Aetna Commercial Clinical Program Summary — medical benefit drug list
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Aetna's commercial medical-benefit drug list describing medications subject to precertification, site-of-care designations, preferred alternatives, HCPCS/CPT codes, and inclusion in the Gene Based, Cellular and Other Innovative Therapy (GCIT®) network. Applies to providers submitting claims under Aetna commercial medical benefit.
No material clinical or coverage changes in this revision.
Coverage Criteria and Administrative Controls
General coverage stance
Coverage is governed by listed administrative attributes and underlying clinical drug policies
Administrative summary only; not a substitute for clinical policy.
Administrative coverage attributes (per-drug)
Coverage attributes provided per drug entry; these are administrative controls rather than clinical criteria.
Providers should consult the specific drug entry for whether precertification and site-of-care restrictions apply.
Benefit assignment and formulary preference
Coverage and benefit assignment are determined by drug lists and Combined Benefit Management status
See Combined Benefit Management Drug List for per-product benefit assignment and applicable state exceptions (e.g., AK, AR, GA, LA, MN, MS, ND, OK, RI, TN, TX, VT).
Immune Checkpoint Inhibitor preferences
Preferred and non-preferred immune checkpoint inhibitors are listed by cancer indication
Providers should select preferred agents when clinically appropriate or follow prior authorization/step requirements.
This partial administrative summary does not list specific clinical exclusion criteria. Rather, it functions as a program-level listing of medications covered under Aetna's commercial medical benefit and directs providers to the insurer's clinical policy resources for exclusionary rules. For specific exclusionary language and clinically-based coverage determinations, refer to the applicable Clinical Policy Bulletins and the Provider Precertification List referenced in the summary.
Some drugs in this program are included on Aetna's Combined Benefit Management Drug List, which can affect whether a product is covered under the plan's pharmacy or medical benefit. The Combined Benefit Management section notes that certain products may be available only under the member's prescription benefit or only under the medical benefit and that applicability is limited to members enrolled in Aetna commercial fully insured plans (subject to state law). Providers should consult the Combined Benefit Management list to confirm benefit assignment for a given product and member.
This summary is administrative in nature and does not enumerate conditions or services that Aetna has determined to be not medically necessary. Medical necessity and NMN determinations are made in Clinical Policy Bulletins; providers should consult those clinical policies when assessing whether a requested drug or service meets Aetna's medical necessity criteria.
Not all health services or medications are covered under every plan. The summary emphasizes that plan documents contain the complete description of benefits, exclusions, limitations, and conditions of coverage. Providers should verify member-specific coverage, benefit limits, and exclusions in the member's plan documents or by contacting member services prior to delivering services that may be excluded or limited under the member's contract.
HCPCS / CPT Codes and Coding Details
| J1602 | Simponi Aria |
Prior Authorization, Documentation, and Preferred Alternatives
Prior Authorization Required
Providers must obtain prior authorization (precertification) for many HCPCS/CPT-coded medical and infused drugs listed in Aetna's Commercial Clinical Program Summary when the drug entry shows "Precert Required = Y." Failure to secure precertification when required may result in claim denial or delayed payment.
- Precertification/Authorization required: Drugs with "Precert Required = Y" in the listing require prior authorization before the service is provided.
- Precertification requirement: Claims for listed drugs marked "Precert Required = Y" may be denied if precertification is not obtained.
- Precert flag per drug: Each drug entry includes a "Precert Required" flag (Y/N) — verify the flag for the specific HCPCS/CPT code prior to administration.
- Documentation for precertification: When requesting precertification, providers must submit clinical documentation supporting medical necessity (including diagnosis, prior therapies, relevant labs/imaging, and treatment rationale) as specified in Aetna Clinical Policy Bulletins.
- Documentation and reference sources: Refer to the Provider Precertification List, Site of Care Policy, Clinical Policy Bulletins, and the Combined Benefit Management Drug List for detailed precertification instructions, required documentation, and applicable coding.
- Plan documentation: Check plan documents and member benefit details for coverage, exclusions, limitations, site-of-care requirements, and any state-specific rules that may affect effective dates or implementation.
- Preferred alternative guidance: Many entries list preferred alternatives or therapeutic substitutes; authorization decisions may consider whether a preferred agent or prior therapy has been tried (e.g., ophthalmic injectables often list Avastin/Byooviz as preferred alternatives).
- Preferred alternatives noted: Specific preferred alternatives are shown beside many drugs (examples: Prolia for certain osteoporosis agents; Avastin and Byooviz for multiple ophthalmic injectables; Immune Checkpoint Inhibitors listed by indication may identify preferred vs non-preferred products).
- Preferred alternatives / prior therapy notes: Some products require documentation of prior therapy or step requirements before approval (example: Parsabiv requires at least 2 phosphate binders and at least 2 vitamin D analogs and failure/contraindication/intolerance of cinacalcet).
Site-of-Care Designations
Preferred Alternatives and Step Requirements
| Drug / entry | Preferred alternative(s) / notes | Implication for step therapy |
|---|---|---|
| Actemra IV | Entyvio; Ilumya; Simponi Aria; Skyrizi; Stelara; Tremfya | Preferred alternatives listed — may be used to guide preferred-product authorization or step prior to Actemra IV |
| Acthar Gel / H.P. Acthar | Conventional therapies (e.g., corticosteroids, immunosuppressive agents) | Preferred alternative class noted — may indicate preference for conventional therapies before Acthar Gel authorization |
| Cosentyx IV | Entyvio; Ilumya; Simponi Aria; Skyrizi; Stelara; Tremfya | Preferred alternatives listed — may inform step or preferred-product selection |
| Bivigam | Gammagard liquid; Gammagard SD; Gammaplex; Octagam; Panzyga; Privigen | Multiple immunoglobulin alternatives listed — could be used to favor listed products before Bivigam |
| Drug / entry | Preferred alternative(s) | Implication for step therapy |
|---|---|---|
| Eylea / Eylea HD | Avastin and Byooviz | Avastin/Byooviz listed as preferred alternatives for ophthalmic injectables — may guide preferred-agent selection prior to authorization of Eylea |
| Byooviz | Avastin | Byooviz lists Avastin as preferred alternative for ocular indications — implies preference for Avastin for ophthalmic use |
| Bosaya / Bildyos / other osteoporosis agents | Prolia | Prolia identified as preferred alternative — may be considered before coverage of listed products |
| Inflectra / Infliximab group | Avsola; Inflectra; Renflexis | Preferred infliximab biosimilars listed — may guide use of biosimilars prior to non-preferred products |
| Drug / entry | Preferred alternative(s) | Implication for step therapy |
|---|---|---|
| Omlyclo | Fasenra; Nucala; Tezspire; Xolair | Multiple severe asthma biologics listed as preferred alternatives — may indicate preference to try listed agents before Omlyclo |
| Exdensur | Fasenra; Nucala; Tezspire; Xolair | Respiratory injectables list same preferred alternatives — suggests preferred-agent sequence for coverage consideration |
| Cinqair / related severe asthma entries (Combined Benefit Management) | Fasenra; Nucala; Tezspire; Xolair shown as preferred in CBM list | Formulary/CBM designations identify preferred agents which could be required prior to coverage of non-preferred products |
| Drug / entry (indication-specific) | Preferred product(s) by indication | Implication for step therapy / formulary preference |
|---|---|---|
| Advanced or Metastatic Merkel Cell Carcinoma | Keytruda IV; Zynyz | Preferred products specified by indication; non-preferred agents (e.g., Bavencio) may necessitate attempting preferred agents or additional authorization |
| Biliary Tract Cancer | Imfinzi | Indication-specific preferred agent listed — suggests preference for Imfinzi over non-preferred products |
| Hepatocellular Carcinoma (subsequent therapy) | Keytruda IV | Preferred product noted; non-preferred agents (Opdivo/Opdivo Qvantig) are identified and may require step through preferred agents |
| Non-Small Cell Lung Cancer (metastatic) | Keytruda IV; Libtayo; Tecentriq; Tecentriq Hybreza | Multiple preferred options given by indication; non-preferred products listed which may trigger preferred-agent sequencing or additional authorization |
Biosimilar Preferences and Notes
Field Definitions and Program Terms
Program Background
This document is an administrative program summary that lists medications covered under Aetna's commercial medical benefit and captures key administrative attributes for each product (for example: therapeutic class, HCPCS/CPT code, whether Precertification is required [Precert = Y/N], listed preferred alternatives, Site of Care designation [Y/N], and GCIT® network inclusion). It is not a detailed clinical policy; providers requiring clinical criteria, exclusion rules, or NMN determinations should consult the Provider Precertification List and the relevant Clinical Policy Bulletins identified in the summary.
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