Aetna medical benefit injectable drugs Coverage

Coverage Criteria Summary

inv-01: General Coverage

Covered when ALL of the following are met:

General coverage conditions: Medications listed are covered under Aetna's commercial medical benefit but are subject to Aetna's clinical drug policies, precertification requirements, and potential additional constraints such as quantity limits, precision dosing, or sourcing restrictions.

Providers should consult the Provider Precertification List, Site of Care Policy, and Clinical Policy Bulletins for detailed clinical criteria and authorization procedures.

inv-02: Program applicability

Applies when ALL of the following conditions are true:

Applicability: Applies to members enrolled in Aetna commercial fully insured medical and pharmacy benefit plans (subject to applicable state laws).

This Combined Benefit Management Drug List excludes members enrolled in Aetna Health Exchange, Federal, Medicare, and Medicaid plans; see state-specific non-preferred designations for AK, AR, GA, LA, MN, MS, ND, OK, RI, TN, TX, VT.

Benefit channel effects: Under the Combined Benefit Management program, some drugs may be available only on the member's prescription (pharmacy) or medical benefit and may have Preferred / Non-Preferred / Excluded designations that affect coverage and member cost share.

Providers must bill to the correct benefit channel and follow prior authorization requirements as applicable.

inv-03: Immune Checkpoint Inhibitors Drug List

For each cancer indication, coverage preference is determined as follows:

Indication-specific preference mapping: For each listed cancer indication (e.g., Merkel cell carcinoma, biliary tract cancer, endometrial carcinoma, hepatocellular carcinoma subsequent therapy, melanoma, nasopharyngeal carcinoma, NSCLC adjuvant/metastatic, renal cell carcinoma, small cell lung cancer extensive stage, etc.), the document lists Preferred and Non-Preferred immune checkpoint inhibitor products by indication.

Preferred and Non-Preferred products vary by specific indication; providers should reference the indication-specific mapping when requesting authorization.

Examples from the list include: for Advanced/Metastatic Merkel Cell Carcinoma — Preferred: Keytruda, Zynyz; Non-Preferred: Bavencio. For Biliary Tract Cancer — Preferred: Imfinzi; Non-Preferred: Keytruda. For Endometrial Carcinoma — Preferred: Imfinzi, Keytruda; Non-Preferred: Jemperli. For Melanoma — Preferred: Keytruda, Opdivo, Tecentriq, Tecentriq Hybreza; Non-Preferred: Opdivo Qvantig, Opdualag. For NSCLC (various settings) and other indications, preferred/non-preferred assignments are listed per indication.

This is a partial extract; consult the full Immune Checkpoint Inhibitors Drug List for the complete indication-to-product mapping.

The extract does not list formal exclusion criteria within the main coverage summary; instead, it states that all listed medications are subject to Aetna's clinical drug policies and that providers should refer to the Provider Precertification List, Site of Care Policy, or Clinical Policy Bulletins for specific documentation and authorization requirements. Additional constraints such as quantity limits, precision dosing, or sourcing restrictions may apply and are governed by those referenced clinical policies.

Within this partial extract there are no explicit clinical exclusion conditions described for individual members or diagnoses; the document shows drug-specific entries and administrative fields (HCPCS, Precert required, Preferred Alternative, Site of Care) but does not provide a standalone exclusions list in the excerpt.

Some entries include indication-specific notes. For example, Mvasi (Q5107) is listed with a preferred-alternative flag and the specific parenthetical note (not indicated for ocular conditions), indicating that coverage or use is restricted by clinical indication.

The Combined Benefit Management Drug List applies only to members enrolled in Aetna commercial fully insured medical and pharmacy benefit plans (subject to applicable state laws) and explicitly excludes members enrolled in Aetna Health Exchange, Federal, Medicare and Medicaid plans. The program may designate drugs as pharmacy-only, medical-only, preferred, non-preferred, or excluded within those plan populations.

Several products are explicitly designated as Excluded on the Combined Benefit Management drug list. Examples shown in the extract include BRIUMVI (J2329), LEMTRADA (J0202), FULPHILA (Q5108), NEULASTA Injectable / NEULASTA ONPRO (J2506), FYLNETRA (Q5130), ROLVEDON (J1449), STIMUFEND (Q5127), UDENYCA (Q5111), ZIEXTENZO (Q5120), and osteoporosis agents such as EVENITY (J3111) and TERIPARATIDE (J3110) when marked as excluded in the listing.

Not specified in this partial extract — refer to the full Provider Precertification List, Site of Care Policy, and Clinical Policy Bulletins for any additional items that would otherwise be listed here.

Coding and HCPCS/J-code Listings

Sample HCPCS codes from extractHCPCS

Q2055	Abecma
J3262	Actemra IV
J0801	Acthar Gel / H. P. Acthar
J0802	Acthar Gel / H. P. Acthar
J0791	Adakveo
J9042	Adcetris

Additional HCPCS codesHCPCS

J3380	Entyvio
J0178	Eylea
J0177	Eylea HD

Sample listed HCPCS codesHCPCS

J3111

Evenity

Additional HCPCS codesHCPCS

J1305	Evkeeza
J8499	Evrysdi
J1428	Exondys 51
J0180	Fabrazyme

Immunoglobulins and othersHCPCS

J1569	Gammagard / Gammaplex (as listed)
J1557	Gammaplex
J0223	Givlaari

Segmented HCPCS codes (sample from chunk 36)HCPCS

Q5107	Mvasi
J3490	Myalept (listed under J3490)
J3590	Myalept (listed under J3590)
J0587	Myobloc
J1458	Naglazyme
J2506	Neulasta ++
J1442	Neupogen

HCPCS codes (chunk 37)HCPCS

J0219	Nexviazyme
Q5110	Nivestym
J0725	Novarel
J7182	NovoEight
J7189	NovoSeven RT
J2182	Nucala

HCPCS codes (chunks 38-55)HCPCS

Q5114	Ogivri
J3590	Omisirge (also appears under multiple codes)
C9399	Omisirge (alternate billing)
J2267	Omvoh
J0222	Onpattro
Q5112	Ontruzant
J9299	Opdivo IV
J9289	Opdivo Qvantig
J9298	Opdualag
Q5153	Opuviz

1–10 of 41

1/5

Listed HCPCS / J / Q / C / A codes in this partial documentmixed

J2781	Syfovre
S9562	Synagis
90378	Synagis
J7331	Synojoynt
J7325	Synvisc / Synvisc-One
J0593	Takhzyro
J3055	Talvey
Q2053	Tecartus
J3490	Tecelra / multiple entries (miscellaneous J3490)
J3590	Tecelra / misc J3590 entries

1–10 of 85

1/9

Combined Benefit Management mapping codes (examples)mixed

J1745	Infliximab / Remicade
Q5121	Avsola
Q5103	Inflectra
Q5104	Renflexis
J2786	Cinqair
J9228	Dupixent
J0517	Fasenra
J2182	Nucala
J2356	Tezspire
J2357	Xolair

1–10 of 15

1/2

Multiple Sclerosis Non-Orals J-codesCPT

J2329	BRIUMVI
J9302	KESIMPTA
J0202	LEMTRADA
J2350	OCREVUS
J2351	OCREVUS ZUNOVO
J2323	TYSABRI

Autoimmune Infused Other J-codesCPT

J1602

SIMPONI ARIA

Hematologic / Colony Stimulating Factors Long Acting J/Q-codesCPT

Q5108	FULPHILA
Q5130	FYLNETRA
J2506	NEULASTA Injectable / NEULASTA ONPRO
Q5122	NYVEPRIA
J1449	ROLVEDON
Q5127	STIMUFEND
Q5111	UDENYCA
Q5120	ZIEXTENZO

Osteoporosis Injectable J-codesCPT

J3111	EVENITY
J3110	FORTEO / TERIPARATIDE
J0897	PROLIA
J3590	TYMLOS

Parsabiv prior therapy requirement

Prior therapy requiredTrial of at least 2 phosphate binders and at least 2 vitamin D analogs

Cinacalcet requirementFailure, contraindication, or intolerance to cinacalcet required

HCPCS codeJ0606

PrecertificationPrecert required = Y

Provider Actions, Precertification & Billing

Prior Authorization

Prior Authorization & Precertification Requirements

Providers must obtain prior authorization (precertification) for HCPCS- and J-/Q-coded drugs listed on Aetna's Provider Precertification List. Many medications in the medical benefit listing are marked "Precert required = Y" — a prior authorization is required before administration and may be denied or subject to additional review if not obtained.

Use the exact HCPCS/J-code shown in the drug listing when submitting a precertification or billing request (example: J1439 for Injectafer).
For drugs with "Precert required = Y", submit a precertification request that references the listed HCPCS/J-code and includes all required clinical documentation.
Prior authorization requirements are tied to the drug J-/Q-code and to benefit assignment (medical vs pharmacy) under the Combined Benefit Management program — ensure authorization is requested for the correct benefit channel.
Excluded drugs listed in the Combined Benefit Management Drug List may be denied if submitted on the non-covered channel or without appropriate coverage (e.g., entries marked "Excluded" or "Pharmacy coverage only").
Each precertification request should include the therapeutic class, HCPCS/J-code, indication, relevant prior therapies or step-therapy history (when applicable), and justification for the site of care when required.
Formulary preference and Combined Benefit Management status (Preferred, Non-Preferred, Excluded, Pharmacy coverage only, Medical coverage only) may affect member cost-sharing and whether the drug is available on the medical or pharmacy benefit; check the Drug List before prescribing.

Step Therapy and Preferred Alternative Guidance

Drug	Preferred alternative / step expectation
Actemra IV (J3262)
Entyvio; Ilumya; Simponi Aria; Skyrizi; Stelara; Tremfya — listed as preferred alternatives (implying these are payer-preferred options before Actemra IV)
Evenity (J3111)
Prolia — listed as the preferred alternative to Evenity (reflects a step/preferred-agent expectation)
Feraheme (Q0138 / Q0139)
Ferrlecit; Infed; Venofer — listed as preferred alternatives (expected alternatives prior to Feraheme)
Injectafer (J1439)
Ferrlecit; Infed; Venofer — listed as preferred alternatives for Injectafer
Parsabiv (J0606)
Prior use of at least 2 phosphate binders and at least 2 vitamin D analogs and failure/contraindication/intolerance of cinacalcet required (preferred-alternative text indicates required prior trials)
Otulfi (Q9999)
Entyvio; Ilumya; Simponi Aria; Skyrizi; Stelara; Tremfya — listed as preferred alternatives
Izervay (J2782)
Syfovre — listed as the preferred alternative

Example listed agent	Preferred alternative (exact wording from source)
Actemra IV (J3262)
Preferred Alternative = Entyvio, Ilumya, Simponi Aria, Skyrizi, Stelara, Tremfya
Conexxence (J3590)
Preferred Alternative = Prolia
Evenity (J3111)
Preferred Alternative = Prolia
Feraheme (Q0138 / Q0139)
Preferred Alternative = Ferrlecit, Infed, Venofer
Injectafer (J1439)
Preferred Alternative = Ferrlecit, Infed, Venofer
Izervay (J2782)
Preferred Alternative = Syfovre

Drug	Prior use / failure requirements
Parsabiv (J0606)
Preferred Alternative = At least 2 phosphate binders and at least 2 vitamin D analogs and failure / contraindication / intolerance of cinacalcet

Program / list	Benefit-channel designation (examples) and implication
Combined Benefit Management Drug List — Severe Asthma (examples)
Dupixent (J9228) = Preferred (Pharmacy & Medical: Preferred); Tezspire (J2356) = Preferred (Pharmacy coverage only) — benefit-channel designation indicates whether product is pharmacy-only or available on medical benefit and may influence coverage path or step edits between benefits
Combined Benefit Management Drug List — Multiple Sclerosis Non-Orals (examples)
Kesimpta (J9302) = Preferred (Pharmacy coverage only); Briumvi (J2329) = Excluded / Non-Preferred — pharmacy vs medical assignment and preferred status may require billing to the designated benefit and can affect prior authorization and step enforcement
Hematologic / Colony Stimulating Factors Long Acting (examples)
Neulasta ONPRO (J2506) = Excluded (medical) / Preferred (pharmacy) or other mixed statuses shown — designation by benefit channel can change which product is preferred and which prior authorization rules apply

Formulary status	Example entries and implication for step or preference
Preferred
Examples: Dupixent = Preferred (Combined Benefit Management listing for severe asthma) — Preferred status implies payer preference and may be required prior to coverage of non-preferred agents
Non-Preferred
Examples: BRIUMVI = Non-Preferred (and Excluded in some benefit channels) — Non-Preferred designation may require trial of preferred agents or result in different coverage rules
Excluded
Examples: EVENITY and TERIPARATIDE shown as Excluded in some listings — Excluded status indicates the product is not covered on that benefit list and may be denied if billed to the plan

Site-of-Care Flags and Billing Location

Documentation Required

Follow Site of Care Policy when Site of Care = Y

When a drug’s Site of Care flag = Y, follow Aetna’s Site of Care Policy and any site-specific requirements (e.g., infusion center, hospital outpatient) when scheduling, authorizing, and billing the service.

Check the drug line Site of Care value before scheduling treatment.
Obtain any site-specific precertification or approvals required by the Site of Care Policy.

Note

Confirm administration site per the Site of Care field

Site of Care values in the listing include inpatient/infusion center, home, or unspecified; confirm the required setting for administration per the drug entry and Site of Care Policy.

Examples: Evkeeza Site of Care = Y (facility/home flagged); many ophthalmic agents list site designations.
Confirm whether home infusion or facility administration is appropriate and authorized.

Biosimilar Preferences and Alternatives

Billing Rule

Use listed preferred biosimilars (e.g., Alymsys, Mvasi) when appropriate

Alymsys and Mvasi are noted as preferred alternatives for oncology indications in the listing; use listed preferred biosimilars when applicable per formulary preference.

Avastin (oncology) Preferred alternatives include Alymsys and Mvasi.
Confirm biosimilar preference during authorization to align with formulary.

Billing Rule

Select payer-preferred infliximab products or document justification

For infliximab products the listing identifies preferred alternatives including Avsola, Inflectra, and Renflexis; select the payer-preferred infliximab product or document clinical justification for alternatives.

Infliximab preferred alternatives = Avsola, Inflectra, Renflexis.

Background and Scope

Background: This document is a commercial clinical program summary listing specialty and medical-benefit injectable drugs. It presents each agent with therapeutic class, HCPCS/J/Q/C coding where applicable, whether Precertification is required, any listed preferred alternatives, and site-of-care flags to guide provider authorization and billing.

Key Definitions

Precert required

Precertification required?Y

MeaningIndicates prior authorization (precertification) is required for the listed medication under Aetna's medical benefit

Provider actionObtain prior authorization per Aetna's clinical drug policies and Provider Precertification List before administration when 'Precert required = Y'

Site of Care

Site-of-care applies?Y/N (specified per drug entry)

MeaningIndicates whether site-of-care designation or constraints apply (Site of Care = Y means follow Site of Care Policy)

Common settings

Policy Revision History

January 2026last_reviewLatest

Policy last reviewed (document metadata indicates last review in January 2026).

OpenPayer

Aetna Commercial Clinical Program Summary — medical benefit injectable and specialty drugs list