Some restoratively regulated Part B medications might have additional necessities or cutoff points on inclusion. These may
incorporate step treatment. This is the point at which we expect you to initially attempt specific favored medications to treat your clinical
condition prior to covering another non-favored drug.
For instance, if drug An and drug B both treat your condition, we might favor drug A, and expect you to attempt it
first. On the off chance that that doesn’t work for you, we will then, at that point, cover drug B. The recorded favored items ought to be utilized
first. An exemption cycle is set up for explicit cases that might require a non-favored item.
Drug classes with favored items are recorded underneath. For explicit clinical signs subject to step
treatment, kindly see the relating clinical strategy announcement on the Aetna® site.
To figure out more, go to . You can likewise call usat the number on your ID card.
Drug Class/Indication(s) Non-Liked
Product(s)
Liked
Product(s)
Acromegaly
Signifor LAR
Somavert
Sandostatin LAR
Somatuline stop
Alpha-1 antitrypsin inadequacy
Aralast NP
Glassia
Zemaira
Prolastin-C
Bone Resorption Inhibitors
• Osteoporosis
Evenity Prolia
Zoledronic corrosive
Bone Resorption Inhibitors
• Hypercalcemia of danger
Xgeva Pamidronate
Zoledronic corrosive
Botulinum Poisons
• Cervical dystonia
• Upper appendage spasticity
Dysport
Xeomin
Botulinum Poisons
• Blepharospasm
• Ongoing sialorrhea
Xeomin
Botulinum Poisons
• Lower appendage spasticity
Botox
Myobloc
Dysport
CSF — Leukocyte Development Elements (filgrastim)
• Anticipation of febrile neutropenia
• Indicative neutropenic problem
• Gathering of fringe blood undeveloped cells
Granix
Neupogen
Nivestym
Releuko
Zarxio
Restrictive
CSF — Leukocyte Development Variables (pegfilgrastim)
• Anticipation of febrile neutropenia
Nyvepria
Ziextenzo
Fulphila
Neulasta
Neulasta Onpro
Udenyca
Erythropoiesis Invigorating Specialists
• Pallor because of persistent kidney infection
• Frailty because of chemotherapy
Aranesp
Procrit
Retacrit
Erythropoiesis Animating Specialists
• Frailty because of Zidovudine use in HIV
• Bonding decrease for select medical procedures
Epogen
Procrit
Retacrit
Gonadotropin-Delivering Chemical Agonists
• High level prostate malignant growth
Lupron terminal
Trelstar
Zoladex
Eligard
Gonadotropin-Delivering Chemical Bad guys
• High level prostate malignant growth
Firmagon
Immunologics
• Crohn’s infection
• Ulcerative colitis
Avsola
Entyvio
Remicade
Immunologics
• Psoriasis
Avsola
Remicade
Immunologics
• Ankylosing spondylitis
• Psoriatic joint pain
• Rheumatoid joint pain
Actemra
Cimzia
Ilumya
Inflectra
Orencia
Renflexis
Riabni
Rituxan
Ruxience
Stelara
Tremfya
Truxima
Tysabri
Avsola
Remicade
Simponi Aria
Intravenous iron
• Lack of iron pallor after prejudice or
inadmissible reaction to oral iron
Feraheme
Injectafer
Monoferric
Ferrlecit
Sodium ferric gluconate
Infed
Venofer
IVIG (intravenous immunoglobulin)*
• Essential immunodeficiency
• Idiopathic thrombocytopenia purpura
• Constant fiery demyelinating
polyneuropathy
Asceniv
Bivigam
Flebogamma
Gammagard
Gammaked
Gammaplex
Gamunex-C
Octagam
Panzyga
Privigen
Restrictive
SCIG (subcutaneous immunoglobulin)*
• Essential immunodeficiency
• Constant fiery demyelinating
polyneuropathy
*IVIG and SCIG are one class. Use by the same token
favored item before a non-favored IVIG or
SCIG.
Cutaquig
Cuvitru
Gammagard
Gammaked
Gamunex-C
HyQvia
Xembify
Hizentra
Numerous myeloma
Darzalex
Darzalex Faspro
Kyprolis
Bortezomib
Velcade
Numerous Sclerosis Lemtrada Tysabri
Myelodysplastic condition
Dacogen
Decitabine
Vidaza
Azacitidine
Oncology (Abraxane)
• Non-little cell cellular breakdown in the lungs
Abraxane
Paclitaxel (protein bound)
Docetaxel
Paclitaxel
Oncology (Herceptin)
• Bosom disease
Herceptin
Herceptin Hylecta
Kanjinti
Trazimera
Oncology (Herceptin)
• Gastrointestinal disease
Herzuma
Ogivri
Ontruzant
Herceptin
Kanjinti
Trazimera
Ophthalmic Issues
Beovu
Byooviz
Eylea
Lucentis
Susvimo
Vabysmo
Bevacizumab (Avastin)
Pneumonic Blood vessel Hypertension (Remodulin) Remodulin Nonexclusive treprostinil
Pneumonic Blood vessel Hypertension (Flolan/Veletri)
Flolan
Veletri
Conventional epoprostenol
Rituximab
• Non-Hodgkin’s lymphoma
• Constant lymphocytic leukemia
• Granulomatosis with polyangiitis (GPA) and
infinitesimal polyangiitis (MPA)
Riabni Rituxan
Rituxan Hycela
Ruxience
Truxima
Extreme asthma
Cinqair Fasenra
Nucala
Xolair
Viscosupplements (single injection)**
• Osteoarthritis
Durolane
Gel-One
Monovisc
Synvisc-One
Viscosupplements (various injections)**
• Osteoarthritis
**Viscosupplements are one class. Utilize any
favored item before a non-favored single or
numerous infusion viscosupplement.
Euflexxa
Gelsyn-3
GenVisc
Hyalgan
Hymovis
Supartz FX
TriVisc
Visco-3
Orthovisc
Synvisc
This rundown demonstrates the normal purposes for which the medication is recommended. A few prescriptions are recommended for
more than one condition. For explicit clinical signs subject to step treatment, kindly see the
comparing clinical arrangement release on the Aetna site.
This archive contains references to mark name doctor prescribed drugs that are reserve or enlisted
brand names of drug makers not subsidiary with Aetna. Recorded items are for
educational purposes just and are not expected to supplant the clinical judgment of the prescriber. Recorded
helpful classes and explicit medication favored assignments are likely to change in view of new medication
dispatches, item endorsements, drug withdrawals and other market changes. Your protection means quite a bit to us.
Our workers are prepared in regards to the suitable method for taking care of your confidential wellbeing data.
The model might change out of the blue. You will get notice when vital. See Proof of
Inclusion for a total depiction of plan benefits, prohibitions, restrictions and states of inclusion.
Plan highlights and accessibility might fluctuate by administration region.
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