Specialty drug coverage

2021 Aetna Specialty Drug List

54.03.907.1D (1/21) You must fill these drugs at an in-network specialty pharmacy. Look up your plan documents for specialty drug coverage details. You’ll also learn more about the requirements and limitations of your pharmacy benefits and insurance plan.

What is a specialty drug? Key Specialty drugs treat complex, chronic conditions. A nurse or UPPERCASE Brand-name medicine pharmacist will often support their use during treatment. These lowercase italics Generic medicine drugs may be injected, infused or taken by mouth. You may need to refrigerate them. They are often expensive and may not be available at retail pharmacies.

Category

Acromegaly BYNFEZIA PEN SANDOSTATIN LAR octreotide acetate SOMATULINE DEPOT (SANDOSTATIN) SOMAVERT

Alpha-1 Antitrypsin ARALAST NP ZEMAIRA Deficiency GLASSIA

Amyloidosis ONPATTRO VYNDAQEL VYNDAMAX

Anemia ARANESP PROCRIT RETACRIT EPOGEN REBLOZYL

Asthma CINQAIR FASENRA XOLAIR DUPIXENT NUCALA

Atopic Dermatitis DUPIXENT

Cardiac Disorders dofetilide (TIKOSYN)

Coagulation Disorders CEPROTIN

Cryopyrin-Associated ARCALYST Periodic Syndromes ILARIS

Cystic Fibrosis CAYSTON PULMOZYME tobramycin (BETHKIS) KITABIS PAK TOBI PODHALER tobramycin nebulizer (TOBI)

Electrolyte Disorders tolvaptan (SAMSCA)

Gastrointestinal GATTEX SOLESTA Disorders – Other OCALIVA

Gout KRYSTEXXA

Health benefits and health insurance plans are offered, underwritten and/or administered by Aetna Health Inc., Aetna Health Insurance Company of New York, Aetna HealthAssurance 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/or Aetna Life Insurance Company. In Maryland by Aetna Health Inc., 151 Farmington Avenue, Hartford, CT 06156. Each insurer has sole financial responsibility for its own products. 2 Category

Growth Hormone & EGRIFTA NORDITROPIN SEROSTIM Related Disorders EGRIFTA SV NUTROPIN AQ ZOMACTON Growth Hormone GENOTROPIN OMNITROPE ZORBTIVE Disorders HUMATROPE SAIZEN

Growth Hormone & INCRELEX Related Disorders IGF-1 Deficiency

Hematopoietics MOZOBIL

Hemophilia, Von ADVATE HELIXATE FS NUWIQ Willebrand ADYNOVATE HEMLIBRA OBIZUR Disease & Related AFSTYLA HEMOFIL M PROFILNINE Bleeding Disorders ALPHANATE HUMATE-P PROFILNINE SD ALPHANINE SD IDELVION REBINYN ALPROLIX IXINITY RECOMBINATE BEBULIN JIVI RIASTAP BENEFIX KOATE RIXUBIS COAGADEX KOATE-DVI SEVENFACT CORIFACT KOGENATE FS STIMATE ELOCTATE KOVALTRY TRETTEN ESPEROCT MONONINE VONVENDI FEIBA NOVOEIGHT WILATE FIBRYGA NOVOSEVEN RT XYNTHA

Hepatitis adefovir dipivoxil (HEPSERA) MAVYRET ribavirin tabs entecavir (BARACLUDE) PEGASYS (ribasphere, MODERIBA) EPCLUSA PEGINTRON SOFOSBUVIR/VELPATASVIR HARVONI REBETOL SOLUTION SOVALDI INTRON-A ribasphere tenofovir disoproxil fumarate lamivudine RIBASPHERE RIBAPAK (VIREAD) (EPIVIR, EPIVIR HBV) ribavirin caps VEMLIDY LEDIPASVIR/SOFOSBUVIR (ribasphere, REBETOL) VIEKIRA PAK VOSEVI ZEPATIER

Hereditary BERINERT icatibant acetate (FIRAZYR) RUCONEST Angioedema CINRYZE KALBITOR TAKHZYRO HAEGARDA

HIV Medications abacavir tab (ZIAGEN) EVOTAZ RESCRIPTOR abacavir / lamivudine (EPZICOM) fosamprenavir (LEXIVA) RETROVIR INJECTABLE abacavir / lamivudine / FUZEON ritonavir (NORVIR) zidovudine tab (TRIZIVIR) GENVOYA RUKOBIA APTIVUS INTELENCE SELZENTRY atazanavir sulfate (REYATAZ) INVIRASE stavudine (ZERIT) ATRIPLA ISENTRESS STRIBILD BIKTARVY JULUCA SYMTUZA CIMDUO lamivudine (EPIVIR) TEMIXYS COMPLERA lamivudine/zidovudine tenofovir disoproxil fumarate CRIXIVAN (COMBIVIR) (VIREAD) DELSTRIGO LEXIVA TIVICAY DESCOVY lopinavir/ritonavir soln (KALETRA) TRIUMEQ didanosine (VIDEX, VIDEX EC) nevirapine (VIRAMUNE, TROGARZO DOVATO VIRAMUNE XR) TRUVADA EDURANT ODEFSEY TYBOST efavirenz (SUSTIVA) PIFELTRO VIDEX SOLUTION EGRIFTA PREZCOBIX VIRACEPT EMTRIVA PREZISTA zidovudine (RETROVIR)

3 Category

Hormonal Therapies AVEED LUPANETA PACK TRELSTAR ELIGARD LUPRON DEPOT VANTAS FIRMAGON NATPARA ZOLADEX leuprolide acetate (LUPRON) SUPPRELIN LA

Immune Deficiencies & ASCENIV GAMMAKED NABI-HB Related Disorders BIVIGAM GAMMAPLEX OCTAGAM CUTAQUIG GAMUNEX C PANZYGA CUVITRU HEPAGAM B PRIVIGEN CYTOGAM HIZENTRA RHOGAM GAMASTAN HYPERHEP B RHOPHYLAC GAMASTAN S/D HYPERRHO S/D VARIZIG GAMMAGARD LIQUID HYQVIA WINRHO SDF GAMMAGARD S/D MICRHOGAM XEMBIFY

Infectious Disease – ACTIMMUNE Other ALFERON N

Infertility CETROTIDE GANIRELIX ACETATE NOVAREL CHORIONIC GONADOTROPIN GONAL-F OVIDREL FOLLISTIM AQ MENOPUR PREGNYL

Inflammatory AVSOLA INFLECTRA STELARA IV Bowel Disease CIMZIA REMICADE TYSABRI ENTYVIO RENFLEXIS XELJANZ HUMIRA SIMPONI ARIA

Iron Overload deferasirox (EXJADE, JADENU) deferoxamine (DESFERAL)

Lysosomal Storage ALDURAZYME ELELYSO miglustat Disorders CERDELGA FABRAZYME NAGLAZYME CEREZYME KANUMA VIMIZIM CYSTAGON LUMIZYME VPRIV ELAPRASE

Mental Health ZULRESSO Conditions

Movement Disorders APOKYN NORTHERA SOLIRIS AUSTEDO NUPLAZID tetrabenazine (XENAZINE) DUOPA RADICAVA

Multiple Sclerosis AUBAGIO EXTAVIA mitoxantrone hcl AVONEX GILENYA OCREVUS BAFIERTAM glatiramer acetate PLEGRIDY BETASERON (COPAXONE, glatopa) REBIF dalfampridine ER KESIMPTA TYSABRI (AMPYRA) LEMTRADA VUMERITY dimethyl fumarate MAVENCLAD ZEPOSIA (TECFIDERA) MAYZENT

Neutropenia FULPHILA NEULASTA UDENYCA GRANIX NEUPOGEN ZARXIO LEUKINE NIVESTYM ZIEXTENZO

Ocular Disorders BEOVU LUCENTIS RETISERT EYLEA MACUGEN TEPEZZA ILUVIEN OZURDEX VISUDYNE

4 Category

Oncology – Injectable ADCETRIS HERCEPTIN POTELIGEO ARZERRA HERCEPTIN HYLECTA PROLEUKIN ASPARLAS HERZUMA RITUXAN AVASTIN IMFINZI RITUXAN HYCELA azacitidine (VIDAZA) INTRON A ROMIDEPSIN BAVENCIO ISTODAX RUXIENCE BELEODAQ IXEMPRA SARCLISA BELRAPZO JEVTANA SYLVANT BENDAMUSTINE KADCYLA TECENTRIQ HYDROCHLORIDE KANJINTI TEMODAR BENDEKA KEYTRUDA temsirolimus (TORISEL) BESPONSA KHAPZORY TEPADINA BLINCYTO KYPROLIS THYROGEN BORTEZOMIB levoleucovorin calcium TRAZIMERA CYRAMZA LUMOXITI TREANDA DARZALEX mitoxantrone hcl TRUXIMA DARZALEX FASPRO MVASI valrubicin (VALSTAR) decitabine (DACOGEN) MYLOTARG VECTIBIX EMPLICITI OGIVRI VELCADE ENHERTU ONCASPAR XGEVA ERBITUX ONTRUZANT YERVOY ERWINAZE OPDIVO YONDELIS EVOMELA PADCEV ZALTRAP FOLOTYN PERJETA ZEPZELCA FUSILEV PHESGO ZIRABEV GAZYVA POLIVY zoledronic acid HALAVEN PORTRAZZA

Oncology – abiraterone acetate (ZYTIGA) IRESSA RYDAPT Oral/Topical ALECENSA JAKAFI SPRYCEL ALUNBRIG KISQALI STIVARGA bexarotene (TARGRETIN) KISQALI FEMARA SUTENT BOSULIF lapatinib ditosylate (TYKERB) TABRECTA CABOMETYX LENVIMA TAFINLAR capecitabine (XELODA) LONSURF TAGRISSO COMETRIQ LORBRENA TALZENNA COTELLIC LYNPARZA TASIGNA DAURISMO MEKINIST temozolomide (TEMODAR) ERIVEDGE MUGARD THALOMID ERLEADA NERLYNX TYKERB erlotinib hydrochloride NEXAVAR VERZENIO (TARCEVA) NINLARO VITRAKVI everolimus (AFINITOR) NUBEQA VIZIMPRO FARYDAK ODOMZO VOTRIENT HYCAMTIN ONUREG XALKORI IBRANCE PIQRAY XTANDI IDHIFA POMALYST YONSA imatinib mesylate PURIXAN ZELBORAF (GLEEVEC) RETEVMO ZOLINZA INLYTA REVLIMID ZYDELIG INREBIC ROZLYTREK ZYKADIA INQOVI RUBRACA

Osteoporosis EVENITY PROLIA TYMLOS FORTEO TERIPARATIDE zoledronic acid (RECLAST)

Paroxysmal Nocturnal SOLIRIS Hemoglobinuria ULTOMIRIS

Phenylketonuria PALYNZIQ sapropterin dihydrochloride (KUVAN)

Pre-Term Birth hydroxyprogesterone capro (MAKENA)

5 Category

Psoriasis AVSOLA INFLECTRA SILIQ CIMZIA OTEZLA SKYRIZI COSENTYX OTREXUP STELARA ENBREL RASUVO TALTZ HUMIRA REMICADE TREMFYA ILUMYA RENFLEXIS XELJANZ

Pulmonary Arterial ADEMPAS OPSUMIT treprostinil sodium (REMODULIN) Hypertension ambrisentan (LETAIRIS) ORENITRAM TYVASO bosentan (TRACLEER) sildenafil citrate(REVATIO) UPTRAVI epoprostenol sodium tadalafil(ADCIRCA, alyq) VENTAVIS (FLOLAN, VELETRI)

Pulmonary ESBRIET Disorders – Other OFEV

Rare Disorders – Other CRYSVITA ENSPRYNG DOJOLVI GAMIFANT

Renal Disease cinacalcet hydrochloride (SENSIPAR) PARSABIV

Respiratory SYNAGIS Syncytial Virus

Rheumatoid Arthritis ACTEMRA KEVZARA RENFLEXIS AVSOLA OLUMIANT RINVOQ CIMZIA ORENCIA RITUXAN ENBREL OTREXUP SIMPONI HUMIRA RASUVO SIMPONI ARIA INFLECTRA REMICADE XELJANZ

Seizure Disorders ACTHAR vigabatrin pwd (SABRIL PWD) EPIDIOLEX vigabatrin tabs (SABRIL TABS)

Sickle Cell Disease ADAKVEO OXBRYTA

Sleep Disorders WAKIX

Systemic Lupus BENLYSTA Erythematosus

Thrombocytopenia DOPTELET NPLATE MULPLETA PROMACTA

Transplant ASTAGRAF XL mycophenolate mofetil PROGRAF INJECTABLE cyclosporine (gengraf, NEORAL, (CELLCEPT) RAPAMUNE SOLUTION SANDIMMUNE) mycophenolic acid dr sirolimus tab (RAPAMUNE) ENVARSUS XR (MYFORTIC) tacrolimus (PROGRAF) everolimus (ZORTRESS) NULOJIX

Urea Cycle Disorders RAVICTI sodium phenylbutyrate (BUPHENYL)

6 Index

A BENDAMUSTINE DARZALEX FASPRO EVOMELA HYDROCHLORIDE abacavir tab (ZIAGEN) DAURISMO EVOTAZ BENDEKA abacavir/lamivudine decitabine (DACOGEN) EXJADE (EPZICOM) BENEFIX deferasirox EXTAVIA abacavir/lamivudine/ BENLYSTA (EXJADE, JADENU) EYLEA zidovudine tab (TRIZIVIR) BEOVU deferoxamine (DESFERAL) F abiraterone acetate (ZYTIGA) BERINERT DELSTRIGO FABRAZYME ACTEMRA BESPONSA DESCOVY FARYDAK ACTIMMUNE BETASERON DESFERAL FASENRA ACTHAR BETHKIS didanosine (VIDEX, VIDEX EC) FEIBA ADAKVEO bexarotene (TARGRETIN) dimethyl fumarate FIBRYGA ADCETRIS BIKTARVY (TECFIDERA) FIRAZYR ADCIRCA BIVIGAM dofetilide (TIKOSYN) FIRMAGON adefovir (HEPSERA) BLINCYTO DOJOLVI FLOLAN BORTEZOMIB ADEMPAS DOPTELET FOLLISTIM AQ bosentan (TRACLEER) DOVATO ADVATE FOLOTYN BOSULIF DUPIXENT ADYNOVATE FORTEO BUPHENYL E AFINITOR fosamprenavir (LEXIVA) BYNFEZIA PEN AFSTYLA EDURANT FULPHILA C ALDURAZYME efavirenz (SUSTIVA) FUSILEV ALECENSA CABOMETYX efavirenz/lamivudine/ FUZEON ALFERON N capecitabine (XELODA) tenofovir (SYMFI, SYMFI LO) G ALPHANATE CAYSTON EGRIFTA SV GAMASTAN ALPHANINE SD CELLCEPT EGRIFTA GAMASTAN S/D ALPROLIX CEPROTIN ELAPRASE GAMIFANT ALUNBRIG CERDELGA ELELYSO GAMMAGARD LIQUID alyq (ADCIRCA, tadalafil) CEREZYME ELIGARD GAMMAGARD S/D ambrisentan (LETAIRIS) CETROTIDE ELOCTATE GAMMAKED AMPYRA CHORIONIC GONADOTROPIN EMPLICITI GAMMAPLEX CIMDUO APOKYN emtricitabine (EMTRIVA) GAMUNEX C CIMZIA APTIVUS EMTRIVA GANIRELIX ACETATE cinacalcet hydrochloride ENBREL ARALAST NP GATTEX (SENSIPAR) ENHERTU ARANESP GAZYVA CINQAIR entecavir (BARACLUDE) ARCALYST gengraf CINRYZE ENTYVIO ARZERRA GENOTROPIN COAGADEX ENVARSUS XR ASCENIV GENVOYA COMBIVIR EPCLUSA GILENYA ASPARLAS COMETRIQ EPIDIOLEX GLASSIA ASTAGRAF XL COMPLERA EPIVIR glatiramer acetate atazanavir sulfate (REYATAZ) COPAXONE EPIVIR HBV (COPAXONE, glatopa) ATRIPLA CORIFACT EPOGEN glatopa (COPAXONE, AUBAGIO COSENTYX epoprostenol sodium (FLOLAN, glatiramer acetate) AUSTEDO COTELLIC VELETRI) GLEEVEC AVASTIN CRIXIVAN EPZICOM GONAL-F AVEED CRYSVITA ERBITUX GRANIX AVONEX CUVITRU ERIVEDGE H AVSOLA cyclosporine (gengraf, ERLEADA H. P. ACTHAR GEL azacitidine (VIDAZA) NEORAL, SANDIMMUNE) erlotinib hydrochloride HAEGARDA B CYRAMZA (TARCEVA) HALAVEN BAFIERTAM CYSTAGON ERWINAZE HARVONI BARACLUDE CYTOGAM ESBRIET HELIXATE FS BAVENCIO D ESPEROCT HEMLIBRA BEBULIN DACOGEN EVENITY HEMOFIL M BELEODAQ dalfampridine ER (AMPYRA) everolimus (AFINITOR) HEPAGAM B BELRAPZO DARZALEX everolimus (ZORTRESS) HEPSERA

7 HERCEPTIN KOATE-DVI NERLYNX POLIVY HERCEPTIN HYLECTA KOGENATE FS NEULASTA POMALYST HERZUMA KOVALTRY NEUPOGEN PORTRAZZA HIZENTRA KRYSTEXXA nevirapine (VIRAMUNE, POTELIGEO HUMATE-P KUVAN VIRAMUNE XR) PREGNYL HUMATROPE KYPROLIS NEXAVAR PREZCOBIX HUMIRA L NINLARO PREZISTA NIVESTYM HYCAMTIN lamivudine (EPIVIR, PRIVIGEN hydroxyprogesterone capro EPIVIR HBV) NORDITROPIN PROCRIT (MAKENA) lamivudine/zidovudine NORTHERA PROFILNINE HYPERHEP B (COMBIVIR) NORVIR PROFILNINE SD HYPERRHO S/D LEDIPASVIR/SOFOSBUVIR NOVAREL PROGRAF HYQVIA LEMTRADA NOVOEIGHT PROLEUKIN I LENVIMA NOVOSEVEN RT PROLIA NPLATE IBRANCE LETAIRIS PROMACTA NUBEQA icatibant acetate (FIRAZYR) LEUKINE PULMOZYME NUCALA IDELVION leuprolide acetate (LUPRON) PURIXAN NULOJIX IDHIFA levoleucovorin calcium R NUPLAZID ILARIS LEXIVA RADICAVA NUTROPIN ILUMYA LONSURF RAPAMUNE NUWIQ ILUVIEN lopinavir/ritonavir soln RASUVO (KALETRA) O imatinib mesylate (GLEEVEC) RAVICTI LORBRENA IMFINZI OBIZUR REBETOL LUCENTIS INBRIJA OCALIVA REBIF LUMIZYME INCRELEX OCREVUS REBINYN LUMOXITI INFLECTRA OCTAGAM REBLOZYL LUPANETA PACK INLYTA octreotide acetate RECLAST LUPRON (SANDOSTATIN) INQOVI RECOMBINATE LUPRON DEPOT ODEFSEY INREBIC REMICADE LYNPARZA ODOMZO INTELENCE REMODULIN M OFEV INTRON A RENFLEXIS OGIVRI INVIRASE MACUGEN RESCRIPTOR OLUMIANT IRESSA MAKENA RETACRIT ONUREG ISENTRESS MAVENCLAD RETEVMO OMNITROPE ISTODAX MAVYRET RETISERT ONCASPAR IXEMPRA MAYZENT RETROVIR ONPATTRO IXINITY MEKINIST RETROVIR INJ ONTRUZANT J MENOPUR REVATIO OPDIVO MICRHOGAM REVLIMID JADENU OPSUMIT miglustat REYATAZ JAKAFI ORENCIA mitoxantrone hcl RHOGAM JEVTANA ORENITRAM MODERIBA RHOPHYLAC JIVI OTEZLA MONONINE RIASTAP JULUCA OTREXUP MOZOBIL ribasphere K OVIDREL MUGARD RIBASPHERE RIBAPAK OXBRYTA KADCYLA MULPLETA ribavirin caps KALBITOR MVASI OZURDEX (ribasphere, REBETOL) KALETRA mycophenolate mofetil P ribavirin tabs KANJINTI (CELLCEPT) PADCEV (ribasphere, MODERIBA) KANUMA mycophenolic acid dr PALYNZIQ RINVOQ KESIMPTA (MYFORTIC) PANZYGA ritonavir (NORVIR) KEVZARA MYFORTIC PARSABIV RITUXAN KEYTRUDA MYLOTARG PEGASYS RITUXAN HYCELA KHAPZORY N PEGINTRON RIXUBIS KISQALI NABI-HB PERJETA ROMIDEPSIN KISQALI FEMARA NAGLAZYME PIFELTRO ROZLYTREK KITABIS PAK NATPARA PIQRAY RUBRACA KOATE NEORAL PLEGRIDY RUCONEST

8 RUXIENCE T TRUVADA W RYDAPT TABRECTA TRUXIMA WAKIX S TYBOST tacrolimus (PROGRAF) WILATE TYKERB SABRIL PWD tadalafil (ADCIRCA) WINRHO SDF TYMLOS SABRIL TABS TAFINLAR X SAIZEN TAGRISSO TYSABRI XALKORI SAMSCA TAKHZYRO TYVASO SANDIMMUNE TALTZ U XELJANZ SANDOSTATIN TALZENNA UDENYCA XELODA SANDOSTATIN LAR TARCEVA ULTOMIRIS XEMBIFY SARCLISA TARGRETIN UPTRAVI XENAZINE SELZENTRY TASIGNA V XGEVA SENSIPAR TECENTRIQ valrubicin (VALSTAR) XOLAIR SEROSTIM TECFIDERA VALSTAR XTANDI SEVENFACT TEMIXYS VANTAS XYNTHA sildenafil citrate (REVATIO) TEMODAR VARIZIG Y SILIQ temozolomide (TEMODAR) VECTIBIX YERVOY SIMPONI temsirolimus (TORISEL) VELCADE YONDELIS SIMPONI ARIA tenofovir disoproxil fumarate VELETRI sirolimus tab (RAPAMUNE) (VIREAD) VEMLIDY YONSA SKYRIZI TEPADINA VENTAVIS Z sodium phenylbutyrate TEPEZZA VERZENIO ZALTRAP (BUPHENYL) TERIPARATIDE VIDAZA ZARXIO SOFOSBUVIR/VELPATASVIR tetrabenazine (XENAZINE) VIDEX ZELBORAF SOLESTA THALOMID VIDEX EC ZEMAIRA SOLIRIS THYROGEN VIEKIRA PAK ZEPATIER SOMATULINE DEPOT TIKOSYN vigabatrin pwd (SABRIL) ZEPOSIA SOMAVERT TIVICAY vigabatrin tabs SOVALDI TOBI (SABRIL TABS) ZERIT SPRYCEL TOBI PODHALER VIMIZIM ZIAGEN stavudine (ZERIT) tobramycin nebulizer (TOBI) VIRACEPT zidovudine (RETROVIR) STELARA tolvaptan (SAMSCA) VIRAMUNE ZIEXTENZO STELARA IV TORISEL VIRAMUNE XR ZIRABEV STIMATE TRACLEER VIREAD ZOLADEX STIVARGA TRAZIMERA VISUDYNE zoledronic acid (RECLAST) STRIBILD VITRAKVI TREANDA ZOLINZA SUPPRELIN LA TRELSTAR VIZIMPRO ZOMACTON SUSTIVA TREMFYA VONVENDI ZORBTIVE SUTENT treprostinil sodium VOSEVI ZORTRESS SYLVANT (REMODULIN) VOTRIENT SYMFI TRETTEN VPRIV ZULRESSO SYMFI LO TRIUMEQ VUMERITY ZYDELIG SYMTUZA TRIZIVIR VYNDAMAX ZYKADIA SYNAGIS TROGARZO VYNDAQEL ZYTIGA

9 Please remember that this is not a complete list of drugs covered under your plan. Products may be subject to plan-specific copayment or coinsurance, additional charges or other restrictions. Certain drugs, such as those for infertility, erectile dysfunction, weight loss, smoking cessation or vitamins, may not be covered by your particular pharmacy plan. Diabetic supplies may be covered under your medical plan. To check coverage and copay information for a specific drug, please visit aetna.com and log in to your secure member website. If you don’t have access to our website, call the toll-free number on your member ID card. Coverage for specialty drugs follows the CVS Caremark Advanced Control Specialty Formulary™ and is being used with permission from CVS Health and/or one of its affiliates. Information is believed to be accurate as of the production date; however, it is subject to change. Policy forms issued in Missouri include: AL HGrpPol 01R5, HI HGrpAG 05, HO HGrpPol 04. Policy forms issued in Oklahoma include: AL COC00010, HC COC00010.

©2020 Aetna Inc. 54.03.907.1D (1/21)