Understanding
prior authorization
Learn what it is and when you need it
Check out the table of contents on the next page
for a closer look at what you’ll nd in this guide.
Aetna is the brand name used for products and services provided by one or more of the Aetna group of
companies, including Aetna Life Insurance Company and its aliates (Aetna). Aetna provides certain
management services on behalf of its aliates. Banner|Aetna, Allina Health|Aetna, Texas Health Aetna
and Sutter Health | Aetna are aliates of Aetna Life Insurance Company and its aliates (Aetna). Aetna
provides certain management services to these entities.
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Table of contents
Services Basics Medicines
Click on the tabs above to go directly to each section.
You can also use Ctrl + F on Windows® (Command + F on Mac®) to search
the document for keywords.
The basics of prior authorization 3
Check out this section to learn what it is and why it’s important.
The services that need prior authorization 6
Check out this section to nd out which services need prior authorization.
The medicines that need prior authorization 8
Check out this section to nd out which prescription drugs need prior authorization.
This information applies to:
• Aetna® plans
• Aetna Medicare plans
• Allina Health|Aetna plans
• Banner | Aetna plans
• Innovation Health® plans
• Sutter Health | Aetna plans
• Texas Health Aetna plans
This information doesn’t apply to you if you’re in a Traditional Choice® plan, an indemnity plan, a Foreign
Se
rvice Benet Plan, a Mail Handlers Benet Plan or a Rural Carrier Benet Plan.
This document was last updated on November 1, 2022.
3
The basics of prior authorization
Services Medicines Basics
What is prior authorization?
We may need more details before we can approve
some care options and products. We call this
prior authorization. Sometimes we may call it
precertication or preapproval. These all mean the
same thing. It’s the process of conrming if your
plan will cover a certain service or prescription drug.
Why it’s needed
Some services or medicines cost more than others. And some have higher risks. Prior authorization
lets us check to see if a treatment or medicine is necessary. This helps:
Keep you safe
Keep your costs down
Keep our plans aordable
How it works
1.
If your doctor thinks you need a service or medicine that requires prior
authorization, they’ll let us know. They do this by sending us a request online, over
the phone, or via fax.
2.
Once we have all the details we need, we’ll review the request. (If we do not receive
all the details needed, this may delay when we can begin the review.)
4
The basics of prior authorization
Services Medicines Basics
How it works (continued)
3.
We’ll let you and your doctor know what we decide via letter. The review process
can take up to two weeks.
a. Medicare members: If the request is for prescription drugs or services not
yet received, Aetna must notify the member (and the prescribing physician or
other prescriber involved, as appropriate) of our decision no later than 24 hours
after receiving the physician’s or other prescriber’s supporting statement for
expedited cases. Or no later than 72 hours after receiving the physician’s or
other prescriber’s supporting statement for standard cases.
b. Medicare members: If the exception request involves reimbursement for
prescription drugs or services already received, Aetna must notify the member
(and the prescribing physician or other prescriber involved, as appropriate) of its
decision (and make payment when appropriate) no later than 14 calendar days
after receiving the request.
4.
If you don’t agree with our decision, you can appeal it. The letter sent regarding the
precertication decision will have the details on how to le an appeal request, along
with the address to submit. You may also call the number on your member ID card
and request an expedited appeal.
a. Important Note: You have 60 days from the date of the letter to
request an appeal.
Note: If you don’t get the prior authorization you need, we may not pay for your treatment. This could mean
you’ll have to pay the bill yourself.
5
The basics of prior authorization
Services Medicines Basics
When you need it
This guide includes lists of the services and medicines that need prior authorization. In some
plans, you might need prior authorization for the place where you get a service or medicine. We
call this the site of service or site of care. You may also need prior authorization for:
• Transplants
• Certain types of genetic testing
• Hip and knee replacements
• Radiology or imaging services
• Out-of-network care
• Fertility services
• Cardiac catheterizations and rhythm implants
• Pain management
• Sleep studies
• Physical therapy, occupational therapy and speech therapy
When you see an in-network doctor, they’ll help you get the prior
authorization you need. Check with your doctor to make sure you
have it before you get care.
If you need prior authorization for care out of our network, you’ll need to
get this approval yourself. You can check your plan documents to see if
this applies to you. You can also ask your doctor for help.
If you have a prescription drug plan from another insurer, it may have
dierent guidelines than we have.
What else you may need
Does your plan make you choose a primary care physician (PCP)? If so, you may also need a
referral for specialist care. This doesn’t apply to all plans. You can check your plan documents
to see if this applies to you.
A referral is not the same as prior authorization. If you need a referral, you should get this from
your PCP before you get your prior authorization. You may need both for us to cover your care.
Questions?
We’re here to help. You can call us at the number on your member ID card.
You can also check your plan documents to learn more about what you
need for your plan.
6
The services that need prior authorization
Basics Medicines Services
Here is a list of the services that need prior authorization.
Remember: You can use Ctrl + F on Windows® (Command + F on Mac®) to search
for keywords.
Inpatient stays (except hospice)
For example, surgical and nonsurgical stays, stays
in a skilled nursing facility or rehabilitation facility,
and maternity and newborn stays that exceed the
standard length of stay (LOS)
Ambulance
Prior authorization needed for transportation by
xed-wing aircraft (plane)
Arthroscopic hip surgery to repair impingement
syndrome including labral repair*
Autologous chondrocyte implantation*
Chiari malformation decompression surgery*
Cochlear device and/or implantation*
Coverage at an in-network benet level for an
out-of-network provider or facility unless it’s an
emergency. Limited or no out-of-network benets
with some plans
Dental implants
Dialysis visits
When an in-network doctor requests care at an
out-of-network facility
Dorsal column (lumbar) neurostimulators: trial
or implantation
Electric or motorized wheelchairs and scooters
Endoscopic nasal balloon dilation procedures*
Functional endoscopic sinus surgery (FESS)*
Gender armation surgery
Hyperbaric oxygen therapy
Lower limb prosthetics, such as microprocessor-
controlled lower limb prosthetics
Services at an out-of-network freestanding
ambulatory surgical center, when referred by
an in-network doctor
Orthognathic surgery procedures, bone grafts,
osteotomies and surgical management of the
temporomandibular joint
Osseointegrated implant*
Osteochondral allograft/knee*
Private duty nursing
Proton beam radiotherapy
*Members in commercial plans need prior authorization for both this service and the place where they get
the service (site of service). A commercial plan is any plan that isn’t part of a government program, like
Medicare or Medicaid.
7
The services that need prior authorization
Basics Medicines Services
Reconstructive or other procedures that may
be considered cosmetic, such as:
• Blepharoplasty
• Breast reconstruction/breast enlargement*
• Breast reduction/mammoplasty*
• Excision of excessive skin due to weight loss*
• Gastroplasty/gastric bypass
• Lipectomy or excess fat removal*
• Surgery for varicose veins, except
stab phlebectomy*
Shoulder arthroplasty including
revision procedures*
Site of service
Prior authorization is needed for the site of a service
when all the following apply:
• The member has an Aetna® fully insured
commercial plan
• The member will get the service or services in an
outpatient hospital setting (NOT in an ambulatory
surgical facility or oce setting)
• The procedure is one of the following:
- Carpal tunnel surgery
- Complex wound repair
- Cystourethroscopy
- Hemorrhoidectomy
- Hernia repair
- Hysteroscopy
- Intranasal dermatoplasty
- Lithotripsy
- Prostate biopsy
- Septoplasty
- Skin tissue transfer or rearrangement
- Subcutaneous soft tissue excision
- Tonsillectomy, ages 12 and older
Note: Some services need prior authorization for
both the service and the site of service. These
services are marked with an asterisk (*) on this list.
Spinal procedures, such as:
•
Articial intervertebral disc surgery*
(cervical spine)
• Arthrodesis for spine deformity
•
Cervical laminoplasty*
•
Cervical, lumbar and thoracic laminectomy
and/or laminotomy procedures*
• Kyphectomy*
• Laminectomy with rhizotomy
• Sacroiliac joint fusion surgery
• Spinal fusion surgery
• Vertebral corpectomy
Uvulopalatopharyngoplasty, including
laser-assisted procedures*
Ventricular assist devices
Whole exome sequencing
*Members in commercial plans need prior authorization for both this service and the place where they get
the service (site of service). A commercial plan is any plan that isn’t part of a government program, like
Medicare or Medicaid.
8
The medicines that need prior authorization
Services Basics Medicines
Here are the prescription drugs that need prior authorization. We’ve divided
them into two lists. The rst one includes blood-clotting factors. The second
one includes all other medicines that need prior authorization.
These lists show drugs you usually wouldn’t give yourself. You may get them at a doctor’s
oce. Or you may get them at a hospital without an overnight stay. These are not the same
as the prescription drugs listed on your plan’s formulary, or drug list.
Remember: You can use Ctrl + F on Windows® (Command + F on Mac®) to search
for keywords.
Blood-clotting factors
Advate (antihemophilic factor, human
recombinant)
Adynovate (antihemophilic factor [recombinant],
PEGylated)
Afstyla (antihemophilic factor [recombinant],
single chain)
Alphanate (antihemophilic factor/von Willebrand
factor complex [human])
AlphaNine SD (coagulation factor IX [human])
Alprolix (coagulation factor IX [recombinant], Fc
fusion protein)
Bebulin (factor IX complex)
BeneFix (coagulation factor IX [recombinant])
Coagadex (coagulation factor X [human])
Corifact (factor XIII concentrate [human])
Eloctate (antihemophilic factor [recombinant], Fc
fusion protein)
Esperoct (antihemophilic factor [recombinant],
glycopegylated-exei)
FEIBA, FEIBA NF (anti-inhibitor coagulant complex)
Fibryga (brinogen, human)
Helixate FS (antihemophilic factor [recombinant])
Hemlibra (emicizumab-kxwh)
Hemol M (antihemophilic factor [human])
Humate-P (antihemophilic factor/von Willebrand
factor complex [human])
Idelvion (antihemophilic factor [recombinant])
Ixinity (coagulation factor IX [recombinant])
Jivi (antihemophilic factor [recombinant],
PEGylated-aucl)
9
The medicines that need prior authorization
Services Basics Medicines
Koate, Koate-DVI (antihemophilic factor [human])
Kogenate FS (antihemophilic factor [recombinant])
Kovaltry (antihemophilic factor [recombinant])
Monoclate-P (antihemophilic factor [human])
Mononine (coagulation factor IX [human])
NovoEight (antihemophilic factor [recombinant])
NovoSeven RT (coagulation factor VIIa
[recombinant])
Nuwiq (simoctocog alfa)
Obizur (antihemophilic factor [recombinant],
porcine sequence)
Prolnine (factor IX complex)
Rebinyn (coagulation factor IX [recombinant],
glycoPEGylated)
Recombinate (antihemophilic factor
[recombinant])
RiaSTAP (brinogen concentrate [human])
Rixubis (coagulation factor IX [recombinant])
Sevenfact (coagulation factor VIIa
[recombinant]-jncw)
Tretten (coagulation factor XIII
a-subunit [recombinant])
Vonvendi (von Willebrand factor [recombinant])
Wilate (von Willebrand factor/coagulation factor
VIII complex [human])
Xyntha, Xyntha Solofuse (antihemophilic factor
[recombinant])
10
The medicines that need prior authorization
Services Basics Medicines
Other prescription drugs
Abraxane (paclitaxel protein-bound particles) —
prior authorization needed for Medicare Advantage
members only
Acthar Gel/H. P. Acthar (corticotropin)
Adakveo (crizanlizumab-tmca) — prior
authorization needed for the drug and site of care
Adcetris (brentuximab vedotin)
Aduhelm (aducanumab-avwa) — prior
authorization needed for the drug and site of care
Alpha 1-proteinase inhibitor (human)
(Prior authorization needed for the drug and site
of care):
Aralast NP (alpha 1-proteinase inhibitor)
Glassia (alpha 1-proteinase inhibitor)
Prolastin-C (alpha 1-proteinase inhibitor)
Zemaira (alpha 1-proteinase inhibitor)
Alymsys (bevacizumab) — prior authorization
needed eective July 8, 2022, for oncology
indications only
Amyotrophic lateral sclerosis (ALS) drugs:
Radicava (edaravone) — prior authorization
needed for the drug and site of care
Autoimmune infused iniximab
Avs
ola (iniximab-axxq) — prior authorization
needed for the drug and site of care
Inectra (iniximab-dyyb) — prior authorization
needed for the drug and site of care
Remicade (iniximab) — prior authorization
needed for the drug and site of care
Renexis (iniximab-abda) — prior authorization
needed for the drug and site of care
Av
ast
in (bevacizumab), 10 mg — prior authorization
needed for oncology indications only
Aveed (testosterone undecanoate)
Belrapzo (bendamustine HCl)
Bendeka (bendamustine HCl)
Benlysta (belimumab) — prior authorization needed
for the drug and site of care
Besponsa (inotuzumab ozogamicin)
Blenrep (belantamab mafodotin-blmf)
Bortezomib — prior authorization needed for
multiple myeloma only
Botulinum toxins:
Botox (onabotulinumtoxinA)
Dysport (abobotulinumtoxinA)
Myobloc (rimabotulinumtoxinB)
Xeomin (incobotulinumtoxinA)
Cablivi (caplacizumab-yhdp)
Calcitonin gene-related peptide (CGRP)
receptor inhibitors
Vyepti (eptinezumab-jjmr) — prior authorization
needed for the drug and site of care
Cardiovascular — PCSK9 inhibitors:
Leqvio (inclisiran) — prior authorization needed
eective March 23, 2022
11
The medicines that need prior authorization
Services Basics Medicines
Chimeric antigen receptor T-cell (CAR-T) therapy
Abecma (idecabtagene vicleucel)
Breyanzi (lisocabtagene maraleucel)
Carvykti (ciltacabtagene autoleucel) — prior
authorization needed eective May 27, 2022
Kymriah (tisagenlecleucel)
Tecartus (brexucabtagene autoleucel)
Yescarta (axicabtagene ciloleucel)
Cortrophin Gel (repository corticotropin) — prior
authorization needed eective February 9, 2022
Cosela (trilaciclib)
Crysvita (burosumab-twza) — prior authorization
needed for the drug and site of care
Cyramza (ramucirumab)
Danyelza (naxitamab-gqgk)
Darzalex (daratumumab)
Darzalex Faspro (daratumumab
and hyaluronidase-hj)
Empliciti (elotuzumab)
Enjaymo (sutimlimab-jome) — prior authorization
for the drug and site of care needed eective
May 1, 2022
Enzyme replacement drugs:
Aldurazyme (laronidase) — prior authorization
needed for the drug and site of care
Brineura (cerliponase alfa)
Cerezyme (imiglucerase) — prior authorization
needed for the drug and site of care
Elaprase (idursulfase) — prior authorization
needed for the drug and site of care
Enzyme replacement drugs (continued):
Elelyso (taliglucerase alfa) — prior authorization
needed for the drug and site of care
Fabrazyme (agalsidase beta) — prior authorization
needed for the drug and site of care
Kanuma (sebelipase alfa) — prior authorization
needed for the drug and site of care
Lumizyme (alglucosidase alfa) — prior
authorization needed for the drug and site
of care
Mepsevii (vestronidase alfa-vjbk) — prior
authorization needed for the drug and site
of care
Naglazyme (galsulfase) — prior authorization
needed for the drug and site of care
Nexviazyme (avalglucosidase alfa-ngpt) — prior
authorization needed for the drug and site
of care
Strensiq (asfotase alfa)
Vimizim (elosulfase alfa) — prior authorization
needed for the drug and site of care
VPRIV (velaglucerase alfa) — prior authorization
needed for the drug and site of care
Erbitux (cetuximab)
Erythropoiesis-stimulating agents:
Aranesp (darbepoetin alfa)
Epogen (epoetin alfa)
Mircera (methoxy polyethylene
glycol-epoetin beta)
Procrit (epoetin alfa)
Retacrit (recombinant human erythropoietin-epbx)
Evkeeza (evinacumab-dgnb) — prior authorization
needed for the drug and site of care
Evrysdi (risdiplam)
Feraheme (ferumoxytol)
12
ServicesBasics Medicines
The medicines that need prior authorization
Fusilev (levoleucovorin)
Fyarro (sirolimus protein-bound particles for
injectable suspension) — prior authorization needed
eective March 15, 2022
Gattex (teduglutide)
Givlaari (givosiran) — prior authorization needed for
the drug and site of care
Granulocyte-colony stimulating factors:
Fulphila (peglgrastim-jmdb)
Fylnetra (peglgrastim-pbbk) - prior authorization
needed eective October 25, 2022
Granix (injection tbo-lgrastim)
Leukine (injection sargramostim, GM-CSF)
Neulasta (injection peglgrastim)
Neupogen (injection lgrastim, G-CSF)
Nivestym (lgrastim-aa)
Nyvepria (peglgrastim-apgf)
Releuko (lgrastim-ayow) — prior authorization
needed eective May 25, 2022
Udenyca (peglgrastim)
Zarxio (injection lgrastim, G-CSF, biosimilar)
Ziextenzo (peglgrastim-bmez)
G
rowth hormone:
Skytrofa (lonapegsomatropin-tcgd) — prior
a
uthorization needed for Medicare Advantage
members only
Sogroya (somapacitan-beco) — prior authorization
needed for Medicare Advantage members only
Hereditary angioedema agents:
Berinert (C1 esterase inhibitor)
C
inryze (C1 esterase inhibitor) — prior
a
uthorization needed for the drug and site
of care
Hereditary angioedema agents (continued):
Firazyr (icatibant acetate)
Haegarda (C1 esterase inhibitor subcutaneous
[human])
Kalbitor (ecallantide)
Ruconest (C1 esterase inhibitor)
Sajazir (icatibant acetate)
Takhzyro (lanadelumab-yo)
H
ereditary Transthyretin-mediated Amyloidosis
(ATTR) Drugs
Amvuttra (vutrisiran) — prior authorization needed
e
ective September 22, 2022
Onpattro (patisiran) — prior authorization needed
for the drug and site of care
Tegsedi (inotersen)
HER2 receptor drugs:
Enhertu (fam-trastuzumab deruxtecan-nxki)
Herceptin (trastuzumab)
Herceptin Hylecta (trastuzumab and
hyaluronidase-oysk)
Herzuma (trastuzumab-pkrb)
Kadcyla (ado-trastuzumab emtansine)
Kanjinti (trastuzumab-anns)
Margenza (margetuximab-cmkb)
Ogivri (trastuzumab-dkst)
Ontruzant (trastuzumab-dttb)
Perjeta (pertuzumab)
Phesgo (pertuzumab/trastuzumab/
hyaluronidase-zzxf)
Trazimera (trastuzumab-qyyp)
Ilaris (canakinumab)
Imlygic (t
alimogene laherparepvec)
13
ServicesBasics Medicines
The medicines that need prior authorization
Immunoglobulins (Prior authorization needed for
the drug and site of care):
Asceniv (immune globulin)
Bivigam (immune globulin)
Carimune NF (immune globulin)
Cutaquig (immune globulin)
Cuvitru (immune globulin SC [human])
Flebogamma (immune globulin)
GamaSTAN (immune globulin)
Gammagard, Gammagard S/D (immune globulin)
Gammaked (immune globulin)
Gammaplex (immune globulin)
Gamunex-C (immune globulin)
Hizentra (immune globulin)
HyQvia (immune globulin)
Octagam (immune globulin)
Panzyga (immune globulin)
Privigen (immune globulin)
Xembify (immune globulin)
Immunologic agents:
Actemra (tocilizumab) — prior authorization
n
eeded for the drug and site of care
Actemra SC (tocilizumab) — prior authorization
needed for Medicare Advantage members only
Cimzia (certolizumab pegol)
Cosentyx (secukinumab) — prior authorization
needed for Medicare Advantage members only
Enspryng (satralizumab) — prior authorization
needed for Medicare Advantage members only
Entyvio (vedolizumab) — prior authorization
needed for the drug and site of care
Ilumya (tildrakizumab)
Orencia SQ (abatacept) — prior authorization
needed for Medicare Advantage members only
Orencia IV (abatacept) — prior authorization
needed for the drug and site of care
Riabni (rituximab-arrx)
Rituxan (rituximab)
Immunologic agents (continued):
Rituxan Hycela (rituximab/hyaluronidase human)
Ruxience (rituximab-pvvr)
Simponi Aria (golimumab) — prior authorization
n
eeded for the drug and site of care
Skyrizi (risankizumab-rzaa) — prior authorization
needed for Medicare Advantage members only
Skyrizi IV (risankizumab-rzaa) — prior
authorization needed eective September 12,
2022
Stelara (ustekinumab) — prior authorization
needed for Medicare Advantage members only
Stelara IV (ustekinumab)
Tremfya (guselkumab) — prior authorization
needed for Medicare Advantage members only
Truxima (rituximab-abbs)
Vyvgart (efgartigimod alfa-fcab) — prior
authorization needed eective March 15, 2022
Injectable infertility drugs:
Chorionic gonadotropin
B
ravelle (urofollitropin)
Cetrotide (cetrorelix acetate)
Follistim AQ (follitropin beta)
Ganirelix AC (ganirelix acetate)
Gonal-f (follitropin alfa)
Gonal-f RFF (follitropin alfa)
Menopur (menotropins)
Novarel (chorionic gonadotropin)
Ovidrel (choriogonadotropin alfa)
Pregnyl (chorionic gonadotropin)
Injectafer (ferric carboxymaltose injection)
Jelmyto (mitomycin)
Khapzory (levoleucovorin)
Kimmtrak (tebentafusp-tebn) — prior authorization
n
eeded eective April 15, 2022
14
ServicesBasics Medicines
The medicines that need prior authorization
Kyprolis (carlzomib) — prior authorization needed
for multiple myeloma only
Lartruvo (olaratumab)
Luteinizing hormone-releasing hormone
(LHRH) agents:
Camcevi (leuprolide mesylate)
Eligard (leuprolide acetate)
Firmagon (degarelix)
Lupron Depot (leuprolide acetate), 7.5 mg
Trelstar (triptorelin pamoate)
Zoladex (goserelin)
Lumoxiti (moxetumomab pasudotox-tdfk)
Makena (hydroxyprogesterone capoate)
Monjuvi (tafasitamab-cxix)
Multiple sclerosis drugs:
Avonex (interferon beta-1a) — prior authorization
needed for Medicare Advantage members only
Kesimpta (ofatumumab) — prior authorization
needed for Medicare Advantage members only
Lemtrada (alemtuzumab) — prior authorization
needed for the drug and site of care
Ocrevus (ocrelizumab) — prior authorization
needed for the drug and site of care
Tysabri (natalizumab) — prior authorization
needed for the drug and site of care
M
us
cular dystrophy drugs:
Amondys 45 (casimersen) — prior authorization
needed for the drug and site of care
Exondys 51 (eteplirsen) — prior authorization
needed for the drug and site of care
Viltepso (viltolarsen) — prior authorization needed
for the drug and site of care
Vyondys 53 (golodirsen) — prior authorization
needed for the drug and site of care
Mvasi (bevacizumab-awwb) — prior authorization
needed for oncology indications only
Myalept (metreleptin)
Natpara (parathyroid hormone)
Nulibry (fosdenopterin)
Ophthalmic injectables:
Beovu (brolucizumab-dbll)
Byooviz (ranibizumab-nuna)
Eylea (aibercept)
L
ucentis (ranibizumab)
Luxturna (voretigene neparvovec-rzyl) — prior
authorization needed for the drug and site
of care
Macugen (pegaptanib)
Susvimo (ranibizumab) — prior authorization
needed eective February 1, 2022
Tepezza (teprotumumab-trbw) — prior
authorization needed for the drug and site
of care
Vabysmo (faricimab-svoa) — prior authorization
needed eective May 1, 2022
Ost
eoporosis drugs: — prior authorization needed
for Med
icare Advantage members only
Bonsity (teriparatide)
Evenity (romosozumab-aqqg)
Forteo (teriparatide)
Miacalcin (calcitonin)
Prolia (denosumab)
Oxlumo (lumasiran) — prior authorization needed
for the drug and site of care
Padcev (enfortumab vedotin)
15
ServicesBasics Medicines
The medicines that need prior authorization
Paroxysmal nocturnal hemoglobinuria (PNH)
Soliris (eculizumab) — prior authorization needed
for the drug and site of care
Ultomiris (ravulizumab-cwvz) — prior authorization
needed for the drug and site of care
Parsabiv (etelcalcetide)
PD1/PDL1 drugs (prior authorization needed for the
drug and site of care):
Bavencio (avelumab)
Imnzi (durvalumab)
Jemperli (dostarlimab-gxly)
Keytruda (pembrolizumab)
Libtayo (cemiplimab-rwlc)
Opdivo (nivolumab)
Opdualag (nivolumab and relatlimab-rmbw) –
prior authorization needed eective July 1, 2022
Tecentriq (atezolizumab)
Pepaxto (melphalan ufenamide)
Polivy (polatuzumab vedotin-piiq)
Provenge (sipuleucel-T)
Pulmonary arterial hypertension drugs:
All epoprostenol sodium and sildenal citrate
Flolan (epoprostenol sodium)
Remodulin (treprostinil sodium)
Tyvaso (treprostinil)
Veletri (epoprostenol sodium)
Ventavis (iloprost)
Reblozyl (luspatercept-aamt)
Respiratory injectables (prior authorization
needed for the drug and site of care):
Cinqair (reslizumab)
Fasenra (benralizumab)
Nucala (mepolizumab)
Tezspire (tezepelumab-ekko) — prior authorization
for the drug and site of care needed eective
March 23, 2022
Xolair (omalizumab)
Rybrevant (amivantamab-vmjw)
Ryplazim (plasminogen, human-tvmh)
Saphnelo (anifrolumab-fnia) — prior authorization
needed for the drug and site of care
Sarclisa (isatuximab-irfc)
Somatostatin agents:
Bynfezia (octreotide)
Sandostatin (octreotide)
Sandostatin LAR (octreotide acetate)
Signifor (pasireotide)
Signifor LAR (pasireotide)
Somatuline (lanreotide)
Somavert (pegvisomant)
Spinraza (nusinersen) — prior authorization needed
for the drug and site of care
Spravato (esketamine)
Synagis (palivizumab)
Tivdak (tisotumab vedotin-tftv)
16
ServicesBasics Medicines
The medicines that need prior authorization
Treanda (bendamustine HCl)
Trodelvy (sacituzumab govitecan-hziy)
Uplizna (inebilizumab-cdon) — prior authorization
needed for the drug and site of care
Vectibix (panitumumab)
Velcade (bortezomib) — prior authorization needed
for multiple myeloma only
Viscosupplementation:
Durolane (hyaluronic acid)
Euexxa, Hyalgan, Genvisc, Supartz FX, TriVisc,
Visco 3 (sodium hyaluronate)
Gel-One (cross-linked hyaluronate)
Gelsyn-3, Hymovis (hyaluronic acid)
Monovisc, Orthovisc (sodium hyaluronate)
Synojoynt, Triluron (1% sodium hyaluronate)
Synvisc, Synvisc-One (hylan)
Xgeva (denosumab)
Xogo (radium Ra 223 dichloride)
Yervoy (ipilimumab) — prior authorization needed
for the drug and site of care
Zirabev (bevacizumab-bvzr) — prior authorization
needed for oncology indications only
Zolgensma (onasemnogene abeparvovec-xioi) —
prior authorization needed for the drug and site
of care
Zulresso (brexanolone)
Zynlonta (loncastuximab tesirine-lpyl)
Trademarks are the property of their respective owners.
See Evidence of Coverage for a complete description of plan benets, exclusions, limitations and conditions
of coverage. Plan features and availability may vary by service area. Participating physicians, hospitals and
other health care providers are independent contractors and are neither agents nor employees of Aetna. The
availability of any particular provider cannot be guaranteed, and provider network composition is subject to
change. Out-of-network/non-contracted providers are under no obligation to treat Aetna members, except
in emergency situations. Please call our customer service number or see your Evidence of Coverage for
more information, including the cost-sharing that applies to out-of-network services. The formulary, provider
and/or pharmacy network may change at any time. You will receive notice when necessary.
NONDISCRIMINATION NOTICE
Discrimination is against the law. Aetna Medicare Preferred Plan (HMO D-SNP) follows State and Federal
civil rights laws. Aetna Medicare Preferred Plan (HMO D-SNP) does not unlawfully discriminate, exclude
people, or treat them dierently because of sex, race, color, religion, ancestry, national origin, ethnic group
identication, age, mental disability, physical disability, medical condition, genetic information, marital
status, gender, gender identity, or sexual orientation.
Aetna Medicare Preferred Plan (HMO D-SNP) provides:
• Free aids and services to people with disabilities to help them communicate better, such as:
• Qualied sign language interpreters
• Written information in other formats (large print, audio, accessible electronic formats, other formats)
• Free language services to people whose primary language is not English, such as:
• Qualied interpreters
• Information written in other languages
If you need these services, contact Aetna Medicare Preferred Plan (HMO D-SNP) between 8 AM-8 PM,
7days a week by calling 1-866-409-1221. If you cannot hear or speak well, please call 711. Upon request, this
document can be made available to you in braille, large print, audiocassette, or electronic form. To obtain a
copy in one of these alternative formats, please call or write to:
Aetna Medicare Preferred Plan (HMO D-SNP)
Aetna Medicare, PO Box 7405 London, KY 40742
1-866-409-1221
TTY/TDD 711
California Relay 711
HOW TO FILE A GRIEVANCE
If you believe that Aetna Medicare Preferred Plan (HMO D-SNP) has failed to provide these services or
unlawfully discriminated in another way on the basis of sex, race, color, religion, ancestry, national origin,
ethnic group identication, age, mental disability, physical disability, medical condition, genetic information,
marital status, gender, gender identity, or sexual orientation, you can le a grievance with Aetna Medicare
Grievances. You can le a grievance by phone, in writing, in person, or electronically:
• By phone: Contact Aetna Medicare Grievances between 8 AM to 8 PM, 7 days a week by calling
1-866-409-1221. Or, if you cannot hear or speak well, please call TTY/TDD 711.
• In writing: Fill out a complaint form or write a letter and send it to:
Aetna Medicare Grievances
PO Box 14834 Lexington, KY 40512
• In person: Visit your doctor’s oce or Aetna Medicare Preferred Plan (HMO D-SNP) and say you want to
le a grievance.
• Electronically: Visit Aetna Medicare Preferred Plan (HMO D-SNP) website at AetnaMedicare.com
OFFICE OF CIVIL RIGHTS – CALIFORNIA DEPARTMENT OF HEALTH CARE SERVICES
You can also le a civil rights complaint with the California Department of Health Care Services, Oce of
Civil Rights by phone, in writing, or electronically:
• By phone: Call 916-440-7370. If you cannot speak or hear well, please call 711 (Telecommunications
RelayService).
• In writing: Fill out a complaint form or send a letter to:
Deputy Director, Oce of Civil Rights
Department of Health Care Services
Oce of Civil Rights
P.O. Box 997413, MS 0009
Sacramento, CA 95899-7413
Complaint forms are available at http://www.dhcs.ca.gov/Pages/Language_Access.aspx.
• Electronically: Send an email to [email protected].
OFFICE OF CIVIL RIGHTS – U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
If you believe you have been discriminated against on the basis of race, color, national origin, age, disability
or sex, you can also le a civil rights complaint with the U.S. Department of Health and Human Services,
Oce for Civil Rights by phone, in writing, or electronically:
• By phone: Call 1-800-368-1019. If you cannot speak or hear well, please call TTY/TDD 1-800-537-7697.
• In writing: Fill out a complaint form or send a letter to:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
Complaint forms are available at http://www.hhs.gov/ocr/oce/le/index.html.
• Electronically: Visit the Oce for Civil Rights Complaint Portal at https://ocrportal.hhs.gov/ocr/portal/
lobby.jsf.
TTY: 711
If you speak a language other than English, free language assistance services are available. Visit our
website or call the phone number listed in this document. (English)
Si habla un idioma que no sea inglés, se encuentran disponibles servicios gratuitos de asistencia de
idiomas. Visite nuestro sitio web o llame al número de teléfono que gura en este documento. (Spanish)
Nếu quý vị nói một ngôn ngữ khác với Tiếng Anh, chúng tôi có dịch vụ hỗ trợ ngôn ngữ miễn phí. Xin vào
trang mạng của chúng tôi hoặc gọi số điện thoại ghi trong tài liệu này. (Vietnamese)
Kung hindi Ingles ang wikang inyong sinasalita, may maaari kayong kuning mga libreng serbisyo ng tulong
sa wika. Bisitahin ang aming website o tawagan ang numero ng telepono na nakalista sa dokumentong
ito. (Tagalog)
如如如如如如如如如如如如如如如如如如如如如如如如如如如如如如如如如如如如如如如如如如如如如如如如如
如如(Traditional Chinese)
©2022 Aetna Inc.
Y0001_NR_30138_2022_C
1055350-01-04 (11/22)
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ԵԵԵԵԵԵԵԵԵԵԵԵԵԵԵԵ (Armenian)
(Farsi)
(Russian)
(Japanese)
(Arabic) .
(Punjabi)
Yog hais tias koj hais ib hom lus uas tsis yog lus Askiv, muaj cov kev pab cuam txhais lus dawb pub rau koj.
Mus saib peb lub website los yog hu rau tus xov tooj sau teev tseg nyob rau hauv daim ntawv no. (Hmong)
ԵԵ ԵԵԵ, ԵԵ ԵԵԵԵԵ ԵԵԵԵ ԵԵԵԵԵԵ ԵԵԵԵԵԵ ԵԵԵԵԵԵ ԵԵԵԵ ԵԵԵԵԵ ԵԵԵԵԵԵԵ ԵԵ ԵԵԵԵ ԵԵ ԵԵ ԵԵԵԵԵԵԵԵԵ ԵԵԵ ԵԵԵ ԵԵ ԵԵԵԵԵԵԵԵ ԵԵ ԵԵԵԵԵ ԵԵԵ ԵԵԵԵ ԵԵԵԵ ԵԵԵ
ԵԵԵ ԵԵ ԵԵԵ ԵԵԵԵ ԵԵ ԵԵԵ ԵԵԵԵԵ (Hindi)
(Thai)
