Aetna prior authorization J3490
Aetna prior authorization for J3490: Alzheimer’s disease (precertification required for the drug and site of care): Leqembi SQ (lecanemab-irmb) — precertification required for Medicare
- Code
- J3490
- Description
- Alzheimer’s disease (precertification required for the drug and site of care): Leqembi SQ (lecanemab-irmb) — precertification required for Medicare
- Description
- Amtagvi (lifileucel,) — precertification required for the drug and site of care Contact National Medical Excellence
- Description
- Avzivi (bevacizumab-tnjn,)— precertification required for the drug and site of care effective October 1, 2026
- Description
- Botulinum toxins: Letybo (letibotulinumtoxinA-wlbg,)
- Description
- Cortrophin Gel (repository corticotropin)
- Description
- Enzyme replacement drugs (continued): Strensiq (asfotase alfa)
- Description
- Gattex (teduglutidem)
- Description
- Genglycos (pariglasgene brecaparvovec)— precertification required for drug effective October 1, 2026
- Description
- Granulocyte-colony stimulating factors: Ennumo (pegfilgrastim-pccg,) — precertification required effective
- Description
- Growth hormone: Skytrofa (lonapegsomatropin-tcgd) — precertification required for Medicare
- Description
- Hereditary angioedema agents: Dawnzera (Donidalorsen Sodium)
- Description
- Poherdy (pertuzumab-dpzb,,
- Description
- Immunologic agents: Enspryng (satralizumab) — precertification required for Medicare
- Description
- Immgolis Intri (golimumab-sldi,) — precertification required for the drug
- Description
- Immunnologics agents (continued): Tyenne (tocilizumab-aazg,) —precertification required for drug and
- Description
- Immunnologics agents (continued): Zimrixby (rituximab-cdxx,) — precertification required for drug and
- Description
- Injectable infertility drugs: Cetrotide (cetrorelix acetate)
- Description
- (eladocagene exuparvovec-tneq,
- Description
- Kresladi (marnetegragene autotemcel)— precertification required for drug effective July 1, 2026 Contact National Medical Excellence
- Description
- Lantidra (donislecel-jujn,) Contact National Medical Excellence
- Description
- Muscular dystrophy drugs: (precertification required for the drug and site of care): Elevidys (delandistrogene moxeparvovec)
- Description
- Myalept (metreleptin) — precertification required for Commercial members only
- Description
- Ophthalmic injectables: Lumvoa (veligrotug-vvze,) —precertification required for the drug and site
- Description
- Ophthalmic injectables: Lytenava (bevacizumab-vikg,) — precertification required effective
- Description
- Ophthalmic injectables: Ranluspec (ranibizumab-hkdz,,
- Description
- Osteoporosis drugs: denosumab-bnht
- Description
- Osteoporosis drugs: denosumab-dssb
- Description
- Otarmeni (lunsotogene parvec-cwah) — precertification required effective July 1, 2026
- Description
- (garetosmab-grts,)
- Description
- penpulimab-kcqx
- Description
- (continued): Winrevair (sotatercept-csrk,)
- Description
- (plozasiran) — precertification
- Description
- Revtorpyk (gedatolisib,)— precertification required effective September 1, 2026
- Description
- Rivfloza (nedosiran,) — precertification required for the drug and site of care
- Description
- Saphnelo SC (Anifrolumab-fnia) — precertification required for the drug and site of care effective July 1, 2026.
- Description
- Sarclisa Escena SC (isatuximab-irfc) — precertification required effective September 1, 2026
- Description
- Somatostatin agents: Signifor (pasireotide) — precertification required for Commercial
- Description
- Somatostatin agents: Somavert (pegvisomant) — precertification required for Commercial
- Description
- Tregzi (T cells-vldq,)— precertification required effective August 1, 2026
- Description
- Tudriqev (vusolimogene oderparepvec) — precertification required effective October 1, 2026 Contact National Medical Excellence
- Description
- Vyjuvek (beremagene geperpavec,)
- Description
- Zanvastro (zilganersen,)— precertification required effective October 1, 2026
- Source
- Participating provider precertification list for Aetna, Pg 19 Original policy
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- Participating provider precertification list for Aetna, Pg 20 Original policy
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- Participating provider precertification list for Aetna, Pg 20 Original policy
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- Participating provider precertification list for Aetna, Pg 21 Original policy
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- Participating provider precertification list for Aetna, Pg 21 Original policy
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- Participating provider precertification list for Aetna, Pg 22 Original policy
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- Participating provider precertification list for Aetna, Pg 23 Original policy
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- Participating provider precertification list for Aetna, Pg 23 Original policy
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- Participating provider precertification list for Aetna, Pg 23 Original policy
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- Participating provider precertification list for Aetna, Pg 24 Original policy
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- Participating provider precertification list for Aetna, Pg 24 Original policy
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- Participating provider precertification list for Aetna, Pg 25 Original policy
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- Participating provider precertification list for Aetna, Pg 25 Original policy
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- Participating provider precertification list for Aetna, Pg 26 Original policy
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- Participating provider precertification list for Aetna, Pg 26 Original policy
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- Participating provider precertification list for Aetna, Pg 26 Original policy
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- Participating provider precertification list for Aetna, Pg 27 Original policy
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- Participating provider precertification list for Aetna, Pg 27 Original policy
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- Participating provider precertification list for Aetna, Pg 27 Original policy
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- Participating provider precertification list for Aetna, Pg 27 Original policy
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- Participating provider precertification list for Aetna, Pg 28 Original policy
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- Participating provider precertification list for Aetna, Pg 28 Original policy
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- Participating provider precertification list for Aetna, Pg 29 Original policy
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- Participating provider precertification list for Aetna, Pg 29 Original policy
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- Participating provider precertification list for Aetna, Pg 29 Original policy
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- Participating provider precertification list for Aetna, Pg 29 Original policy
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- Participating provider precertification list for Aetna, Pg 29 Original policy
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- Participating provider precertification list for Aetna, Pg 30 Original policy
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- Participating provider precertification list for Aetna, Pg 30 Original policy
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- Participating provider precertification list for Aetna, Pg 31 Original policy
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- Participating provider precertification list for Aetna, Pg 31 Original policy
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- Participating provider precertification list for Aetna, Pg 31 Original policy
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- Participating provider precertification list for Aetna, Pg 32 Original policy
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- Participating provider precertification list for Aetna, Pg 32 Original policy
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- Participating provider precertification list for Aetna, Pg 32 Original policy
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- Participating provider precertification list for Aetna, Pg 32 Original policy
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- Participating provider precertification list for Aetna, Pg 32 Original policy
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- Participating provider precertification list for Aetna, Pg 32 Original policy
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- Participating provider precertification list for Aetna, Pg 33 Original policy
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- Participating provider precertification list for Aetna, Pg 33 Original policy
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- Participating provider precertification list for Aetna, Pg 33 Original policy
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- Participating provider precertification list for Aetna, Pg 34 Original policy