Changes to commercial medical plan drug list starting on April 1, 2025 Form

Changes coming to our commercial medical plan drug lists Starting April 1, 2025, we’re making changes to our medical plan drug lists. These changes support our commitment to high quality, cost-effective health care. Please note these changes do not apply to our Medicare and Medicaid plans. It’s likely some of your patients are taking these drugs. We’ve notified your impacted patients of these changes and suggested they talk to you about changing to a preferred alternative drug if appropriate. UPPER CASE = brand-name
drug lower case = generic drug Prescription drug name Change MARGENZA J9353 Moving to non-Preferred
ENHERTU J9358 Moving to Preferred
KADCYLA J9354 Moving to Preferred
PERJETA
J9306 Moving to Preferred
PHESGO
J9316 Moving to Preferred
MONOFERRIC J1437 Moving to non-Preferred
ALYGLO J1599 Moving to non-Preferred
ASCENIV J1554 Moving to non-Preferred
BIVIGAM J1556 Moving to non-Preferred
GAMMAKED J1556 Moving to non-Preferred
GAMUNEX-C J1556 Moving to non-Preferred
PANZYGA J1576 Moving to non-Preferred
GAMMAGARD LIQUID J1569 Moving to Preferred
GAMMAGARD SD J1569 Moving to Preferred
GAMMAPLEX J1557 Moving to Preferred
OCTAGAM J1568 Moving to Preferred
PRIVIGEN
J1459 Moving to Preferred
Medical exceptions You can request a medical exception for drugs that need precertification.
If we approve the exception, your patient will pay their plan copay or cost share after they meet their
deductible or out-of-pocket requirements.
For specialty drugs covered under the medical benefit that are on the Aetna National Precert List you
can:
• Call 1-866-752-7021 • Go to Aetna.com and access the forms library to complete the specific medication Specialty Pharmacy Precertification Prior Authorization Request Form. Then fax your completed form to the number listed on the form. 3805701-01-02 (4/25)

Your plan may not cover certain drugs to treat conditions such as infertility, erectile dysfunction and weight loss. 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 Assurance Pennsylvania Inc., Aetna Health Insurance company 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 06156. Pharmacy benefits are administered by an affiliated pharmacy benefit manager, CVS Caremark. Aetna® is part of the CVS Health® family of companies. Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. To check coverage and copay information for a specific medicine, log into your member website. For questions, please call the toll-free number on the back of your member ID card. Information is subject to change. In accordance with state law or insurer policies, changes to drug coverage are not effective for commercial fully insured plans (including HMOs) in Louisiana, New York, Texas, and in most circumstances Connecticut and Vermont, until the plans’ renewal date. This document contains trademarks or registered trademarks of CVS Pharmacy, Inc. or one of its affiliates; it may also contain references to products that are trademarks or registered trademarks of entities not affiliated with CVS Health. Policy forms issued in Oklahoma include: AL SG HGrpPol-1A 01, AL SG HCOC-2024-PPO 08, AL SG SOB PPO 14052798 08,
HI SG HGrpAg-1A 01, HI SG HCOC-2024 08, HI SG SOB HMO 14052797 08,
AL HGrpPol 07 AL HCOC 11, AL HSOB 09, AL HSOBNM 09, HI HGrpAg 06, HC HCOC 10, HC HSOB 09
Policy forms issued in Missouri include: AL HGrpPol 07, AL SG HGrpPol-1A 01, HI HGrpAg 05, HI GrpAgAmend-2022 01, HO HGrpPol 04, HO GrpPolAmend-2022 01, HI SG HGrpAg-1A 01. AL IVL HPOL-1A-2024-EPO-HIX 03, AL IVL SOB 1A EPO HIX 03, AL IVL HPOL-1A-2024-EPO 03, AL IVL SOB 1A EPO 03. Aetna complies with applicable Federal civil rights laws and does not discriminate, exclude or treat people differently based on their race, color, national origin, sex, age, or disability. Aetna provides free aids/services to people with disabilities and to people who need language assistance. If you need a qualified interpreter, written information in other formats, translation or other services, call the number on your ID card. If you believe we have failed to provide these services or otherwise discriminated based on a protected class noted above, you can also file a grievance with the Civil Rights Coordinator by contacting: Civil Rights Coordinator P.O. Box 14462, Lexington, KY 40512 (CA HMO customers: PO Box 24030 Fresno, CA 93779), 1-800-648-7817, TTY: 711,
Fax: 859-425-3379 (CA HMO customers: 860-262-7705), CRCoordinator@aetna.com.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights
Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or at: U.S. Department of Health and Human
Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, or at 1-800-368-1019, 800­ 537-7697 (TDD).
3805701-01-02 (4/25)

Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company, Coventry Health Care plans and their affiliates (Aetna). 3805701-01-02 (4/25)