3253356-01-02 (7/24)
Specialty
Drug List
2024 Aetna Specialty Drug List
2024 Aetna Specialty Drug List (7/24)
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.
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.
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.
Key
UPPERCASE Brand-name medicine
lowercase italics Generic medicine
Category
Drug class
Analgesics
Viscosupplements DUROLANE
EUFLEXXA
GELSYN-3
SUPARTZ FX
Anti-Infectives
Antiretroviral Agents abacavir
atazanavir
darunavir
efavirenz
etravirine
lamivudine
maraviroc
nevirapine
nevirapine ext-rel
ritonavir
zidovudine
EMTRIVA
FUZEON
ISENTRESS
TIVICAY
Antiretroviral Agents
Antiretroviral Combinations §
abacavir-lamivudine
efavirenz-emtricitabine-tenofovir
disoproxil fumarate
efavirenz-lamivudine-tenofovir
disoproxil fumarate
emtricitabine-tenofovir disoproxil
fumarate
lamivudine-zidovudine
lopinavir-ritonavir
BIKTARVY
CABENUVA
CIMDUO
DESCOVY
DOVATO
GENVOYA
ODEFSEY
SYMTUZA
TRIUMEQ
Antivirals
Hepatitis B Agents §
entecavir
lamivudine
tenofovir disoproxil fumarate
VEMLIDY
Antivirals
Hepatitis C Agents §
ribavirin
EPCLUSA
(genotypes 1, 2, 3, 4, 5, 6)
HARVONI
(genotypes 1, 4, 5, 6)
VOSEVI
2024 Aetna Specialty Drug List (7/24)
Category
Drug class
Antineoplastic Agents
Alkylating Agents § temozolomide
MATULANE
Antimetabolites § capecitabine
LONSURF
Biologic Response Modifiers BESREMI
ERIVEDGE
REVLIMID
THALOMID
Biosimilars HERZUMA
OGIVRI
RUXIENCE
ZIRABEV
Hormonal Antineoplastic Agents
Antiandrogens §
abiraterone
leuprolide acetate
ELIGARD
ERLEADA
LYSODREN
NUBEQA
XTANDI
YONSA
Kinase Inhibitors § erlotinib
everolimus
getinib
imatinib mesylate
lapatinib
pazopanib
sorafenib
sunitinib
ALECENSA
ALUNBRIG
BOSULIF
BRAFTOVI
BRUKINSA
CABOMETYX
CALQUENCE
COPIKTRA
COTELLIC
GAVRETO
IBRANCE
INLYTA
KISQALI
KISQALI FEMARA CO-PACK
KOSELUGO
LENVIMA
MEKTOVI
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
KRAZATI
LUMAKRAS
LYNPARZA
ODOMZO
VISTOGARD
ZEJULA
ZOLINZA
Prostate Cancer
Luteinizing Hormone-Releasing Hormone (LHRH)
Agonists §
leuprolide acetate
ELIGARD
Cardiovascular
Antilipemics
PCSK9 Inhibitors
REPATHA
2024 Aetna Specialty Drug List (7/24)
Category
Drug class
Pulmonary Arterial Hypertension
Endothelin Receptor Antagonists §
ambrisentan
bosentan
OPSUMIT
Pulmonary Arterial Hypertension
Phosphodiesterase Inhibitors §
sildenal
tadalal
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
TADLIQ
Botulinum Toxins DYSPORT
XEOMIN
Movement Disorders § tetrabenazine
AUSTEDO
AUSTEDO XR
INGREZZA
Multiple Sclerosis Agents § delayed-rel
dimethyl fumarate
ngolimod
glatiramer
teriunomide
AVONEX
BETASERON
COPAXONE
KESIMPTA
MAYZENT
OCREVUS
REBIF
TYSABRI
VUMERITY
ZEPOSIA
Narcolepsy LUMRYZ
WAKIX
XYWAV
Endocrine and Metabolic
Acromegaly SOMATULINE DEPOT
Calcium Regulators Antagonists § cinacalcet
Calcium Regulators
Parathyroid Hormones
teriparatide
TYMLOS
Calcium Regulators
Miscellaneous
PROLIA
Central Precosious Puberty FENSOLVI
LUPRON DEPOT-PED
SUPPRELIN LA
Contraceptives
Progestin Intrauterine Devices
KYLEENA
MIRENA
SKYLA
2024 Aetna Specialty Drug List (7/24)
Category
Drug class
Fertility Regulators
GNRH/LHRH Antagonists
CETROTIDE
Fertility Regulators
Ovulation Stimulants, Gonadotropins
FOLLISTIM AQ
GANIRELIX ACETATE
MENOPUR
OVIDREL
Gaucher Disease CERDELGA
CEREZYME
Hereditary Tyrosinemia Type 1 Agents ORFADIN
Human Growth Hormones GENOTROPIN
NORDITROPIN
SOGROYA
PHENYLKETONURIA TREATMENT AGENTS § sapropterin
Polyneuropathy TEGSEDI
Urea Cycle Disorders § sodium phenylbutyrate
Miscellaneous betaine
carglumic acid
CYSTAGON
PHEBURANE
Genitourinary
Miscellaneous § tiopronin
Hematologic
Chelating Agents § deferasirox
deferiprone
deferoxamine
penicillamine capsule
trientine
Hematopoietic Growth Factors ARANESP
FYLNETRA
NIVESTYM
NYVEPRIA
PROCRIT
RETACRIT
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
2024 Aetna Specialty Drug List (7/24)
Category
Drug class
Immunologic Agents
Allergenic Extracts ORALAIR
Autoimmune Agents*
(Physician Administered)
AVSOLA
ILUMYA
REMICADE
SIMPONI ARIA
SKYRIZI INTRAVENOUS
STELARA INTRAVENOUS
Autoimmune Agents*
(Self-Administered)
See table 1 for indication based coverage details
Autoimmune Agents*
Ankylosing Spondylitis
ADALIMUMAB-ADAZ
COSENTYX
ENBREL
HUMIRA
HYRIMOZ
RINVOQ
Autoimmune Agents*
Crohn's Disease
ADALIMUMAB-ADAZ
HUMIRA
HYRIMOZ
RINVOQ
SKYRIZI SUBCUTANEOUS
STELARA SUBCUTANEOUS
Autoimmune Agents*
Non-Radiographic Axial Spondyloarthritis
CIMZIA PREFILLED SYRINGE
COSENTYX
RINVOQ
Autoimmune Agents*
Psoriasis
ADALIMUMAB-ADAZ
HUMIRA
HYRIMOZ
OTEZLA
SKYRIZI SUBCUTANEOUS
SOTYKTU
STELARA SUBCUTANEOUS
TA LT Z
TREMFYA
Autoimmune Agents*
Psoriatic Arthritis
ADALIMUMAB-ADAZ
COSENTYX
ENBREL
HUMIRA
HYRIMOZ
OTEZLA
RINVOQ
SKYRIZI SUBCUTANEOUS
STELARA SUBCUTANEOUS
TREMFYA
Autoimmune Agents*
Rheumatoid Arthritis
ADALIMUMAB-ADAZ
ENBREL
HUMIRA
HYRIMOZ
KEVZARA
ORENCIA CLICKJECT
ORENCIA SUBCUTANEOUS
RINVOQ
XELJANZ
XELJANZ XR
Autoimmune Agents*
Ulcerative Colitis
ADALIMUMAB-ADAZ
HUMIRA
HYRIMOZ
RINVOQ
STELARA SUBCUTANEOUS
XELJANZ
XELJANZ XR
ZEPOSIA
Autoimmune Agents*
All Other Conditions
ADALIMUMAB-ADAZ
ENBREL
HUMIRA
HYRIMOZ
Disease-Modifying Antirheumatic
Drugs (DMARDs)
RASUVO
Hereditary Angioedema icatibant
ORLADEYO
RUCONEST
TAKHZYRO
Immunomodulators
Immune Globulins
CUTAQUIG
Immunosuppressants
Antimetabolites §
mycophenolate mofetil
mycophenolate sodium
2024 Aetna Specialty Drug List (7/24)
Category
Drug class
Immunosuppressants
Calcineurin Inhibitors §
cyclosporine
cyclosporine, modied
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
BYOOVIZ
CIMERLI
2024 Aetna Specialty Drug List (7/24)
A
abacavir
abacavir-lamivudine
abiraterone
ADALIMUMAB-ADAZ
ADBRY
ADEMPAS
ADVATE
ADYNOVATE
AFSTYLA
ALECENSA
ALPROLIX
ALUNBRIG
ambrisentan
ARANESP
atazanavir
AUGTYRO
AUSTEDO
AUSTEDO XR
AVONEX
AVSOLA
B
BESREMI
betaine
BETASERON
bexarotene
BIKTARVY
bortezomib
bosentan
BOSULIF
BRAFTOVI
BRUKINSA
BYOOVIZ
C
CABENUVA
CABOMETYX
CALQUENCE
capecitabine
carglumic acid
CERDELGA
CEREZYME
CIBINQO
CIMDUO
CIMERLI
CIMZIA PREFILLED
SYRINGE
cinacalcet
COPAXONE 40 MG/
ML
COPIKTRA
COSENTYX
COTELLIC
CUTAQUIG
cyclosporine
cyclosporine modied
CYSTAGON
D
darunavir
deferasirox
deferiprone
deferoxamine
DESCOVY
dimethyl fumarate
delayed-rel
DOPTELET
DOVATO
DUPIXENT
DUPIXENT
DUROLANE
DYSPORT
E
efavirenz
efavirenz-
emtricitabine-
tenofovir disoproxil
fumarate
efavirenz-lamivudine-
tenofovir disoproxil
fumarate
ELFABRIO
ELIGARD
ELOCTATE
EMPAVELI
emtricitabine-tenofovir
disoproxil fumarate
EMTRIVA
ENBREL
ENDARI
ENSPRYNG
entecavir
EPCLUSA (genotypes
1, 2, 3, 4, 5, 6)
ERIVEDGE
ERLEADA
erlotinib
ESPEROCT
etravirine
EUFLEXXA
everolimus
F
FABRAZYME
FASENRA
FENSOLVI
ngolimod
FOLLISTIM AQ
FUZEON
FYLNETRA
G
GALAFOLD
GANIRELIX ACETATE
GAVRETO
getinib
GELSYN-3
GENVOYA
glatiramer
H
HARVONI (genotypes
1, 4, 5, 6)
HERZUMA
HUMATROPE
HUMIRA
HYRIMOZ
I
IBRANCE
icatibant
ILUMYA
imatinib mesylate
INBRIJA
INGREZZA
INLYTA
ISENTRESS
J
JIVI
K
KESIMPTA
KEVZARA
KISQALI
KISQALI FEMARA CO-
PACK
KOGENATE FS
KOSELUGO
KOVALTRY
KRAZATI
KYLEENA
L
lamivudine
lamivudine
lamivudine-zidovudine
lapatinib
LENVIMA
leuprolide acetate
LONSURF
lopinavir-ritonavir
LUMAKRAS
LUMRYZ
LUPRON DEPOT-PED
LYNPARZA
LYSODREN
M
maraviroc
MATULANE
MAYZENT
MEKTOVI
MENOPUR
MIRENA
MUGARD
mycophenolate
mofetil
mycophenolate
sodium
N
nevirapine
nevirapine ext-rel
NINLARO
NIVESTYM
NORDITROPIN
NOVOEIGHT
NOVOSEVEN RT
NUBEQA
NUCALA (except
lyophilized powder)
NUWIQ
NYVEPRIA
O
OCREVUS
ODEFSEY
ODOMZO
OFEV
OGIVRI
OPSUMIT
ORALAIR
ORENCIA CLICKJECT
ORENCIA
SUBCUTANEOUS
ORENITRAM
ORFADIN
ORLADEYO
OTEZLA
OVIDREL
P
pazopanib
penicillamine
PERJETA
PHEBURANE
PHESGO
pirfenidone
PROCRIT
PROLASTIN-C
PROLIA
PROMACTA
R
RADICAVA ORS
RASUVO
REBIF
REBINYN
REMICADE
REPATHA
RETACRIT
RETEVMO
REVLIMID
ribavirin
RINVOQ
ritonavir
ROZLYTREK
RUCONEST
RUXIENCE
RYDAPT
S
sapropterin
SEVENFACT
sildenal
SIMPONI ARIA
sirolimus
SKYLA
SKYRIZI
INTRAVENOUS
SKYRIZI
SUBCUTANEOUS
sodium
phenylbutyrate
SOGROYA
SOMATULINE DEPOT
sorafenib
SOTYKTU
SPRYCEL
STELARA
INTRAVENOUS
STELARA
SUBCUTANEOUS
STIVARGA
sunitinib
SUPARTZ FX
SUPPRELIN LA
SYMTUZA
T
tacrolimus
tadalal
TADLIQ
TAGRISSO
TAKHZYRO
TA LT Z
TAVALISSE
TEGSEDI
temozolomide
tenofovir disoproxil
fumarate
teriunomide
teriparatide
tetrabenazine
TEZSPIRE
THALOMID
tiopronin
TIVICAY
tobramycin inhalation
solution
TREMFYA
treprostinil
trientine
TRIUMEQ
TYMLOS
TYSABRI
U
UPTRAVI
V
VEMLIDY
vigabatrin
VISTOGARD
VITRAKVI
VOSEVI
VUMERITY
W
WAKIX
X
XELJANZ
XELJANZ XR
XEOMIN
XOLAIR
XOSPATA
XTANDI
XYNTHA
XYWAV
Y
YONSA
Z
ZEJULA
ZELBORAF
ZEMAIRA
ZEPOSIA
zidovudine
ZIRABEV
ZOLINZA
ZYDELIG
ZYKADIA
Quick reference drug list.
2024 Aetna Specialty Drug List (7/24)
Drug name(s) Preferred option(s)*
ACTEMRA INTRAVENOUS AVSOLA, REMICADE, SIMPONI ARIA
ADCIRCA sildenal, tadalal, TADLIQ
AFINITOR, AFINITOR DISPERZ everolimus
ALIQOPA Consult doctor
APOKYN INBRIJA
APTIVUS Consult doctor
ARALAST NP PROLASTIN-C, ZEMAIRA
ARCALYST Consult doctor
AUBAGIO dimethyl fumarate delayed-rel, ngolimod, glatiramer, teriunomide, AVONEX, BETASERON,
COPAXONE, KESIMPTA, MAYZENT, OCREVUS, REBIF, TYSABRI, VUMERITY, ZEPOSIA
AVASTIN ZIRABEV
BARACLUDE TABLET entecavir, lamivudine, tenofovir disoproxil fumarate, VEMLIDY
BENEFIX ALPROLIX, REBINYN
BERINERT RUCONEST, icatibant
BETHKIS tobramycin inhalation solution
BORTEZOMIB bortezomib, NINLARO
BOTOX DYSPORT, XEOMIN
BUPHENYL sodium phenylbutyrate, PHEBURANE
CARBAGLU carglumic acid
CAYSTON tobramycin inhalation solution
CETROTIDE GANIRELIX ACETATE
CHORIONIC GONADOTROPIN OVIDREL
CIMZIA LYOPHILIZED POWDER AVSOLA, ILUMYA, REMICADE, SIMPONI ARIA, SKYRIZI INTRAVENOUS, STELARA
INTRAVENOUS
CINRYZE ORLADEYO, TAKHZYRO
COMPLERA efavirenz-emtricitabine-tenofovir disoproxil fumarate, efavirenz-lamivudine-tenofovir disoproxil
fumarate, BIKTARVY, CABENUVA, DOVATO, GENVOYA, ODEFSEY, SYMTUZA, TRIUMEQ
COPAXONE 20 MG/ML dimethyl fumarate delayed-rel, ngolimod, glatiramer, teriunomide, AVONEX, BETASERON,
COPAXONE 40 MG/ML, KESIMPTA, MAYZENT, OCREVUS, REBIF, TYSABRI, VUMERITY,
ZEPOSIA
CUPRIMINE penicillamine capsule
CYSTADANE betaine
DESFERAL deferasirox, deferiprone, deferoxamine
DIACOMIT Consult doctor
EDURANT efavirenz
Preferred options for excluded specialty medications
3
2024 Aetna Specialty Drug List (7/24)
Drug name(s) Preferred option(s)*
ELELYSO CERDELGA, CEREZYME
ENTYVIO
(For Crohn’s Disease only)
AVSOLA, REMICADE, SKYRIZI INTRAVENOUS, STELARA INTRAVENOUS
EPIVIR HBV entecavir, lamivudine, tenofovir disoproxil fumarate, VEMLIDY
EPOGEN ARANESP, PROCRIT, RETACRIT
ESBRIET pirfenidone, OFEV
EXJADE deferasirox, deferiprone, deferoxamine
EXTAVIA dimethyl fumarate delayed-rel, ngolimod, glatiramer, teriunomide, AVONEX, BETASERON,
COPAXONE 40 MG/ML, KESIMPTA, MAYZENT, OCREVUS, REBIF, TYSABRI, VUMERITY,
ZEPOSIA
EYLEA BYOOVIZ, CIMERLI
FEIBA NOVOSEVEN RT, SEVENFACT
FERRIPROX deferasirox, deferiprone, deferoxamine
FINTELPA clobazam, clonazepam, lamotrigine, runamide, topiramate
FIRAZYR icatibant, RUCONEST
FIRMAGON ELIGARD
FULPHILA FYLNETRA, NYVEPRIA
fyremadel GANIRELIX ACETATE
ganirelix acetate GANIRELIX ACETATE
GEL-ONE DUROLANE, EUFLEXXA, GELSYN-3, SUPARTZ FX
GILENYA dimethyl fumarate delayed-rel, ngolimod, glatiramer, teriunomide, AVONEX, BETASERON,
COPAXONE, KESIMPTA, MAYZENT, OCREVUS, REBIF, TYSABRI, VUMERITY, ZEPOSIA
GENOTROPIN HUMATROPE, NORDITROPIN, SOGROYA
GLASSIA PROLASTIN-C, ZEMAIRA
GLEEVEC imatinib mesylate, BOSULIF, SPRYCEL
GONAL-F FOLLISTIM AQ
GRANIX NIVESTYM
HERCEPTIN HERZUMA, OGIVRI
HERCEPTIN HYLECTA KANJINTI, TRAZIMERA
HYALGAN DUROLANE, EUFLEXXA, GELSYN-3, SUPARTZ FX
HYQVIA CUTAQUIG
ICLUSIG imatinib mesylate, BOSULIF, SPRYCEL
IMBRUVICA BRUKINSA, CALQUENCE
INFLECTRA AVSOLA, ILUMYA, REMICADE, SIMPONI ARIA, SKYRIZI INTRAVENOUS, STELARA
INTRAVENOUS
INTELENCE etravirine
IRESSA erlotinib, getinib
2024 Aetna Specialty Drug List (7/24)
Drug name(s) Preferred option(s)*
IXINITY ALPROLIX, REBINYN
JADENU deferasirox, deferiprone, deferoxamine
JAKAFI (For Polycythemia Vera
Only)
BESREMI
JUX TAPID REPATHA
JYNARQUE Consult doctor
KALETRA atazanavir, darunavir, lopinavir-ritonavir
KANJINTI HERZUMA, OGIVRI
KITABIS PAK tobramycin inhalation solution
KORLYM Consult doctor
KUVAN sapropterin
KYPROLIS NINLARO, bortezomib
LEMTRADA dimethyl fumarate delayed-rel, ngolimod, glatiramer, teriunomide, AVONEX, BETASERON,
COPAXONE 40 MG/ML, KESIMPTA, MAYZENT, OCREVUS, REBIF, TYSABRI, VUMERITY,
ZEPOSIA
LETAIRIS ambrisentan, bosentan, OPSUMIT
LEUKINE NIVESTYM
LEXIVA atazanavir, darunavir, lopinavir-ritonavir
LILETTA KYLEENA, MIRENA, SKYLA
LORBRENA ALECENSA, ALUNBRIG
LUCENTIS BYOOVIZ, CIMERLI
LUPRON DEPOT 7.5 MG, 22.5
MG, 30 MG, 45 MG
ELIGARD
MAVYRET EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6), VOSEVI
MEKINIST COTELLIC, MEKTOVI
MONOVISC DUROLANE, EUFLEXXA, GELSYN-3, SUPARTZ FX
MYOBLOC DYSPORT, XEOMIN
NEULASTA, NEULASTA ONPRO FYLNETRA, NYVEPRIA
NEUPOGEN NIVESTYM
NEXAVAR pazopanib, sorafenib, sunitinib, CABOMETYX, INLYTA, LENVIMA
NEXTERONE amiodarone
NITYR ORFADIN
NORTHERA midodrine
NORVIR ritonavir
NOVAREL OVIDREL
NPLATE DOPTELET, PROMACTA, TAVALISSE
2024 Aetna Specialty Drug List (7/24)
Drug name(s) Preferred option(s)*
NUCALA LYOPHILIZED
POWDER
DUPIXENT, FASENRA, NUCALA (except lyophilized powder), TEZSPIRE, XOLAIR
NUTROPIN AQ HUMATROPE, NORDITROPIN, SOGROYA
OCTAGAM Consult doctor
OMNITROPE HUMATROPE, NORDITROPIN, SOGROYA
ORENCIA AVSOLA, REMICADE, SIMPONI ARIA
ORTHOVISC DUROLANE, EUFLEXXA, GELSYN-3, SUPARTZ FX
OTREXUP RASUVO
PEGASYS Consult doctor
PRALUENT REPATHA
PREGNYL OVIDREL
PREZISTA atazanavir, darunavir
PROCYSBI CYSTAGON
RAVICTI sodium phenylbutyrate, PHEBURANE
REMODULIN treprostinil
RENFLEXIS AVSOLA, ILUMYA, REMICADE, SIMPONI ARIA, SKYRIZI INTRAVENOUS, STELARA
INTRAVENOUS
REVATIO sildenal, tadalal, TADLIQ
REYATA Z atazanavir, darunavir
RIABNI RUXIENCE
RITUXAN RUXIENCE
RIXUBIS ALPROLIX, REBINYN
RUBRACA LYNPARZA, ZEJULA
SABRIL vigabatrin
SAIZEN HUMATROPE, NORDITROPIN, SOGROYA
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, CABENUVA, DOVATO, GENVOYA, ODEFSEY, SYMTUZA, TRIUMEQ
SUTENT pazopanib, sunitinib, CABOMETYX, INLYTA, LENVIMA
SYNVISC, SYNVISC-ONE DUROLANE, EUFLEXXA, GELSYN-3, SUPARTZ FX
SYPRINE trientine
TAFINLAR BRAFTOVI, ZELBORAF
TASIGNA imatinib mesylate, BOSULIF, SPRYCEL
2024 Aetna Specialty Drug List (7/24)
Drug name(s) Preferred option(s)*
TARGRETIN bexarotene
TECFIDERA dimethyl fumarate delayed-rel, ngolimod, glatiramer, teriunomide, AVONEX, BETASERON,
COPAXONE 40 MG/ML, KESIMPTA, MAYZENT, OCREVUS, REBIF, TYSABRI, VUMERITY,
ZEPOSIA
THIOLA, THIOLA EC tiopronin
TOBI, TOBI PODHALER tobramycin inhalation solution
TRACLEER ambrisentan, bosentan, OPSUMIT
TRAZIMERA HERZUMA, OGIVRI
TRELSTAR MIXJECT ELIGARD
TRIPTODUR FENSOLVI, LUPRON DEPOT-PED, SUPPRELIN LA
TRUVADA abacavir-lamivudine, emtricitabine-tenofovir disoproxil fumarate, lamivudine-zidovudine,
CIMDUO, DESCOVY
TRUXIMA RUXIENCE
TYVASO DPI Consult doctor
UDENYCA FYLNETRA, NYVEPRIA
VIRACEPT atazanavir, darunavir, lopinavir-ritonavir
VISCO-3 DUROLANE, EUFLEXXA, GELSYN-3, SUPARTZ FX
VOTRIENT pazopanib, sunitinib, CABOMETYX, INLYTA, LENVIMA
VPRIV CERDELGA, CEREZYME
XALKORI ALECENSA, ALUNBRIG, AUGTYRO, ZYKADIA
XENAZINE tetrabenazine, AUSTEDO, AUSTEDO XR, INGREZZA
XYREM LUMRYZ, WAKIX, XYWAV
ZARXIO NIVESTYM
ZEPATIER EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6)
ZIEXTENZO FYLNETRA, NYVEPRIA
ZOLADEX ELIGARD, ORILISSA
ZYTIGA abiraterone, bicalutamide, ERLEADA, NUBEQA, XTANDI, YONSA
2024 Aetna Specialty Drug List (7/24)
Condition Excluded drug name(s) Preferred option(s)
Ankylosing Spondylitis AMJEVITA
SIMPONI
TA LT Z
XELJANZ
XELJANZ XR
ADALIMUMAB-ADAZ
COSENTYX
ENBREL
HUMIRA
HYRIMOZ
RINVOQ
Crohn's Disease AMJEVITA ADALIMUMAB-ADAZ
HUMIRA
HYRIMOZ
RINVOQ
SKYRIZI SUBCUTANEOUS
STELARA SUBCUTANEOUS
Non-Radiographic Axial
Spondyloarthritis
TA LT Z CIMZIA PREFILLED SYRINGE
COSENTYX
RINVOQ
Psoriasis AMJEVITA
COSENTYX
ENBREL
ADALIMUMAB-ADAZ
HUMIRA
HYRIMOZ
OTEZLA
SKYRIZI SUBCUTANEOUS
SOTYKTU
STELARA SUBCUTANEOUS
TA LT Z
TREMFYA
Psoriatic Arthritis AMJEVITA
ORENCIA CLICKJECT
ORENCIA SUBCUTANEOUS
SIMPONI
TA LT Z
XELJANZ
XELJANZ XR
ADALIMUMAB-ADAZ
COSENTYX
ENBREL
HUMIRA
HYRIMOZ
OTEZLA
RINVOQ
SKYRIZI SUBCUTANEOUS
STELARA SUBCUTANEOUS
TREMFYA
Rheumatoid Arthritis ACTEMRA ACTPEN
ACTEMRA SUBCUTANEOUS
AMJEVITA
KINERET
SIMPONI
ADALIMUMAB-ADAZ
ENBREL
HUMIRA
HYRIMOZ
KEVZARA
ORENCIA CLICKJECT
ORENCIA SUBCUTANEOUS
RINVOQ
XELJANZ
XELJANZ XR
Table 1 – Preferred options for indication based
autoimmune excluded medications
# After Failure Of Humira
Condition Excluded drug name(s) Preferred option(s)
Ulcerative Colitis AMJEVITA
SIMPONI
ADALIMUMAB-ADAZ
HUMIRA
HYRIMOZ
RINVOQ
STELARA SUBCUTANEOUS
XELJANZ
XELJANZ XR
ZEPOSIA
All other conditions ACTEMRA ACTPEN
ACTEMRA SUBCUTANEOUS
AMJEVITA
KINERET
ORENCIA CLICKJECT
ORENCIA SUBCUTANEOUS
ADALIMUMAB-ADAZ
ENBREL
HUMIRA
HYRIMOZ
* 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 a complete list of drugs covered under your plan. Check your plan documents for coverage information. Your
plan may not cover certain drugs to treat conditions such as infertility, erectile dysfunction, and weight loss. To check
coverage and copay information for a specific medicine, log into your member website. If you’re still not sure whether
your plan benefits include coverage, call the toll-free number on the back of your ID card. Diabetic Supplies may be
covered under your medical plan.
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.
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-2024-EPO-HIX 03, AL IVL SOB 1A EPO HIX 03, AL IVL HPOL-1A-2024-EPO 03, AL IVL SOB 1A EPO 03.
Policy forms issued in Oklahoma include: AL SG HGrpPol-1A 01, AL SG HCOC-2024-PPO 08, AL SG SOB PPO 14052798
08, HI SG HGrpAg-1A 01, HI SG HCOC-2024 08, HI SG SOB HMO 14052797 08, AL HGrpPol 07 AL HCOC 11, AL HSOB 09,
AL HSOBNM 09, HI HGrpAg 06, HC HCOC 10, HC HSOB 09.
©2024 Aetna Inc.
3253356-01-02 (7/24)
