Specialty drug. coverage

Transcription

1 Ut labo. Mil mo blabore Specialty drug ssumque conet officim. coverage For members with the Aetna Premier Plus plan Aetna Specialty Drug List aetna.com

2 You may get your first fill of these drugs at any 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 Key NPL Drug on Aetna s National Precertification List. Drug requires precertification on some plans. ^ Drug may not be available through Aetna Specialty Pharmacy. > Specialty drugs are also available through a retail pharmacy or through Aetna Specialty Pharmacy. + If your doctor supplies or administers these drugs, they may continue to do so. Your medical plan may continue to cover your drug. *Aetna Specialty Pharmacy refers to Aetna Specialty Pharmacy, LLC, a subsidiary or Aetna Inc., which is a licensed pharmacy that operates through specialty pharmacy prescription fulfillment. Health benefits and health insurance plans are offered and/or underwritten by Aetna Health Inc., Aetna Health Insurance Company of New York, Aetna Health Insurance Company, Aetna Health Assurance Pennsylvania Inc. 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 Each insurer has sole financial responsibility for its own products. Aetna Pharmacy Management refers to an internal business unit of Aetna Health Management, LLC.

3 2018 Specialty Drug List Premier Plus plan Antineoplastic agents Antineoplastics (oral) bexarotene capecitabine imatinib temozolomide tretinoin NPL NPL AFINITOR AFINITOR DIS ALECENSA ALUNBRIG ^ BOSULIF CABOMETYX ^ CALQUENCE CAELSA ^ COMETRIQ ^ COTELLIC ERIVEDGE ERLEADA FARYDAK GILOTRIF ^ GLEEVEC HYCAMTIN IBRANCE ICLUSIG ^ IDHIFA IMBRUVICA ^ INLY TA IRESSA ^ JAK AFI ^ KISQALI LENVIMA ^ LONSURF ^ LYNPARZA ^ MEKINIST NERLYNX ^ NEX AVAR NINLARO ODOMZO POMALYST PURIX AN RUBRACA ^ RYDAPT SYCEL STIVARGA SUTENT TAFINLAR TAGRISSO ^ TARCEVA TARGRETIN TASIGNA NPL TEMODAR TYKERB VENCLEXTA ^ VERZENIO VOTRIENT NPL XELODA X ALKORI ZELBORAF ZEJULA ZOLINZA ZYDELIG ^ ZYKADIA Antineoplastics hormonal agents leuprolide ELIGARD FASLODEX + TRELSTAR DEPOT + TRELSTAR MIX + FIRMAGON + TRIPTODUR + LUPANETA LUON LUON DEPOT + TRELSTAR LA + VANTAS + XTANDI ZOLADEX + ZYTIGA + Antineoplastics miscellaneous NPL ACTIMMUNE ALFERON N + SYLATRON TARGRETIN Gel INTRON A VALCHLOR ^ IRESSA ^

4 Blood products modifiers volume expanders Anti-inhibitor coagulant complex Blood-clotting factor VIIa (recombinant) FEIBA NF FEIBA VH NOVOSEVEN NPL NOVOSEVEN RT Von Willebrand factor VONVENDI NPL NPL Blood-clotting factor VIII (human) NPL ALPHANATE NPL CORIFACT NPL HEMOFIL M NPL HUMATE-P NPL KOATE-DVI MONOCLATE-P NPL WILATE NPL Blood-clotting factor VIII (recombinant) Blood-clotting factor IX (nonrecombinant) Blood-clotting factor IX (recombinant) Blood-clotting factor X (human) Blood-clotting factor XIII (recombinant) NPL ADVATE NPL ADYNOVATE NPL AFST YLA NPL ELOCTATE NPL HELIX ATE FS NPL IXINIT Y NPL ALPHANINE SD OFILNINE NPL MONONINE NPL ALOLIX NPL BEBULIN VH NPL BENEFIX NPL COAGADEX ^ NPL REBINYN NPL TRETTEN NPL Blood-clotting complex KCENTRA NPL KOGENATE FS NPL KOVALTRY NPL NOVOEIGHT NPL NUWIQ NPL RECOMBINATE NPL XYNTHA NPL IDELVION NPL IXINIT Y Fibrinogen concentrate (human) Hematopoietic growth factors NPL FIBRYGA RIASTAP NPL + NPL + ARANESP NPL + EPOGEN NPL GRANIX NPL + LEUKINE NPL + MIRCERA ^ NPL + NEULASTA Hereditary angioedema ^NPL + BERINERT NPL + CINRYZE ^ NPL + FIRAZYR Monoclonal modified immunoglobulin Paroxysmal nocturnal hemoglobinuria NPL HEMLIBRA NPL + SOLIRIS RIXUBIS NPL NEUMEGA + NPL + NEUPOGEN NPLATE ^ + NPL + OCRIT OMACTA + NPL + ZARXIO HAEGARDA ^ K ALBITOR ^ RUCONEST ^ NPL NPL + NPL +

5 Cardiovascular system Hypertension VECAMYL Inherited homozygous familial hyper-cholesterolemia Inherited heterozygous familial hyper-cholesterolemia JUXTAPID^ K YNAMRO REPATHA NPL ALUENT NPL NPL REPATHA Orthostatic hypotension NORTHERA ^ Pulmonary hypertension agents Central nervous system NPL + epoprostenol ^ ADCIRCA NPL sildenafil NPL Analgesics non-narcotic IALT + Anticonvulsants GABA modulators Huntington s disease chorea Multiple sclerosis agents ADEMPAS ^NPL NPL + FLOLAN ^ NPL LETAIRIS OPSUMIT ^NPL NPL ORENITRAM ^ NPL + REMODULIN ^ NPL REVATIO NPL TRACLEER NPL T Y VASO ^ NPL UPTRAVI ^ NPL + VELETRI ^ VENTAVIS ^ NPL SABRIL ^ VIGABATRIN PAK + tetrabenazine AUSTEDO ^ XENAZINE ^ + NPL glatopa AMPYRA NPL glatiramer inj NPL AUBAGIO NPL AVONEX NPL BETASERON NPL COPAXONE 20 mg NPL COPAXONE 40 mg NPL EXTAVIA NPL GILENYA NPL + LEMTRADA NPL PLEGRIDY NPL REBIF NPL TECFIDERA NPL + T YSABRI NPL QL ZINBRYTA Tardive dyskinesia INGREZZA ^ Dermatological agents Antineoplastic-alkylating agents VALCHLOR Gel ^ Antipsoriatics COSENTYX NPL ENBREL NPL HUMIRA NPL INFLECTRA KINERET ^NPL NPL OTEZLA OTREXUP > RASUVO > NPL Atopic dermatitis DUPIXENT NPL + REMICADE NPL RENFLEXIS NPL SILIQ NPL + SIMPONI NPL + STELARA NPL TALTZ NPL TREMFYA

6 Endocrine system Acromegaly octreotide + SANDOSTATIN + Congenital sucrase-isomaltase deficiency SANDOSTATIN LAR + SIGNIFOR LAR ^ SUCRAID ^ Corticotropin ACTHAR HP NPL + NPL + SOMATULINE SOMAVERT Cushing s disease SIGNIFOR ^ KORLYM ^ Diagnostic drugs THYROGEN + Fabry disease FABRAZYME Fertility agents chorionic gonadotropin leuprolide novarel pregnyl NPL BRAVELLE CETROTIDE FOLLISTIM AQ GANIRELIX NPL GONAL-F Gaucher disease CERDELGA NPL + NPL NPL CEREZYME NPL + ELELYSO ^ NPL + NPL Growth factors, insulin-like INCRELEX Growth hormone agents NPL GENOTROPIN NPL HUMATROPE NORDITROPIN NPL NUSPIN NPL NUTROPIN NUTROPIN AQ NUTROPIN AQ NPL NUSPIN NPL NPL NPL GONAL-F RFF LUON NPL MENOPUR NPL OVIDREL NPL REONEX NPL NPL + VIV NPL + ZAVESCA ^ NPL OMNITROPE NPL SAIZEN NPL SEROSTIM NPL ZOMACTON NPL ZORBTIVE Hereditary orotic aciduria XURIDEN ^ Hereditary tyrosinemia NITYR ORFADIN ^ Homocystinuria CYSTADANE ^ Hormone replacement progestins MAKENA Hunter syndrome ELAASE NPL + NPL Hyperammonemia phenylbutyrate AMMONUL + Hyperparathyroidism BUPHENYL CARBAGLU ^ Hypoparathyroidism NATPARA ^ Hypophosphatasia NPL STRENSIQ ^ NPL

7 Leptin deficiency MYALEPT ^NPL LHRH/GnRH agonist analog pituitary suppressants Lysosomal acid lipase (LAL) deficiency) SUPELIN LA + KANUMA ^ NPL + Morquio A syndrome VIMIZIM ^NPL SYNAREL Mucopolysaccharidosis I ALDURAZYME NPL + Mucopoly-saccharidosis VI NPL + NAGLAZYME Phenylketonuria KUVAN ^ Pompe disease LUMIZYME NPL + MYOZYME NPL + Vasopressin receptor antagonists SAMSCA Gastrointestinal system Bile acid synthesis disorders Carcinoid syndrome diarrhea CHOLBAM ^ XERMELO Crohn s disease CIMZIA ENTYVIO HUMIRA Short bowel syndrome GATTEX ^ NPL + NPL + NPL NPL NPL INFLECTRA NPL + REMICADE NPL RENFLEXIS Infections and infestations Antiretrovirals fusion inhibitors FUZEON Antivirals cytomegalovirus (CMV) agents cidofovir + foscarnet + ganciclovir valganciclovir valganciclovir sol CYTOGAM + CYTOVENE + FOSCAVIR + EVYMIS VALCYTE VALCYTE SOL VISTIDE Antivirals hepatitis agents adefovir entecavir lamivudine ribapak ribasphere ribavirin BARACLUDE COPEGUS DAKLINZA EPCLUSA EPIVIR HBV HARVONI HEPSERA MAVYRET NPL OLYSIO PEGASYS NPL NPL NPL NPL PEGINTRON REBETOL NPL SOVALDI TECHNIVIE TYZEKA VEMLIDY NPL VIEKIRA VIEKIRA XR NPL VOSEVI NPL ZEPATIER NPL NPL QL

8 Musculoskeletal system Bone-modifying agents Ibandronate (inj only) + pamidronate + zoledronic acid + BONIVA (inj only) + NPL + FORTEO GANITE NPL + NPL + OLIA Enzymes XIAFLEX ^ + RECLAST + TYMLOS XGEVA ZOMETA + NPL NPL + Gout KRYSTEXXA + Interleukin-1 beta blockers ILARIS ^ NPL + Interleukin-1 blockers ARCALYST ^ + Muscular dystrophy EMFLAZA Neuromuscular blocking agent neurotoxins ^NPL NPL + BOTOX XEOMIN NPL + DYSPORT NPL + Osteoarthritis DUROLANE EUFLEXXA GEL-ONE INJ GELGELSYN-3 HYALGAN NPL HYMOVIS Rheumatoid arthritis ACTEMRA ACTEMRA SC NPL + CIMZIA NPL ENBREL INFLECTRA NPL HUMIRA KINERET ^ NPL KEVZARA ORENCIA Ophthalmic agents NPL + NPL + NPL + NPL + NPL NPL NPL + NPL NPL MONOVISC ORTHOVISC SUPARTZ NPL + SYNVISC SYNVISC ONE NPL + NPL + OTREXUP > RASUVO > REMICADE RENFLEXIS NPL SIMPONI SIMPONI ARIA NPL XELJANZ XELJANZ XR NPL + Macular degeneration EYLEA MACUGEN NPL + LUCENTIS NPL + VISUDYNE + Macular edema OZURDEX + Vitreomacular adhesion JETREA + NPL + NPL + NPL + NPL NPL + NPL + Respiratory tract agents Alpha-proteinase inhibitors Antiasthmatic monoclonal antibodies ARALAST ARALAST NP GLASSIA NPL + NPL + NPL + OLASTIN ^ NPL + OLASTIN-C ^ NPL + ZEMAIRA ^ NPL + NPL CINQAIR NUCALA NPL + FASENRA NPL ^ XOLAIR NPL +

9 Cystic fibrosis colistimethate sodium + tobramycin neb sol BETHKIS NEB CAYSTON ^ COLY-MYCIN M + KALYDECO ^ SYMDEKO ^ ORKAMBI ^ PULMOZYME TOBI TOBI podhaler Idiopathic pulmonary fibrosis Respiratory syncytial virus monoclonal antibodies ESBRIET OFEV ^ SYNAGIS NPL + Tuberculosis SIRTURO Therapeutic nutrients vitamins minerals electrolytes Mineral supplements ferric gluconate + FERRIOX ^ FERRLECIT + VENOFER + Toxicologic agents Alcohol dependence VIVITROL + Antidotes deferoxamine DESFERAL + mesylate + EXJADE JADENU VISTOGARD Vaccines, toxoids and biologics Immune globulin CMV CYTOGAM + Immune globulin immune disorders ADAGEN ^ NPL + BIVIGAM CARIMUNE NANOFILTERED CUVITRU ^NPL FLEBOGAMMA GAMASTAN S/D GAMMAGARD GAMMAGARD S/D Immune globulin HEPAGAM B + hepatitis B HYPERHEP B + NABI-HB + Immune globulin rabies HYPERRAB S/D + KEDRAB NPL + NPL + NPL + NPL + NPL + NPL + NPL GAMMAKED GAMMAPLEX NPL + GAMUNEX GAMUNEX-C NPL + HIZENTRA NPL + HYQVIA NPL + OCTAGAM NPL + IVIGEN VIVAGLOBIN NPL + NPL + NPL + IMOGAM RABIES + Immune globulin Rh isoimmunization Immune globulin tetanus HYPERRHO S/D + MICRHOGAM ULTRA FILTERED + RHOGAM ULTRA FILTERED PLUS + RHOPHYLAC + WINRHO SDF + HYPERTET S/D +

10 Miscellaneous Cystinosis CYSTARAN ^ OCYSBI Immunosuppressive agents azathioprine (inj only) + cyclosporine + gengraf + mycophenolic acid mycophenolate mofetil sirolimus tacrolimus ASTAGRAF ATGAM + CELLCEPT ENVARSUS XR MYFORTIC NEORAL NULOJIX + OGRAF RAPAMUNE SANDIMMUNE SIMULECT + THYMOGLOBULIN ^ + ZORTRESS + Narcolepsy XYREM ^ Primary periodic paralysis KEVEYIS ^ Systemic lupus erythematosus agents BENLYSTA NPL + BENLYSTA SQ NPL Urea cycle disorder RAVICTI ^ Anxiolytics, sedatives, hypnotics miscellaneous HETLIOZ Parkinson s disease DUOPA ^ Parkinson s disease psychosis Primary biliary cholangitis (PBC) NUPLAZID ^ OCALIVA ^ Chelating agents trientine CUIMINE DEPEN TITRA SYINE Urinary stone agents THIOLA ^ Agents for pheochromocytoma phenoxbenzamine DIBENZYLINE Immunomodulators REVLIMID THALOMID

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 CareRx SM 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 steptherapy 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. 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. Provider participation may change without notice. Aetna 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. For more information about Aetna plans, refer to aetna.com. Policy forms issued in OK include: HMO OK COC-5 09/07, HMO/OK GA-3 11/01, HMO OK POS RIDER 08/07, GR-23 and/or GR-29N. Policy forms issued in Missouri include: AL HGrpPol 01R5, HI HGrpAg 01, HO HGrpPol 01. ta Aetna Inc. aetna.com F (4/18)