin Derivatives §
everolimus
sirolimus
Respiratory
Alpha-1 Antitrypsin Deficiency Agents PROLASTIN-C
ZEMAIRA
Cystic Fibrosis § tobramycin inhalation solution
Pulmonary Fibrosis Agents pirfenidone
OFEV
Severe Asthma Agents DUPIXENT
FASENRA
NUCALA (except lyophilized
powder)
TEZSPIRE
XOLAIR
Topical
Dermatology
Atopic Dermatitis
ADBRY INJECTABLE
CIBINQO ORAL
DUPIXENT INJECTABLE
RINVOQ ORAL
Mouth/Throat/Dental Agents
Protectants
MUGARD
Ophthalmic
Retinal Disorders
EYLEA
LUCENTIS
2023 Aetna Specialty Drug List (10/23)
Quick reference drug list.
A
abacavir
abacavir-lamivudine
abiraterone
ADBRY
ADEMPAS
ADVATE
ADYNOVATE
AFSTYLA
ALECENSA
ALPROLIX
ALUNBRIG
ambrisentan
atazanavir
AUBAGIO
AUSTEDO
AVONEX
B
betaine
BETASERON
BETHKIS
bexarotene capsule
BIKTARVY
bortezomib
bosentan
BOSULIF
BRAFTOVI
BRUKINSA
C
CABOMETYX
CALQUENCE
capecitabine
carglumic acid
CERDELGA
CEREZYME
CETROTIDE
CIBINQO
CIMDUO
CIMZIA PREFILLED
SYRINGE
cinacalcet
COPAXONE
COPIKTRA
COSENTYX
COTELLIC
CUTAQUIG
cyclosporine
cyclosporine, modied
CYSTAGON
D
deferasirox
deferiprone
deferoxamine
DESCOVY
dimethyl fumarate
delayed-rel
DOPTELET
DOVATO
DUPIXENT
DUROLANE
E
EDURANT
efavirenz
efavirenz-
emtricitabine-
tenofovir disoproxil
fumarate
efavirenz-lamivudine-
tenofovir disoproxil
fumarate
ELIGARD
ELOCTATE
EMPAVELI
emtricitabine-tenofovir
disoproxil fumarate
EMTRIVA
ENBREL
ENDARI
ENSPRYNG
entecavir
EPCLUSA
ERIVEDGE
ERLEADA
erlotinib
ESPEROCT
EUFLEXXA
everolimus
EVOTAZ
EYLEA
F
FASENRA
FENSOLVI
ngolimod
FORTEO
FUZEON
G
GAVRETO
GELSYN-3
GENOTROPIN
GENVOYA
glatiramer
GONAL-F
H
HARVONI
HUMIRA
I
IBRANCE
icatibant
ILARIS
ILUMYA
imatinib mesylate
IMBRUVICA
INBRIJA
INGREZZA
INLYTA
INTELENCE
IRESSA
ISENTRESS
J
JIVI
K
KANJINTI
KESIMPTA
KEVZARA
KISQALI
KISQALI FEMARA CO-
PACK
KOGENATE FS
KOSELUGO
KOVALTRY
KYLEENA
KYNMOBI
L
lamivudine
lamivudine-zidovudine
lapatinib
LENVIMA
leuprolide acetate
LONSURF
lopinavir-ritonavir
LUCENTIS
LUPRON DEPOT-PED
LYNPARZA
LYSODREN
M
maraviroc
MATULANE
MAYZENT
MEKTOVI
MENOPUR
MIRENA
MUGARD
mycophenolate
mofetil
mycophenolate
sodium
N
nevirapine
nevirapine ext-rel
NEXAVAR
NINLARO
NIVESTYM
NORDITROPIN
NORVIR
NOVOEIGHT
NOVOSEVEN RT
NUBEQA
NUCALA (except
lyophilized powder)
NUWIQ
O
OCREVUS
ODEFSEY
ODOMZO
OFEV
OPSUMIT
ORALAIR
ORENCIA CLICKJECT
ORENCIA
SUBCUTANEOUS
ORENITRAM
ORFADIN
ORLADEYO
OTEZLA
OVIDREL
P
penicillamine capsule
PERJETA
PHESGO
pirfenidone
PREZCOBIX
PREZISTA
PROCRIT
PROLASTIN-C
PROLIA
PROMACTA
R
RASUVO
REBIF
REBINYN
REMICADE
REPATHA
RETACRIT
RETEVMO
REVLIMID
ribavirin
RINVOQ
ROZLYTREK
RUCONEST
RUXIENCE
RYDAPT
S
sapropterin
SEVENFACT
sildenal
SIMPONI ARIA
sirolimus
SKYLA
SKYRIZI
INTRAVENOUS
SKYRIZI
SUBCUTANEOUS
sodium
phenylbutyrate
SOMATULINE DEPOT
SPRYCEL
stavudine
STELARA
INTRAVENOUS
STELARA
SUBCUTANEOUS
STIVARGA
sunitinib
SUPARTZ FX
SUPPRELIN LA
SYMTUZA
T
tacrolimus
tadalal
TAGRISSO
TAKHZYRO
TA LT Z
TAVALISSE
TEGSEDI
temozolomide
tenofovir disoproxil
fumarate
teriunomide
tetrabenazine
TEZSPIRE
THALOMID
tiopronin
TIVICAY
tobramycin inhalation
solution
TRAZIMERA
TREMFYA
treprostinil
trientine
TRIPTODUR
TRIUMEQ
TYMLOS
TYSABRI
U
UPTRAVI
V
vigabatrin
VISTOGARD
VITRAKVI
VOSEVI
2
VUMERITY
W
WAKIX
X
XELJANZ
XELJANZ XR
XOLAIR
XOSPATA
XTANDI
XYNTHA
XYWAV
Y
YONSA
Z
ZEJULA
ZELBORAF
ZEMAIRA
ZEPOSIA
zidovudine
ZIEXTENZO
ZIRABEV
ZOLINZA
ZYDELIG
ZYKADIA
2023 Aetna Specialty Drug List (10/23)
Preferred options for excluded specialty medications
3
Drug name(s) Preferred option(s)*
ACTEMRA INTRAVENOUS REMICADE, SIMPONI ARIA
ADCIRCA sildenal, tadalal
AFINITOR, AFINITOR DISPERZ everolimus
ALIQOPA Consult doctor
APOKYN INBRIJA, KYNMOBI
APTIVUS Consult doctor
ARALAST NP PROLASTIN-C
ARCALYST ILARIS
AUBAGIO dimethyl fumarate delayed-rel, ngolimod, glatiramer, teriunomide, AVONEX, BETASERON,
COPAXONE, KESIMPTA, MAYZENT, OCREVUS, REBIF, TYSABRI, VUMERITY, ZEPOSIA
AVASTIN ZIRABEV
AVSOLA ILUMYA, REMICADE, SIMPONI ARIA, SKYRIZI INTRAVENOUS, STELARA INTRAVENOUS
BARACLUDE TABLET entecavir, lamivudine, tenofovir disoproxil fumarate
BENEFIX ALPROLIX, REBINYN
BERINERT RUCONEST, icatibant
BETHKIS tobramycin inhalation solution
BORTEZOMIB bortezomib, NINLARO
BOTOX Consult doctor
BUPHENYL sodium phenylbutyrate
CARBAGLU garglumic acid
CAYSTON tobramycin inhalation solution, BETHKIS
CHORIONIC GONADOTROPIN OVIDREL
CIMZIA LYOPHILIZED POWDER ILUMYA, REMICADE, SIMPONI ARIA, SKYRIZI INTRAVENOUS, STELARA INTRAVENOUS
CINRYZE ORLADEYO, TAKHZYRO
COMPLERA efavirenz-emtricitabine-tenofovir disoproxil fumarate, efavirenz-lamivudine-tenofovir disoproxil
fumarate, BIKTARVY, DOVATO, GENVOYA, ODEFSEY, SYMTUZA, TRIUMEQ
CUPRIMINE penicillamine capsule
CYSTADANE betaine
DESFERAL deferasirox, deferiprone, deferoxamine
DIACOMIT Consult doctor
ELELYSO CERDELGA, CEREZYME
ENTYVIO
(For Crohn’s Disease only)
REMICADE, SKYRIZI INTRAVENOUS, STELARA INTRAVENOUS
EPIVIR HBV entecavir, lamivudine, tenofovir disoproxil fumarate, BARACLUDE SOLUTION, VEMLIDY
2023 Aetna Specialty Drug List (10/23)
Drug name(s) Preferred option(s)*
EPOGEN ARANESP, PROCRIT, RETACRIT
ESBRIET pirfenidone, OFEV
EXJADE deferasirox, deferiprone, deferoxamine
EXTAVIA dimethyl fumarate delayed-rel, ngolimod, glatiramer, AVONEX, BETASERON, COPAXONE,
KESIMPTA, MAYZENT, OCREVUS, REBIF, TYSABRI, VUMERITY, ZEPOSIA
FEIBA NOVOSEVEN RT, SEVENFACT
FERRIPROX deferasirox, deferiprone, deferoxamine
FINTELPA clobazam, clonazepam, lamotrigine, runamide, topiramate, TROKENDI XR
FIRAZYR icatibant, RUCONEST
FIRMAGON ELIGARD
FOLLISTIM AQ GONAL-F
FULPHILA ZIEXTENZO
GEL-ONE DUROLANE, EUFLEXXA, GELSYN-3, SUPARTZ FX
GILENYA dimethyl fumarate delayed-rel, ngolimod, glatiramer, teriunomide, AVONEX, BETASERON,
COPAXONE, KESIMPTA, MAYZENT, OCREVUS, REBIF, TYSABRI, VUMERITY, ZEPOSIA
GLASSIA PROLASTIN-C, ZEMAIRA
GLEEVEC imatinib mesylate, BOSULIF, SPRYCEL
GRANIX NIVESTYM
HERCEPTIN KANJINTI, TRAZIMERA
HERCEPTIN HYLECTA KANJINTI, TRAZIMERA
HUMATROPE GENOTROPIN, NORDITROPIN
HYALGAN DUROLANE, EUFLEXXA, GELSYN-3, SUPARTZ FX
ICLUSIG imatinib mesylate, BOSULIF, SPRYCEL
INFLECTRA ILUMYA, REMICADE, SIMPONI ARIA, SKYRIZI INTRAVENOUS, STELARA INTRAVENOUS
IXINITY ALPROLIX, REBINYN
JADENU deferasirox, deferiprone, deferoxamine
JUX TAPID REPATHA
JYNARQUE Consult doctor
KITABIS PAK tobramycin inhalation solution
KORLYM Consult doctor
KUVAN sapropterin
KYPROLIS NINLARO, VELCADE
LEMTRADA dimethyl fumarate delayed-rel, ngolimod, glatiramer, teriunomide, AVONEX, BETASERON,
COPAXONE, KESIMPTA, MAYZENT, OCREVUS, REBIF, TYSABRI, VUMERITY, ZEPOSIA
LETAIRIS ambrisentan, bosentan, OPSUMIT
LEUKINE NIVESTYM
2023 Aetna Specialty Drug List (10/23)
Drug name(s) Preferred option(s)*
LEXIVA atazanavir, lopinavir-ritonavir solution, EVOTAZ, PREZCOBIX, PREZISTA
LILETTA KYLEENA, MIRENA, SKYLA
LUPRON DEPOT
(For Prostate Cancer only)
ELIGARD
MAVYRET EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6), VOSEVI
2
MEKINIST COTELLIC, MEKTOVI
MONOVISC DUROLANE, EUFLEXXA, GELSYN-3, SUPARTZ FX
NEULASTA, NEULASTA ONPRO ZIEXTENZO
NEUPOGEN NIVESTYM
NEXTERONE amiodarone
NITYR ORFADIN
NORTHERA midodrine
NOVAREL OVIDREL
NPLATE DOPTELET, PROMACTA, TAVALISSE
NUCALA LYOPHILIZED
POWDER
DUPIXENT, FASENRA, NUCALA (except lyophilized powder), TEZSPIRE, XOLAIR
NUTROPIN AQ GENOTROPIN, NORDITROPIN
OMNITROPE GENOTROPIN, NORDITROPIN
ORENCIA REMICADE, SIMPONI ARIA
ORTHOVISC DUROLANE, EUFLEXXA, GELSYN-3, SUPARTZ FX
OTREXUP RASUVO
PEGASYS Consult doctor
PRALUENT REPATHA
PREGNYL OVIDREL
PROCYSBI CYSTAGON
RAVICTI sodium phenylbutyrate
REMODULIN treprostinil
RENFLEXIS ILUMYA, REMICADE, SIMPONI ARIA, SKYRIZI INTRAVENOUS, STELARA INTRAVENOUS
REVATIO sildenal, tadalal
RIABNI RUXIENCE
RITUXAN RUXIENCE
RIXUBIS ALPROLIX, REBINYN
RUBRACA LYNPARZA, ZEJULA
SABRIL vigabatrin
SAIZEN GENOTROPIN, NORDITROPIN
2023 Aetna Specialty Drug List (10/23)
Drug name(s) Preferred option(s)*
SANDOSTATIN LAR SOMATULINE DEPOT
SELZENTRY maraviroc
SIGNIFOR LAR SOMATULINE DEPOT
SOMAVERT SOMATULINE DEPOT
STRIBILD efavirenz-emtricitabine-tenofovir disoproxil fumarate, efavirenz-lamivudine-tenofovir disoproxil
fumarate, BIKTARVY, DOVATO, GENVOYA, ODEFSEY, SYMTUZA, TRIUMEQ
SUTENT sunitinib, CABOMETYX, INLYTA, LENVIMA, NEXAVAR
SYNVISC, SYNVISC-ONE DUROLANE, EUFLEXXA, GELSYN-3, SUPARTZ FX
SYPRINE trientine
TAFINLAR BRAFTOVI, ZELBORAF
TASIGNA imatinib mesylate, BOSULIF, SPRYCEL
TARGRETIN bexarotene
TECFIDERA dimethyl fumarate delayed-rel, ngolimid, glatiramer, AUBAGIO, AVONEX, BETASERON,
COPAXONE, GILENYA, KESIMPTA, MAYZENT, OCREVUS, REBIF, TYSABRI, VUMERITY, ZEPOSIA
THIOLA, THIOLA EC tiopronin
TOBI, TOBI PODHALER tobramycin inhalation solution, BETHKIS
TRACLEER ambrisentan, bosentan, OPSUMIT
TRELSTAR MIXJECT ELIGARD, FIRMAGON
TRUVADA abacavir-lamivudine, emtricitabine-tenofovir disoproxil fumarate, lamivudine-zidovudine,
CIMDUO, DESCOVY
TRUXIMA RUXIENCE
TYVASO DPI Consult doctor
UDENYCA ZIEXTENZO
VEMLIDY entecavir, lamivudine, tenofovir disoproxil fumarate
VIEKIRA PAK EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6)
VIRACEPT atazanavir, lopinavir-ritonavir solution, EVOTAZ, PREZCOBIX, PREZISTA
VISCO-3 DUROLANE, EUFLEXXA, GELSYN-3, SUPARTZ FX
VOTRIENT sunitinib, CABOMETYX, INLYTA, LENVIMA, NEXAVAR
XALKORI ALECENSA, ALUNBRIG, ZYKADIA
XENAZINE tetrabenazine, AUSTEDO
ZARXIO NIVESTYM
ZEPATIER EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6)
ZOLADEX ELIGARD, FIRMAGON, ORILISSA
ZYTIGA abiraterone, bicalutamide, ERLEADA, XTANDI, YONSA
2023 Aetna Specialty Drug List (10/23)
Table 1 – Preferred options for indication based
autoimmune excluded medications
Condition Excluded drug name(s) Preferred option(s)
Ankylosing Spondylitis SIMPONI
TA LTZ
XELJANZ
XELJANZ XR
COSENTYX
ENBREL
HUMIRA
RINVOQ
Crohn's Disease None HUMIRA
RINVOQ
SKYRIZI SUBCUTANEOUS
STELARA SUBCUTANEOUS
Non-Radiographic Axial
Spondyloarthritis
TA LTZ CIMZIA PREFILLED SYRINGE
COSENTYX
RINVOQ
Psoriasis COSENTYX
ENBREL
HUMIRA
OTEZLA
SKYRIZI SUBCUTANEOUS
STELARA SUBCUTANEOUS
TALTZ
TREMFYA
Psoriatic Arthritis ORENCIA CLICKJECT
ORENCIA SUBCUTANEOUS
SIMPONI
TA LTZ
XELJANZ
XELJANZ XR
COSENTYX
ENBREL
HUMIRA
OTEZLA
RINVOQ
SKYRIZI SUBCUTANEOUS
STELARA SUBCUTANEOUS
TREMFYA
Rheumatoid Arthritis ACTEMRA ACTPEN
ACTEMRA SUBCUTANEOUS
KINERET
SIMPONI
ENBREL
HUMIRA
KEVZARA
ORENCIA CLICKJECT
ORENCIA SUBCUTANEOUS
RINVOQ
XELJANZ
XELJANZ XR
Ulcerative Colitis SIMPONI HUMIRA
RINVOQ
STELARA SUBCUTANEOUS
XELJANZ
XELJANZ XR
ZEPOSIA
All other conditions ACTEMRA ACTPEN
ACTEMRA SUBCUTANEOUS
KINERET
ORENCIA CLICKJECT
ORENCIA SUBCUTANEOUS
ENBREL
HUMIRA
# After Failure Of Humira
* The preferred options in this list are a broad representation within therapeutic categories of available treatment options
and do not necessarily represent clinical equivalency.
§ Generics are available in this class and should be considered the first line of prescribing.
1
Copayment, copay or coinsurance means the amount a member is required to pay for a prescription in accordance
with a Plan, which may be a deductible, a percentage of the prescription price, a fixed amount or other charge, with
the balance, if any, paid by a Plan.
2
For use in patients previously treated with an HCV regimen containing an NS5A inhibitor (for genotypes 1-6) or
sofosbuvir without an NS5A inhibitor (for genotypes 1a or 3).
3
An exception process is in place for specific clinical or regulatory circumstances that may require coverage of an
excluded medication.
This is not an inclusive list. Products may be subject to plan-specific copayment or coinsurance, additional charges or
other restrictions. Some prescription benefit plan designs may not cover certain categories, regardless of their appearance
in this document.
This document contains trademarks or registered trademarks of CVS Pharmacy, Inc. or one of its affiliates; it may also
contain references to products that are trademarks or registered trademarks of entities not affiliated with CVS Health.
Information is believed to be accurate as of the production date; however, it is subject to change. To check coverage and
copay information for a specific medicine, log into your member website. For questions, please call the toll-free number
on the back of your member ID card.
Policy forms issued in Missouri include: AL HGrpPol 07, AL SG HGrpPol-1A 01, HI HGrpAg 05, HI GrpAgAmend-2022
01, HO HGrpPol 04, HO GrpPolAmend-2022 01, HI SG HGrpAg-1A 01.
AL IVL HPOL-1A-2023-EPO-HIX 02, AL IVL SOB 1A EPO HIX 02R2, AL IVL HPOL-1A-2023-EPO 02, AL IVL SOB 1A EPO 02R1.
Policy forms issued in Oklahoma include: AL OK HCOC, HC OK HCOC.
©2023 Aetna Inc.
1011950-01-07 (10/23)