Specialty. Drug. coverage reviews

Transcription

1 Call to action small copy (especially related to mobile apps). Hendani adionse rferum faceatis incte voluptassi aut maximpe rumquid ebita- Call out bold Call out light Contact information, Specialty call X-XXX-XXX-XXXX or visit tur? Drug Ut labo. Mil mo blabore ssumque conet officim. coverage reviews Specialty drugs requiring prior authorization 2018 Aetna Standard plan Disclaimer. Disclaimer. Disclaimer. Disclaimer. Disclaimer. Disclaimer. Disclaimer. Disclaimer. Disclaimer. Disclaimer. Disclaimer. Disclaimer. Disclaimer. Disclaimer. Disclaimer. Disclaimer Aetna Inc. XX.XX.XXX.X (X/13) (10/17) aetna.com

2 The drugs on this list require prior authorization* review under the Aetna Standard plan. If you have a medical need for one of these drugs, your doctor can ask for an exception. *Prior authorization (also called preauthorization): Your doctor needs to get our approval ahead of time before we cover certain drugs. Key UPPERCASE lowercase italics Brand-name medicine Generic medicine 2018 Standard specialty prior authorization drug list Acromegaly Alcohol and Opioid Dependency octreotide (SANDOSTATIN) SANDOSTATIN LAR VIVITROL DEPOT SIGNIFOR LAR SOMATULINE DEPOT SOMAVERT Allergic Asthma CINQAIR NUCALA XOLAIR Alpha1- Antitrypsin (AAT) Deficiency ARALAST NP GLASSIA PROLASTIN-C ZEMAIRA Anemia ARANESP EPOGEN MIRCERA PROCRIT Atopic Dermatitis Bone Disorders DUPIXENT STRENSIQ Botulinum Toxins BOTOX DYSPORT MYOBLOC XEOMIN Cardiac Disorders Central Precocious Puberty (CPP) Cryopyrin Associated Periodic Syndromes (CAPS) TIKOSYN leuprolide LUPRON DEPOT-PED SUPPRELIN LA ARCALYST ILARIS KINERET Cushing s Syndrome KORLYM SIGNIFOR ORKAMBI tobramycin inhalation solution (TOBI) Cystic Fibrosis (CF) BETHKIS CAYSTON KALYDECO KITABIS PAK PULMOZYME TOBI PODHALER Electrolyte Disorders SAMSCA Gastrointestinal Disorders Other Gout CHOLBAM GATTEX OCALIVA ZORBTIVE KRYSTEXXA 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 Insurance Company, Aetna HealthAssurance 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 Growth Hormone (GH) and Related Disorders GENOTROPIN HUMATROPE INCRELEX NORDITROPIN NUTROPIN/ NUTROPIN AQ OMNITROPE SAIZEN ZOMACTON Hematopoietics MOZOBIL NEUMEGA Hemophilia And Related Bleeding Disorders ADVATE ADYNOVATE AFSTYLA ALPHANATE ALPHANINE SD ALPROLIX BEBULIN VH BENEFIX COAGADEX ELOCTATE FEIBA NF FEIBA VH HELIXATE FS HEMOFIL M HUMATE-P IDELVION IXINITY KOATE-DVI KOGENATE FS KOVALTRY MONOCLATE-P MONONINE NOVOEIGHT NOVOSEVEN NUWIQ OBIZUR PROFILNINE SD RECOMBINATE RIXUBIS STIMATE NASAL SPRAY VONVENDI WILATE XYNTHA Hepatitis C DAKLINZA EPCLUSA HARVONI MAVYRET OLYSIO PEGASYS PEG-INTRON RIBAVIRIN (ribavirin capsules/tablets, REBETOL, RIBASPHERE, RIBASPHERE RIBAPAK, RIBATAB) SOVALDI TECHNIVIE VIEKIRA PAK VIEKIRA XR VOSEVI ZEPATIER Hereditary Angioedema (HAE) BERINERT CINRYZE HAEGARDA FIRAZYR KALBITOR RUCONEST Hormonal Therapies AVEED ELIGARD FIRMAGON leuprolide LUPANETA PACK LUPRON DEPOT NATPARA TRELSTAR VANTAS ZOLADEX Human Immunodeficiency Virus (HIV) EGRIFTA SEROSTIM Immune Therapies BIVIGAM CARIMUNE NF CUVITRU FLEBOGAMMA GAMASTAN S/D GAMMAGARD GAMMAKED GAMMAPLEX GAMUNEX HIZENTRA HYQVIA OCTAGAM PRIVIGEN Immune (Idiopathic) Hrombocytopenia (ITP) NPLATE PROMACTA Infectious Disease ACTIMMUNE Infertility BRAVELLE CETROTIDE chorionic gonadotropin (NOVAREL, OVIDREL, PREGNYL) FOLLISTIM AQ ganirelix acetate GONAL-F leuprolide MENOPUR REPRONEX Inflammatory Bowel Disease (IBD) CIMZIA ENTYVIO HUMIRA INFLECTRA REMICADE RENFLEXIS SIMPONI STELARA TYSABRI Iron Overload deferoxamine (DESFERAL) EXJADE FERRIPROX JADENU Lipid Disorders JUXTAPID KYNAMRO PRALUENT Lipodystrophy MYALEPT

4 Lysosomal Storage Disorders (LSD) and Related Disorders ADAGEN ALDURAZYME BRINEURA CERDELGA CEREZYME CYSTAGON CYSTARAN ELAPRASE ELELYSO FABRAZYME KANUMA NITYR ORFADIN LUMIZYME NAGLAZYME PROCYSBI VIMIZIM VPRIV ZAVESCA Movement Disorders APOKYN AUSTEDO INGREZZA NORTHERA NUPLAZID RADICAVA XENAZINE Multiple Sclerosis (MS) AMPYRA AUBAGIO AVONEX BETASERON COPAXONE EXTAVIA GILENYA GLATOPA LEMTRADA mitoxantrone OCREVUS PLEGRIDY REBIF TECFIDERA TYSABRI ZINBRYTA Muscular Dystrophy EMFLAZA EXONDYS 51 Neuromuscular SPINRAZA Neutropenia GRANIX LEUKINE NEULASTA NEUPOGEN ZARXIO Oncology ADCETRIS AFINITOR ALECENSA ALUNBRIG ARZERRA AVASTIN azacitidine (VIDAZA) BAVENCIO BELEODAQ BENDEKA BESPONSA BLINCYTO BOSULIF capecitabine (XELODA) CAPRELSA CABOMETYX COMETRIQ COTELLIC CYRAMZA DARZALEX decitabine (DACOGEN) EMPLICITI ERBITUX ERIVEDGE ERWINAZE FARYDAK FOLOTYN FUSILEV GAZYVA GILOTRIF GLEEVEC HALAVEN HERCEPTIN HYCAMTIN CAPSULES IBRANCE ICLUSIG IDHIFA IMFINZI IMLYGIC INLYTA INTRON-A IRESSA ISTODAX IXEMPRA JAKAFI JEVTANA KADCYLA KEYTRUDA KISQALI KYPROLIS LARTRUVO LENVIMA LONSURF LYNPARZA MEKINIST mitoxantrone MYLOTARG NERLYNX NEXAVAR NINLARO ODOMZO ONCASPAR OPDIVO PERJETA POMALYST PORTRAZZA PROLEUKIN REVLIMID RITUXAN RITUXAN HYCELA RUBRACA RYDAPT SPRYCEL STIVARGA SUTENT SYLATRON SYLVANT SYNRIBO TAFINLAR TAGRISSO TARCEVA TARGRETIN TASIGNA TECENTRIQ temozolomide (TEMODAR) THALOMID TORISEL TREANDA TYKERB VALCHLOR VECTIBIX VELCADE VENCLEXTA VOTRIENT XALKORI XERMELO XGEVA XTANDI YERVOY ZALTRAP ZEJULA ZELBORAF zoledronic acid (ZOMETA) ZOLINZA ZYDELIG ZYKADIA ZYTIGA Osteoarthritis (OA) EUFLEXXA GEL-ONE GELSYN-3 GENVISC-850 HYALGAN HYMOVIS MONOVISC ORTHOVISC SUPARTZ SYNVISC/ SYNVISC ONE Osteoporosis FORTEO PROLIA TYMLOS zoledronic acid (RECLAST) Paroxysmal Nocturnal Hemoglobinuria (PNH) Phenylketonuria (PKU) SOLIRIS KUVAN

5 Pre-Term Birth MAKENA Psoriasis COSENTYX ENBREL HUMIRA OTEZLA OTREXUP RASUVO REMICADE RENFLEXIS SILIQ STELARA TALTZ TREMFYA Pulmonary Arterial Hypertension (PAH) ADCIRCA ADEMPAS epoprostenol (FLOLAN) LETAIRIS OPSUMIT ORENITRAM REMODULIN sildenafil (REVATIO) TRACLEER TYVASO UPTRAVI VELETRI VENTAVIS Pulmonary Disorders Other ESBRIET OFEV Renal Disorders SENSIPAR Respiratory Syncytial Virus SYNAGIS Retinal Disorders AVASTIN EYLEA LUCENTIS Rheumatoid Arthritis (RA) ACTEMRA CIMZIA ENBREL HUMIRA INFLECTRA KEVZARA KINERET ORENCIA OTREXUP REMICADE RITUXAN SIMPONI ARIA XELJANZ XR Seizure Disorders ACTHAR SABRIL Sleep Disorders Systemic Lupus Erythematosus HETLIOZ BENLYSTA Urea Cycle Disorders BUPHENYL CARBAGLU RAVICTI

6 Medications on the drug coverage review lists are subject to change and may not be all-inclusive. For example, safety edits and specialty medications may require prior authorization and may be found on a separate list. Specific prescription plan designs may not cover certain categories or may be subject to additional restrictions, regardless of their appearance in this document. Prior authorization and step therapy programs are subject to state law restrictions and may not apply in all areas or for all plans. Step therapy does not apply to fully insured members in New Jersey. However, these programs are available to self-funded plans. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers that are not affiliated with Aetna. Listed products are for informational purposes only and are not intended to replace the clinical judgment of the prescriber. Aetna Pharmacy Management refers to an internal business unit of Aetna Health Management, LLC. Information is believed to be accurate as of the production date; however, it is subject to change. If you have questions, see your plan materials or call Member Services. For more information about Aetna plans, refer to aetna.com Aetna Inc (10/17) aetna.com