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CurrentAetnaPolicy N/A

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.

Policy Summary

PayerAetna

PolicyAetna Commercial Clinical Program Summary — medical benefit drug list

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization when a listed drug shows 'Precert Required = Y' and reference the specific HCPCS code on the request.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20+sample drug entries shown

HCPCScodes used

Y/Nprecert flag present

Y/Nsite-of-care noted

CBMCombined Benefit Management

Coverage Criteria and Administrative Controls

General coverage stance

Coverage is governed by listed administrative attributes and underlying clinical drug policies

Program summary logic: Drugs listed are covered under the Aetna commercial medical benefit and are subject to Aetna's clinical drug policies; providers must refer to the Provider Precertification List, Site of Care Policy, and Clinical Policy Bulletins for detailed medical necessity criteria.

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.

Per-drug attributes: Each listed drug entry includes: Therapeutic Class; HCPCS/CPT Code(s); Precert Required (Y/N); Preferred Alternative(s); Site of Care (Y/N); GCIT® Network flag (Y/N).

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

Combined Benefit Management applicability: Combined Benefit Management indicates certain drugs may be assigned to the pharmacy or medical benefit and may be designated Preferred, Non-Preferred, Pharmacy-only, Medical-only, or Excluded for members enrolled in Aetna commercial fully insured plans (subject to state law).

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

Indication-specific preference: For each listed cancer indication the Immune Checkpoint Inhibitors Drug List specifies Preferred Product(s) and Non-Preferred Product(s) (examples: Merkel Cell Carcinoma — Preferred: Keytruda IV, Zynyz; Non-Preferred: Bavencio).

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

Covered HCPCS CodesHCPCSCovered

J1602

Simponi Aria

Prior Authorization, Documentation, and Preferred Alternatives

Prior Authorization

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.

Site-of-Care Designations

Note

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

Note

Field Definitions and Program Terms

Precertification (definition)Administrative requirement indicated as 'Precert Required = Y' for certain medications; providers should refer to the Provider Precertification List for specifics

Action when requiredObtain prior authorization referencing the drug and HCPCS code when Precert Required = Y

Reference sourcesSee Provider Precertification List and Clinical Policy Bulletins for detailed requirements

Site of Care (definition)Designation (Y/N) indicating whether a specific site-of-care applies to the drug (e.g., infusion center vs office)

Implication'Site of Care = Y' may restrict where infusion/administration is authorized

Provider actionFollow site-of-care designation when arranging services

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.

Policy Summary

PayerAetna

PolicyAetna Commercial Clinical Program Summary — medical benefit drug list

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization when a listed drug shows 'Precert Required = Y' and reference the specific HCPCS code on the request.

SourceLink

On This Page

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).

GCIT® Network (definition)Indicates membership in the Gene Based, Cellular and Other Innovative Therapy (GCIT®) network when noted

ExampleSome gene and cellular therapies are flagged GCIT® Network = Y in entries (see Casgevy, Itvisma)

RelevanceMay affect network routing or specialized program requirements

Precert Required (flag)Indicates whether prior authorization / precertification is required for the listed drug (Precert Required = Y or N)

Provider requirementProviders must obtain precertification when flagged Y to avoid denial or delay

Applies toHCPCS-coded infused/injected specialty drugs listed in this summary

Precert Required (HCPCS-coded drugs)Indicates whether prior authorization (precert) is required (Y) or not (N) for the listed HCPCS-coded drug

ExampleImfinzi (J9173) — Precert Required = Y

ConsequenceClaims may be denied if precertification not obtained when required

Precert Required = Y (indicator)Indicates that Aetna requires prior authorization/precertification for the drug

Provider actionSubmit prior authorization requests referencing the specific HCPCS/J code shown for each product

ScopeMany listed products in this excerpt show Precert Required = Y

Site of Care = Y (indicator)Indicates a specified site-of-care designation is applicable for the drug (e.g., infusion center, home infusion)

ActionFollow the recorded site-of-care designation when arranging administration

ExampleOmisirge (J3490) — Site of Care = Y

Combined Benefit Management Drug List (program)A program where some drugs may be available under either the member's prescription or medical benefit; applies to certain fully insured commercial plans (subject to state law)

ImplicationDrugs on this list may have different benefit assignments (pharmacy vs medical) and non-preferred or excluded status by state

State-specific noteCertain drugs are non-preferred on the medical benefit in specified states (see list)

Immune Checkpoint Inhibitors Drug List (definition)A list of immune checkpoint inhibitor drugs arranged by cancer indication with preferred and non-preferred products

PurposePreferred product may vary by specific cancer indication; providers should consult the list when selecting agents

ImplicationPreferred and non-preferred designations imply formulary preference and may affect prior authorization or step expectations