Changes to our medical plan drug list starting on January 1, 2026 Form

3805701-01-04(1/26)

Changes coming to our medical plan drug lists

Starting January 1, 2026, we’re making changes to our medical plan drug lists. These changes support our commitment to high quality, cost-effective health care.

It’s likely some of your patients are taking these drugs. Patients with current prior authorizations (PA) will not be impacted until their existing PA expires. We will also notify your impacted patients of these changes and suggested they talk to you about changing to a preferred alternative drug, if appropriate, as their PAs expire.

UPPER CASE = brand-name

drug lower case = generic drug Drug Name Class Change(s) COSENTYX Autoimmune-Infused Other Adding to non-preferred
IMULDOSA Autoimmune-Infused Other Adding to non-preferred
OTULFI Autoimmune-Infused Other Adding to non-preferred
PYZCHIVA Autoimmune-Infused Other Adding to non-preferred
SELSARDI Autoimmune-Infused Other Adding to non-preferred
STEQEYMA Autoimmune-Infused Other Adding to non-preferred
USTEKINUMAB Autoimmune-Infused Other Adding to non-preferred
USTEKINUMAB-TTWE Autoimmune-Infused Other Adding to non-preferred
WEZLANA Autoimmune-Infused Other Adding to non-preferred
YESINTEK Autoimmune-Infused Other Adding to non-preferred
JOBEVNE Avastin/Biosimilars (Oncology) Adding to non-preferred
OSENVELT Bone Density Regulators-Oncology Adding to preferred WYOST Bone Density Regulators-Oncology Adding to non-preferred
XGEVA Bone Density Regulators-Oncology Adding to non-preferred
DYSPORT Botulinum Toxins Moving from non-preferred to preferred PERJETA Breast Cancer Mab Moving from preferred to non-preferred BAVENCIO Checkpoint Inhibitor- Advanced or Metastatic Merkel Cell Carcinoma Adding to non-preferred
KEYTRUDA Checkpoint Inhibitor- Advanced or Metastatic Merkel Cell Carcinoma Adding to preferred ZYNYZ Checkpoint Inhibitor- Advanced or Metastatic Merkel Cell Carcinoma Adding to preferred IMFINZI Checkpoint Inhibitor- Biliary Tract Cancer Adding to preferred KEYTRUDA Checkpoint Inhibitor- Biliary Tract Cancer Adding to non-preferred
IMFINZI Checkpoint Inhibitor- Endometrial Carcinoma Adding to preferred JEMPERLI Checkpoint Inhibitor- Endometrial Carcinoma Adding to non-preferred

3805701-01-04(1/26) KEYTRUDA Checkpoint Inhibitor- Endometrial Carcinoma Adding to preferred KEYTRUDA Checkpoint Inhibitor- Hepatocellular Carcinoma Subsequent Therapy Adding to preferred OPDIVO Checkpoint Inhibitor- Hepatocellular Carcinoma Subsequent Therapy Adding to non-preferred
OPDIVO QVANTIG Checkpoint Inhibitor- Hepatocellular Carcinoma Subsequent Therapy Adding to non-preferred
KEYTRUDA Checkpoint Inhibitor- Melanoma Adding to preferred OPDIVO Checkpoint Inhibitor- Melanoma Adding to preferred OPDIVO QVANTIG Checkpoint Inhibitor- Melanoma Adding to non-preferred
OPDUALAG Checkpoint Inhibitor- Melanoma Adding to non-preferred
TECENTRIQ Checkpoint Inhibitor- Melanoma Adding to preferred TECENTRIQ HYBREZA Checkpoint Inhibitor- Melanoma Adding to preferred LOQTORZI Checkpoint Inhibitor- Nasopharyngeal Carcinoma Adding to preferred IMFINZI Checkpoint Inhibitor- Non-Small Cell Lung Cancer- Adjuvant Adding to preferred KEYTRUDA Checkpoint Inhibitor- Non-Small Cell Lung Cancer- Adjuvant Adding to preferred OPDIVO Checkpoint Inhibitor- Non-Small Cell Lung Cancer- Adjuvant Adding to non-preferred
OPDIVO QVANTIG Checkpoint Inhibitor- Non-Small Cell Lung Cancer- Adjuvant Adding to non-preferred
TECENTRIQ Checkpoint Inhibitor- Non-Small Cell Lung Cancer- Adjuvant Adding to preferred TECENTRIQ HYBREZA Checkpoint Inhibitor- Non-Small Cell Lung Cancer- Adjuvant Adding to preferred IMFINZI Checkpoint Inhibitor- Non-Small Cell Lung Cancer- Metastatic Adding to non-preferred
IMJUDO Checkpoint Inhibitor- Non-Small Cell Lung Cancer- Metastatic Adding to non-preferred
KEYTRUDA Checkpoint Inhibitor- Non-Small Cell Lung Cancer- Metastatic Adding to preferred LIBTAYO Checkpoint Inhibitor- Non-Small Cell Lung Cancer- Metastatic Adding to preferred OPDIVO Checkpoint Inhibitor- Non-Small Cell Lung Cancer- Metastatic Adding to non-preferred
OPDIVO QVANTIG Checkpoint Inhibitor- Non-Small Cell Lung Cancer- Metastatic Adding to non-preferred
TECENTRIQ Checkpoint Inhibitor- Non-Small Cell Lung Cancer- Metastatic Adding to preferred TECENTRIQ HYBREZA Checkpoint Inhibitor- Non-Small Cell Lung Cancer- Metastatic Adding to preferred YERVOY Checkpoint Inhibitor- Non-Small Cell Lung Cancer- Metastatic Adding to non-preferred
BAVENCIO Checkpoint Inhibitor- Renal Cell Carcinoma Adding to non-preferred

3805701-01-04(1/26) KEYTRUDA Checkpoint Inhibitor- Renal Cell Carcinoma Adding to preferred OPDIVO Checkpoint Inhibitor- Renal Cell Carcinoma Adding to preferred OPDIVO QVANTIG Checkpoint Inhibitor- Renal Cell Carcinoma Adding to preferred IMFINZI Checkpoint Inhibitor- Small-Cell Lung Cancer-Extensive Stage Adding to preferred TECENTRIQ Checkpoint Inhibitor- Small-Cell Lung Cancer-Extensive Stage Adding to non-preferred
TECENTRIQ HYBREZA Checkpoint Inhibitor- Small-Cell Lung Cancer-Extensive Stage Adding to non-preferred
FOLLISTIM AQ Fertility Regulators-FSH Moving from non-preferred to preferred GONAL-F Fertility Regulators-FSH Moving from preferred to non-preferred UDENYCA Hematologic, Neutropinia Colony Stimulating Facors-Long Acting Moving from non-preferred to preferred PANZYGA Immune Globulin-IV Moving from non-preferred to preferred XEMBIFY Immune Globulin-SC Moving from non-preferred to preferred BRIUMVI Multiple Sclerosis (Infused) Moving from non-preferred to preferred BKEMV Myasthenia Gravis Adding to non-preferred
EPYSQLI Myasthenia Gravis Adding to preferred IMAAVY Myasthenia Gravis Adding to non-preferred
SOLIRIS Myasthenia Gravis Moving from preferred to non-preferred ULTOMIRIS Myasthenia Gravis Moving from preferred to non-preferred BKEMV Paroxysmal Nocturnal Hemoglobinuria (PNH) Adding to non-preferred
EPYSQLI Paroxysmal Nocturnal Hemoglobinuria (PNH) Adding to preferred PIASKY Paroxysmal Nocturnal Hemoglobinuria (PNH) Adding to non-preferred
SOLIRIS Paroxysmal Nocturnal Hemoglobinuria (PNH) Moving from preferred to non-preferred ULTOMIRIS Paroxysmal Nocturnal Hemoglobinuria (PNH) Moving from preferred to non-preferred CIMERLI Retinal Disorders Agents (ARMD) Age- Related Macular Degeneration Moving from preferred to non-preferred EYLEA HD Retinal Disorders Agents (ARMD) Age- Related Macular Degeneration Adding to non-preferred
SUSVIMO Retinal Disorders Agents (ARMD) Age- Related Macular Degeneration Adding to non-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.

3805701-01-04(1/26) 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.

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.

3805701-01-04(1/26) 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).

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).