Aetna Commercial Formulary for Self

2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
DRUG_NAME
PA_GROUP_NAME
COVERED USES
ADRENACLICK
EPI
emergency treatment of severe allergic reactions
including anaphylaxis
EXCLUSION CRITERIA
REQUIRED MEDICAL INFORMATION
AGE
RESTRICTIO
N
PRESCRIB COVERAGE
DURATION
ER
RESTRICTI
ON
1 year
OTHER CRITERIA
STEP_GR STEP_ALTS
OUP_NA
ME
EPI
Trial of 1 of Auvi-Q, Epipen,
Epipen JR
ELIQUIS
PRADAXA
XARELTO
2/ day
2/ day
35/365
days,
15mg
42/30Day
s, 20mg
2/day
ADVICOR
ALTOPREV
STATIN
Trial of 1 generic statin,
atorvastatin, fluvastatin,
lovastatin, pravastatin,
simvastatin (NSO)
ATORVASTATIN
CRESTOR
FLUVASTATIN
LESCOL
STATIN
LESCOL XL
STATIN
LIPITOR
STATIN
Trial of 1 generic statin,
atorvastatin, fluvastatin,
lovastatin, pravastatin,
simvastatin (NSO)
Trial of 1 generic statin,
atorvastatin, fluvastatin,
lovastatin, pravastatin,
simvastatin (NSO)
Trial of 1 generic statin,
atorvastatin, fluvastatin,
lovastatin, pravastatin,
simvastatin (NSO)
LIPTRUZET
LIVALO
STATIN
LOVASTATIN
MEVACOR
PRAVACHOL
PRAVASTATIN
SIMCOR
SIMVASTATIN
VYTORIN
ZETIA
ZOCOR
APLENZIN
BRINTELLIX
BUDEPRION SR
BUPROPION
BUPROPION XL
QL
Major Depressive Disorder
MDD as defined in DSM V
1 year
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit) OR
Member has had
intolerance to drug
administered as a single
daily dose OR
Member's dose cannot be
achieved with proposed qty
limits for a given strength
(ex. Mm needs 375mg per
day and would require 5
capsules of venlafaxine sr
cap or Effexor XR 75mg to
achieve dose )
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit) OR
Member has had
intolerance to drug
administered as a single
daily dose OR
Member's dose cannot be
achieved with proposed qty
limits for a given strength
(ex. Mm needs 375mg per
day and would require 5
capsules of venlafaxine sr
cap or Effexor XR 75mg to
achieve dose.)
Covered for fully insured
member in the state of CT
who requires the prescribed
drug for the diagnosis of
gender dysphoria, as
defined in the most recent
edition DSM V.
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit) OR
Member has had
intolerance to drug
administered as a single
daily dose OR
Member's dose cannot be
achieved with proposed qty
limits for a given strength
(ex. Mm needs 375mg per
day and would require 5
capsules of venlafaxine sr
cap or Effexor XR 75mg to
achieve dose )
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit) OR
Member has had
intolerance to drug
administered as a single
daily dose OR
Member's dose cannot be
achieved with proposed qty
limits for a given strength
(ex. Mm needs 375mg per
day and would require 5
capsules of venlafaxine sr
cap or Effexor XR 75mg to
achieve dose )
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit) OR
Member has had
intolerance to drug
administered as a single
daily dose OR
Member's dose cannot be
achieved with proposed qty
limits for a given strength
(ex. Mm needs 375mg per
day and would require 5
capsules of venlafaxine sr
cap or Effexor XR 75mg to
achieve dose )
Trial of 1 generic statin,
atorvastatin, fluvastatin,
lovastatin, pravastatin,
simvastatin (NSO)
ANTIDEP Trial of 1 month of 1 of
RESSION budeprion SR/XL,
1
bupropion/SR/XL, citalopram,
escitalopram, fluoxetine,
fluvoxamine, paroxetine/sr,
mirtazapine, selfemra,
sertraline, venlafaxine,
venlafaxine sr cap
1/ day
1/ day
2/ day
2/ day
1/ day
1/ day
1/ day
1/ day
2/ day
2/ day
1/ day
1/ day
2/ day
1/ day
1/ day
1/ day
1/ day
1/ day
1/ day
ANTIDEP Trial of 3 different
RESSION antidepressants from at least
2
two different therapeutic
subclasses, i.e., SSRIs
(fluoxetine, citalopram), SNRIs
(duloxetine, venlafaxine),
TCAs (amitriptyline,
nortriptyline), heterocyclic
antidepressants (mirtazapine,
trazodone) (NSO)
2/ day
6/ day
1/ day
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
CELEXA
CITALOPRAM
DESVENLAFAXINE ER
DEPRESSION
Major Depressive Disorder
1 year
EFFEXOR XR
EMSAM
ESCITALOPRAM
FETZIMA CAP/
TITRATION PACK
FLUOXETINE CAP/ TAB/
SOL
DEPRESSION
Major Depressive Disorder
1 year
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit) OR
Member has had
intolerance to drug
administered as a single
daily dose OR
Member's dose cannot be
achieved with proposed qty
limits for a given strength
(ex. Mm needs 375mg per
day and would require 5
capsules of venlafaxine sr
cap or Effexor XR 75mg to
achieve dose )
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit) OR
Member has had
intolerance to drug
administered as a single
daily dose OR
Member's dose cannot be
achieved with proposed qty
limits for a given strength
(ex. Mm needs 375mg per
day and would require 5
capsules of venlafaxine sr
cap or Effexor XR 75mg to
achieve dose )
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit) OR
Member has had
intolerance to drug
administered as a single
daily dose OR
Member's dose cannot be
achieved with proposed qty
limits for a given strength
(ex. Mm needs 375mg per
day and would require 5
capsules of venlafaxine sr
cap or Effexor XR 75mg to
achieve dose )
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit) OR
Member has had
intolerance to drug
administered as a single
daily dose OR
Member's dose cannot be
achieved with proposed qty
limits for a given strength
(ex. Mm needs 375mg per
day and would require 5
capsules of venlafaxine sr
cap or Effexor XR 75mg to
achieve dose )
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit) OR
Member has had
intolerance to drug
administered as a single
daily dose OR
Member's dose cannot be
achieved with proposed qty
limits for a given strength
(ex. Mm needs 375mg per
day and would require 5
capsules of venlafaxine sr
cap or Effexor XR 75mg to
achieve dose )
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit) OR
Member has had
intolerance to drug
administered as a single
daily dose OR
Member's dose cannot be
achieved with proposed qty
limits for a given strength
(ex. Mm needs 375mg per
day and would require 5
capsules of venlafaxine sr
cap or Effexor XR 75mg to
achieve dose )
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit) OR
Member has had
intolerance to drug
administered as a single
daily dose OR
Member's dose cannot be
achieved with proposed qty
limits for a given strength
(ex. Mm needs 375mg per
day and would require 5
capsules of venlafaxine sr
cap or Effexor XR 75mg to
achieve dose )
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit) OR
Member has had
intolerance to drug
administered as a single
daily dose OR
Member's dose cannot be
achieved with proposed qty
limits for a given strength
(ex. Mm needs 375mg per
day and would require 5
capsules of venlafaxine sr
cap or Effexor XR 75mg to
achieve dose )
1/ day
ANTIDEP Trial of 3 different
1/ day
RESSION antidepressants from at least
2
two different therapeutic
subclasses, i.e., SSRIs
(fluoxetine, citalopram), SNRIs
(duloxetine, venlafaxine),
TCAs (amitriptyline,
nortriptyline), heterocyclic
antidepressants (mirtazapine,
trazodone) (NSO)
37.5, 75
mg 1/ day;
150 mg 2/
day
1/ day
1/ day; 20
ml/ day
ANTIDEP Trial of 3 different
1/ day; 1
RESSION antidepressants from at least pack/ 28
2
two different therapeutic
days
subclasses, i.e., SSRIs
(fluoxetine, citalopram), SNRIs
(duloxetine, venlafaxine),
TCAs (amitriptyline,
nortriptyline), heterocyclic
antidepressants (mirtazapine,
trazodone) (NSO)
10 mg 1/
day; 40
mg 2/ day;
20 mg 4/
day; 20
ml/ day;
delayed
release 4/
28 days
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
FLUOXETINE 60MG
FLUVOXAMINE
FLUVOXAMINE ER
KHEDEZLA
LEXAPRO
LUVOX
OLEPTRO
PAROXETINE/ ER
DEPRESSION
Major Depressive Disorder
1 year
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit) OR
Member has had
intolerance to drug
administered as a single
daily dose OR
Member's dose cannot be
achieved with proposed qty
limits for a given strength
(ex. Mm needs 375mg per
day and would require 5
capsules of venlafaxine sr
cap or Effexor XR 75mg to
achieve dose )
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit) OR
Member has had
intolerance to drug
administered as a single
daily dose OR
Member's dose cannot be
achieved with proposed qty
limits for a given strength
(ex. Mm needs 375mg per
day and would require 5
capsules of venlafaxine sr
cap or Effexor XR 75mg to
achieve dose )
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit) OR
Member has had
intolerance to drug
administered as a single
daily dose OR
Member's dose cannot be
achieved with proposed qty
limits for a given strength
(ex. Mm needs 375mg per
day and would require 5
capsules of venlafaxine sr
cap or Effexor XR 75mg to
achieve dose )
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit) OR
Member has had
intolerance to drug
administered as a single
daily dose OR
Member's dose cannot be
achieved with proposed qty
limits for a given strength
(ex. Mm needs 375mg per
day and would require 5
capsules of venlafaxine sr
cap or Effexor XR 75mg to
achieve dose )
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit) OR
Member has had
intolerance to drug
administered as a single
daily dose OR
Member's dose cannot be
achieved with proposed qty
limits for a given strength
(ex. Mm needs 375mg per
day and would require 5
capsules of venlafaxine sr
cap or Effexor XR 75mg to
achieve dose )
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit) OR
Member has had
intolerance to drug
administered as a single
daily dose OR
Member's dose cannot be
achieved with proposed qty
limits for a given strength
(ex. Mm needs 375mg per
day and would require 5
capsules of venlafaxine sr
cap or Effexor XR 75mg to
achieve dose )
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit) OR
Member has had
intolerance to drug
administered as a single
daily dose OR
Member's dose cannot be
achieved with proposed qty
limits for a given strength
(ex. Mm needs 375mg per
day and would require 5
capsules of venlafaxine sr
cap or Effexor XR 75mg to
achieve dose )
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit) OR
Member has had
intolerance to drug
administered as a single
daily dose OR
Member's dose cannot be
achieved with proposed qty
limits for a given strength
(ex. Mm needs 375mg per
day and would require 5
capsules of venlafaxine sr
cap or Effexor XR 75mg to
achieve dose )
FLUOXETI Trial of fluoxetine (NSO)
NE
1/ day
25, 50 mg
1/ day;
100 mg
3/day
2/ day
1/ day
ANTIDEP Trial of 3 different
RESSION antidepressants from at least
2
two different therapeutic
subclasses, i.e., SSRIs
(fluoxetine, citalopram), SNRIs
(duloxetine, venlafaxine),
TCAs (amitriptyline,
nortriptyline), heterocyclic
antidepressants (mirtazapine,
trazodone) (NSO)
1/ day; 20
ml/ day
2/ day
OLEPTRO- Trial of 1 month of trazodone
PRE
(NSO)
150 mg
1.5/ day;
300 mg 1/
day
10, 20 mg
1/ day; 30,
40, 60 mg
2/ day; 30
ml/ day
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
PAXIL CR
PAROXETINE SR
PAXIL
PEXEVA
PRISTIQ
PROZAC CAP/ TAB
SARAFEM CAP/ TAB
SERTRALINE
VENLAFAXINE/ ER
DEPRESSION
Major Depressive Disorder
1 year
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit) OR
Member has had
intolerance to drug
administered as a single
daily dose OR
Member's dose cannot be
achieved with proposed qty
limits for a given strength
(ex. Mm needs 375mg per
day and would require 5
capsules of venlafaxine sr
cap or Effexor XR 75mg to
achieve dose )
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit) OR
Member has had
intolerance to drug
administered as a single
daily dose OR
Member's dose cannot be
achieved with proposed qty
limits for a given strength
(ex. Mm needs 375mg per
day and would require 5
capsules of venlafaxine sr
cap or Effexor XR 75mg to
achieve dose )
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit) OR
Member has had
intolerance to drug
administered as a single
daily dose OR
Member's dose cannot be
achieved with proposed qty
limits for a given strength
(ex. Mm needs 375mg per
day and would require 5
capsules of venlafaxine sr
cap or Effexor XR 75mg to
achieve dose )
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit) OR
Member has had
intolerance to drug
administered as a single
daily dose OR
Member's dose cannot be
achieved with proposed qty
limits for a given strength
(ex. Mm needs 375mg per
day and would require 5
capsules of venlafaxine sr
cap or Effexor XR 75mg to
achieve dose )
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit) OR
Member has had
intolerance to drug
administered as a single
daily dose OR
Member's dose cannot be
achieved with proposed qty
limits for a given strength
(ex. Mm needs 375mg per
day and would require 5
capsules of venlafaxine sr
cap or Effexor XR 75mg to
achieve dose )
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit) OR
Member has had
intolerance to drug
administered as a single
daily dose OR
Member's dose cannot be
achieved with proposed qty
limits for a given strength
(ex. Mm needs 375mg per
day and would require 5
capsules of venlafaxine sr
cap or Effexor XR 75mg to
achieve dose ) OR
Member requires
continuous daily dosing for
premenstrual dysphoric
disorder (PMDD) – For
Sarafem, Selfemra,
fluoxetine PMDD (10mg - 30
tabs/caps in 30 days are
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit) OR
Member has had
intolerance to drug
administered as a single
daily dose OR
Member's dose cannot be
achieved with proposed qty
limits for a given strength
(ex. Mm needs 375mg per
day and would require 5
capsules of venlafaxine sr
cap or Effexor XR 75mg to
achieve dose )
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit) OR
Member has had
intolerance to drug
administered as a single
daily dose OR
Member's dose cannot be
achieved with proposed qty
limits for a given strength
(ex. Mm needs 375mg per
day and would require 5
capsules of venlafaxine sr
cap or Effexor XR 75mg to
achieve dose )
12.5 mg
25 mg
37.5 mg :
2/day
10, 20 mg
1/ day; 30,
40, 60 mg
2/ day; 30
ml/ day
PAXIL
Trial of paroxetine (NSO)
10, 20 mg
1/ day; 30,
40, 60 mg
2/ day; 30
ml/ day
1/ day
ANTIDEP Trial of 3 different
RESSION antidepressants from at least
2
two different therapeutic
subclasses, i.e., SSRIs
(fluoxetine, citalopram), SNRIs
(duloxetine, venlafaxine),
TCAs (amitriptyline,
nortriptyline), heterocyclic
antidepressants (mirtazapine,
trazodone) (NSO)
14/ 30
days
25 mg 1/
day; 50
mg 1.5/
day; 100
mg 2/ day;
10 ml/ day
37.5 mg,
75 mg 1/
day; 150
mg 2/ day
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
VENLAFAXINE ER TAB
VIIBRYD
DEPRESSION
Major Depressive Disorder
1 year
WELLBUTRIN
WELLBUTRIN SR
WELLBUTRIN XL
ZOLOFT
ABILIFY
ABILIFY
Major depressive disorder
Bipolar disorder
Schizophrenia
Psychomotor agitation associated with autistic disorder
1 year
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit) OR
Member has had
intolerance to drug
administered as a single
daily dose OR
Member's dose cannot be
achieved with proposed qty
limits for a given strength
(ex. Mm needs 375mg per
day and would require 5
capsules of venlafaxine sr
cap or Effexor XR 75mg to
achieve dose )
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit) OR
Member has had
intolerance to drug
administered as a single
daily dose OR
Member's dose cannot be
achieved with proposed qty
limits for a given strength
(ex. Mm needs 375mg per
day and would require 5
capsules of venlafaxine sr
cap or Effexor XR 75mg to
achieve dose )
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit) OR
Member has had
intolerance to drug
administered as a single
daily dose OR
Member's dose cannot be
achieved with proposed qty
limits for a given strength
(ex. Mm needs 375mg per
day and would require 5
capsules of venlafaxine sr
cap or Effexor XR 75mg to
achieve dose )
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit) OR
Member has had
intolerance to drug
administered as a single
daily dose OR
Member's dose cannot be
achieved with proposed qty
limits for a given strength
(ex. Mm needs 375mg per
day and would require 5
capsules of venlafaxine sr
cap or Effexor XR 75mg to
achieve dose )
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit) OR
Member has had
intolerance to drug
administered as a single
daily dose OR
Member's dose cannot be
achieved with proposed qty
limits for a given strength
(ex. Mm needs 375mg per
day and would require 5
capsules of venlafaxine sr
cap or Effexor XR 75mg to
achieve dose )
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit) OR
Member has had
intolerance to drug
administered as a single
daily dose OR
Member's dose cannot be
achieved with proposed qty
limits for a given strength
(ex. Mm needs 375mg per
day and would require 5
capsules of venlafaxine sr
cap or Effexor XR 75mg to
achieve dose )
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit); except
Risperdal/risperidone 4mg
OR
Member has had
intolerance to drug
administered as a single
daily dose (Abilify 10mg,
15mg; Zyprexa/Zyprexa
Zydis/olanzapine/olanzapine
ODT 5mg, 7.5mg, 10mg)
OR
Member has failed the
maximum labeled dose AND
has a therapeutic response
to a higher dose (Abilify
20mg, 30mg tablets;
Clozaril 100mg; Fanapt 12
mg; Fazaclo 100mg;
Geodon/ziprasidone 60mg,
80mg capsules; Invega 6
VENLAFA Trial of venlafaxine (NSO)
XINE
1/ day
ANTIDEP Trial of 3 different
1/ day; 1
RESSION antidepressants from at least kit/ 30
2
two different therapeutic
days
subclasses, i.e., SSRIs
(fluoxetine, citalopram), SNRIs
(duloxetine, venlafaxine),
TCAs (amitriptyline,
nortriptyline), heterocyclic
antidepressants (mirtazapine,
trazodone) (NSO)
6/ day
2/ day
1/ day
25 mg 1/
day; 50
mg 1.5/
day; 100
mg 2/ day;
10 ml/ day
ANTIPSYC Trial of 1 atypical generic
HOTICS2- antipsychotic, i.e. olanzapine,
PRE
quetiapine, risperidone,
ziprasidone, AND Latuda
(NSO)
1/ day
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
ABILIFY SOLUTION
CLOZAPINE
CLOZARIL
FANAPT
FAZACLO
GEODON
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit); except
Risperdal/risperidone 4mg
OR
Member has had
intolerance to drug
administered as a single
daily dose (Abilify 10mg,
15mg; Zyprexa/Zyprexa
Zydis/olanzapine/olanzapine
ODT 5mg, 7.5mg, 10mg)
OR
Member has failed the
maximum labeled dose AND
has a therapeutic response
to a higher dose (Abilify
20mg, 30mg tablets;
Clozaril 100mg; Fanapt 12
mg; Fazaclo 100mg;
Geodon/ziprasidone 60mg,
80mg capsules; Invega 6
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit); except
Risperdal/risperidone 4mg
OR
Member has failed the
maximum labeled dose AND
has a therapeutic response
to a higher dose (Abilify
20mg, 30mg tablets;
Clozaril 100mg; Fanapt 12
mg; Fazaclo 100mg;
Geodon/ziprasidone 60mg,
80mg capsules; Invega 6
mg, 9 mg; Latuda 160mg;
Risperdal/Risperdal
M/risperidone/risperidone
odt 3mg, 4mg tablets;
Saphris 10mg,
Seroquel/quetiapine
200mg, 300mg, 400mg;
Seroquel XR 300mg,
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit); except
Risperdal/risperidone 4mg
OR
Member has failed the
maximum labeled dose AND
has a therapeutic response
to a higher dose (Abilify
20mg, 30mg tablets;
Clozaril 100mg; Fanapt 12
mg; Fazaclo 100mg;
Geodon/ziprasidone 60mg,
80mg capsules; Invega 6
mg, 9 mg; Latuda 160mg;
Risperdal/Risperdal
M/risperidone/risperidone
odt 3mg, 4mg tablets;
Saphris 10mg,
Seroquel/quetiapine
200mg, 300mg, 400mg;
Seroquel XR 300mg,
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit); except
Risperdal/risperidone 4mg
OR
Member has failed the
maximum labeled dose AND
has a therapeutic response
to a higher dose (Abilify
20mg, 30mg tablets;
Clozaril 100mg; Fanapt 12
mg; Fazaclo 100mg;
Geodon/ziprasidone 60mg,
80mg capsules; Invega 6
mg, 9 mg; Latuda 160mg;
Risperdal/Risperdal
M/risperidone/risperidone
odt 3mg, 4mg tablets;
Saphris 10mg,
Seroquel/quetiapine
200mg, 300mg, 400mg;
Seroquel XR 300mg,
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit); except
Risperdal/risperidone 4mg
OR
Member has failed the
maximum labeled dose AND
has a therapeutic response
to a higher dose (Abilify
20mg, 30mg tablets;
Clozaril 100mg; Fanapt 12
mg; Fazaclo 100mg;
Geodon/ziprasidone 60mg,
80mg capsules; Invega 6
mg, 9 mg; Latuda 160mg;
Risperdal/Risperdal
M/risperidone/risperidone
odt 3mg, 4mg tablets;
Saphris 10mg,
Seroquel/quetiapine
200mg, 300mg, 400mg;
Seroquel XR 300mg,
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit); except
Risperdal/risperidone 4mg
OR
Member has failed the
maximum labeled dose AND
has a therapeutic response
to a higher dose (Abilify
20mg, 30mg tablets;
Clozaril 100mg; Fanapt 12
mg; Fazaclo 100mg;
Geodon/ziprasidone 60mg,
80mg capsules; Invega 6
mg, 9 mg; Latuda 160mg;
Risperdal/Risperdal
M/risperidone/risperidone
odt 3mg, 4mg tablets;
Saphris 10mg,
Seroquel/quetiapine
200mg, 300mg, 400mg;
Seroquel XR 300mg,
ABILIFY
SOLN
Trial of Abilify tablet (NSO)
900 ml/ 30
days
25 mg, 50
mg 3/ day;
100 mg 9/
day
25 mg, 50
mg 3/ day;
100 mg 9/
day
ANTIPSYC Trial of 1 atypical generic
HOTICS2- antipsychotic, i.e. olanzapine,
PRE
quetiapine, risperidone,
ziprasidone, AND Latuda
(NSO)
2/ day; 1
pack/ 30
days
12.5 mg
1/day; 25
mg 3/ day;
100 mg 9/
day; 150
mg 6/ day;
200 mg 4/
day
ANTIPSYC Trial of 1 month of Latuda
HOTICS1PRE
2/ day
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
INVEGA
LATUDA
OLANZAPINE/ ODT
QUETIAPINE
RISPERDAL
RISPERIDONE/ ODT
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit); except
Risperdal/risperidone 4mg
OR
Member has failed the
maximum labeled dose AND
has a therapeutic response
to a higher dose (Abilify
20mg, 30mg tablets;
Clozaril 100mg; Fanapt 12
mg; Fazaclo 100mg;
Geodon/ziprasidone 60mg,
80mg capsules; Invega 6
mg, 9 mg; Latuda 160mg;
Risperdal/Risperdal
M/risperidone/risperidone
odt 3mg, 4mg tablets;
Saphris 10mg,
Seroquel/quetiapine
200mg, 300mg, 400mg;
Seroquel XR 300mg,
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit); except
Risperdal/risperidone 4mg
OR
Member has failed the
maximum labeled dose AND
has a therapeutic response
to a higher dose (Abilify
20mg, 30mg tablets;
Clozaril 100mg; Fanapt 12
mg; Fazaclo 100mg;
Geodon/ziprasidone 60mg,
80mg capsules; Invega 6
mg, 9 mg; Latuda 160mg;
Risperdal/Risperdal
M/risperidone/risperidone
odt 3mg, 4mg tablets;
Saphris 10mg,
Seroquel/quetiapine
200mg, 300mg, 400mg;
Seroquel XR 300mg,
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit); except
Risperdal/risperidone 4mg
OR
Member has had
intolerance to drug
administered as a single
daily dose (Abilify 10mg,
15mg; Zyprexa/Zyprexa
Zydis/olanzapine/olanzapine
ODT 5mg, 7.5mg, 10mg)
OR
Member has failed the
maximum labeled dose AND
has a therapeutic response
to a higher dose (Abilify
20mg, 30mg tablets;
Clozaril 100mg; Fanapt 12
mg; Fazaclo 100mg;
Geodon/ziprasidone 60mg,
80mg capsules; Invega 6
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit); except
Risperdal/risperidone 4mg
OR
Member has failed the
maximum labeled dose AND
has a therapeutic response
to a higher dose (Abilify
20mg, 30mg tablets;
Clozaril 100mg; Fanapt 12
mg; Fazaclo 100mg;
Geodon/ziprasidone 60mg,
80mg capsules; Invega 6
mg, 9 mg; Latuda 160mg;
Risperdal/Risperdal
M/risperidone/risperidone
odt 3mg, 4mg tablets;
Saphris 10mg,
Seroquel/quetiapine
200mg, 300mg, 400mg;
Seroquel XR 300mg,
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit); except
Risperdal/risperidone 4mg
OR
Member has failed the
maximum labeled dose AND
has a therapeutic response
to a higher dose (Abilify
20mg, 30mg tablets;
Clozaril 100mg; Fanapt 12
mg; Fazaclo 100mg;
Geodon/ziprasidone 60mg,
80mg capsules; Invega 6
mg, 9 mg; Latuda 160mg;
Risperdal/Risperdal
M/risperidone/risperidone
odt 3mg, 4mg tablets;
Saphris 10mg,
Seroquel/quetiapine
200mg, 300mg, 400mg;
Seroquel XR 300mg,
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit); except
Risperdal/risperidone 4mg
OR
Member has failed the
maximum labeled dose AND
has a therapeutic response
to a higher dose (Abilify
20mg, 30mg tablets;
Clozaril 100mg; Fanapt 12
mg; Fazaclo 100mg;
Geodon/ziprasidone 60mg,
80mg capsules; Invega 6
mg, 9 mg; Latuda 160mg;
Risperdal/Risperdal
M/risperidone/risperidone
odt 3mg, 4mg tablets;
Saphris 10mg,
Seroquel/quetiapine
200mg, 300mg, 400mg;
Seroquel XR 300mg,
ANTIPSYC Trial of 1 atypical generic
HOTICS2- antipsychotic, i.e. olanzapine,
PRE
quetiapine, risperidone,
ziprasidone, AND Latuda
(NSO)
1.5 mg; 3
mg; 6 mg
2/ day; 9
mg 1/ day
20 mg; 40
mg; 60
mg; 120
mg 1/ day;
80 mg 2/
day
2.5 mg 2/
day; 5 mg;
7.5 mg; 10
mg; 15
mg; 20 mg
1/ day
25 mg 6/
day; 50
mg; 100
mg 3/ day;
200 mg 4/
day; 300
mg; 400
mg 2/ day
ANTIPSYC Trial of 1 month of Latuda
HOTICS1PRE
0.25 mg;
0.5 mg; 1
mg; 2 mg;
3 mg 2/
day; 4 mg
4/ day
0.25 mg;
0.5 mg; 1
mg; 2 mg;
3 mg 2/
day; 4 mg
4/ day
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
SAPHRIS
SEROQUEL
SEROQUEL XR
VERSACLOZ
ZIPRASIDONE
ZYPREXA/ ZYDIS
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit); except
Risperdal/risperidone 4mg
OR
Member has failed the
maximum labeled dose AND
has a therapeutic response
to a higher dose (Abilify
20mg, 30mg tablets;
Clozaril 100mg; Fanapt 12
mg; Fazaclo 100mg;
Geodon/ziprasidone 60mg,
80mg capsules; Invega 6
mg, 9 mg; Latuda 160mg;
Risperdal/Risperdal
M/risperidone/risperidone
odt 3mg, 4mg tablets;
Saphris 10mg,
Seroquel/quetiapine
200mg, 300mg, 400mg;
Seroquel XR 300mg,
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit); except
Risperdal/risperidone 4mg
OR
Member has failed the
maximum labeled dose AND
has a therapeutic response
to a higher dose (Abilify
20mg, 30mg tablets;
Clozaril 100mg; Fanapt 12
mg; Fazaclo 100mg;
Geodon/ziprasidone 60mg,
80mg capsules; Invega 6
mg, 9 mg; Latuda 160mg;
Risperdal/Risperdal
M/risperidone/risperidone
odt 3mg, 4mg tablets;
Saphris 10mg,
Seroquel/quetiapine
200mg, 300mg, 400mg;
Seroquel XR 300mg,
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit); except
Risperdal/risperidone 4mg
OR
Member has failed the
maximum labeled dose AND
has a therapeutic response
to a higher dose (Abilify
20mg, 30mg tablets;
Clozaril 100mg; Fanapt 12
mg; Fazaclo 100mg;
Geodon/ziprasidone 60mg,
80mg capsules; Invega 6
mg, 9 mg; Latuda 160mg;
Risperdal/Risperdal
M/risperidone/risperidone
odt 3mg, 4mg tablets;
Saphris 10mg,
Seroquel/quetiapine
200mg, 300mg, 400mg;
Seroquel XR 300mg,
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit); except
Risperdal/risperidone 4mg
OR
Member has failed the
maximum labeled dose AND
has a therapeutic response
to a higher dose (Abilify
20mg, 30mg tablets;
Clozaril 100mg; Fanapt 12
mg; Fazaclo 100mg;
Geodon/ziprasidone 60mg,
80mg capsules; Invega 6
mg, 9 mg; Latuda 160mg;
Risperdal/Risperdal
M/risperidone/risperidone
odt 3mg, 4mg tablets;
Saphris 10mg,
Seroquel/quetiapine
200mg, 300mg, 400mg;
Seroquel XR 300mg,
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit); except
Risperdal/risperidone 4mg
OR
Member has failed the
maximum labeled dose AND
has a therapeutic response
to a higher dose (Abilify
20mg, 30mg tablets;
Clozaril 100mg; Fanapt 12
mg; Fazaclo 100mg;
Geodon/ziprasidone 60mg,
80mg capsules; Invega 6
mg, 9 mg; Latuda 160mg;
Risperdal/Risperdal
M/risperidone/risperidone
odt 3mg, 4mg tablets;
Saphris 10mg,
Seroquel/quetiapine
200mg, 300mg, 400mg;
Seroquel XR 300mg,
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit); except
Risperdal/risperidone 4mg
OR
Member has had
intolerance to drug
administered as a single
daily dose (Abilify 10mg,
15mg; Zyprexa/Zyprexa
Zydis/olanzapine/olanzapine
ODT 5mg, 7.5mg, 10mg)
OR
Member has failed the
maximum labeled dose AND
has a therapeutic response
to a higher dose (Abilify
20mg, 30mg tablets;
Clozaril 100mg; Fanapt 12
mg; Fazaclo 100mg;
Geodon/ziprasidone 60mg,
80mg capsules; Invega 6
ANTIPSYC Trial of 1 atypical generic
HOTICS2- antipsychotic, i.e. olanzapine,
PRE
quetiapine, risperidone,
ziprasidone, AND Latuda
(NSO)
2/ day
ANTIPSYC Trial of 1 month of Latuda
HOTICS1PRE
25 mg 6/
day; 50
mg; 100
mg 3/ day;
200 mg 4/
day; 300
mg; 400
mg 2/ day
50 mg 6/
day; 150
mg; 200
mg 1/ day;
300 mg;
400 mg 2/
day
VERSACL Trial of clozapine (NSO)
OZ
2/ day
ANTIPSYC Trial of 1 month of Latuda
HOTICS1PRE
2.5 mg 2/
day; 5 mg;
7.5 mg; 10
mg; 15
mg; 20 mg
1/ day
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
CYMBALTA
Major depressive disorder (MDD)
Diabetic peripheral neuropathic pain (DPN)
Generalized anxiety disorder (GAD)
FibromyalgiaChronic musculoskeletal pain due to
osteoarthritis
Chronic musculoskeletal pain due to chronic low back
pain
1 year
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit) OR
Member has had
intolerance to drug
administered as a single
daily dose OR
Member's dose cannot be
achieved with proposed qty
limits for a given strength
(ex. Mm needs 375mg per
day and would require 5
capsules of venlafaxine sr
cap or Effexor XR 75mg to
achieve dose ) OR
Member has a diagnosis of
Diabetic Peripheral
Neuropathy -For Cymbalta
or duloxetine (60mg; 60
capsules in 30 days are
20, 30 mg
2/ day; 60
mg 1/ day
DULOXETINE
For coverage of additional
quantities:
Member requires a dose
including half tablets OR
Member's dose is being
titrated by physician (3month limit) OR
Member has had
intolerance to drug
administered as a single
daily dose OR
Member's dose cannot be
achieved with proposed qty
limits for a given strength
(ex. Mm needs 375mg per
day and would require 5
capsules of venlafaxine sr
cap or Effexor XR 75mg to
achieve dose ) OR
Member has a diagnosis of
Diabetic Peripheral
Neuropathy -For Cymbalta
or duloxetine (60mg; 60
capsules in 30 days are
20, 30 mg
2/ day; 60
mg 1/ day
GABAPENTIN TAB/ CAP
For coverage of additional
quantities:
Member's dose is being
titrated by physician (3
month limit) OR
Member is taking Neurontin
or gabapentin 300mg
caps/tabs, using three
caps/tabs, three times daily
for a total daily dose of
2700mg (gabapentin,
Neurontin - 300mg
tablets/capsules only) OR
Member has been titrated
up to 3600mg and requires
additional/higher dosing up
to 4800mg due to lack of
response (gabapentin,
Neurontin only)
6/ day
GRALISE
For coverage of additional GRALISE
quantities:
One additional Gralise
Starter Pack will be allowed
within 365 days for those
members that might need a
second course for titration
HORIZANT
LIDODERM
LYRICA CAP/ SOL
LIDODERM
LYRICA
Pain associated with post-herpetic neuralgia
Partial-onset seizures
Diabetic Peripheral Neuropathy (DPN)
Postherpetic Neuralgia (PHN)
Fibromyalgia
Neuropathic pain associated with spinal cord injury
1 year
1 year
NEURONTIN TAB/ CAP
For coverage of additional
quantities:
Member's dose is being
titrated by physician (3
month limit) OR
Member is taking Neurontin
or gabapentin 300mg
caps/tabs, using three
caps/tabs, three times daily
for a total daily dose of
2700mg (gabapentin,
Neurontin - 300mg
tablets/capsules only) OR
Member has been titrated
up to 3600mg and requires
additional/higher dosing up
to 4800mg due to lack of
response (gabapentin,
Neurontin only)
SAVELLA
AVINZA
For coverage of additional
quantities:
Member's dose is being
titrated by physician (3
month limit)
Trial of gabapentin (NSO)
300mg 5/
day; 600
mg 3/ day
HORIZAN Trial of 1 of cabergoline,
T
gabapentin, or pramipexole
(NSO)
2/ day
LYRICA
25 mg, 50
mg, 75
mg, 100
mg, 150
mg, 200
mg 3/day;
225 mg,
300 mg 2/
day; 30
ml/
day
6/ day
Trial of 1 month each of 3 of
the following drugs/ drug
classes: 1 tricyclic
antidepressant (i.e.,
amitriptyline), 1 muscle
relaxant (i.e.,
cyclobenzaprine), SSRI (i.e.,
citalopram), 1 SNRI (i.e.,
venlafaxine), gabapentin, or
tramadol
2/ day; 1
pack/ 30
days
2/ day
LA
Trial of 1 month each of
OPIOIDS- morphine sulfate cr tablets
PRE
(MS Contin) and oxymorphone
extended release (Opana ER)
LA OPIODS-PRE
moderate to severe pain when a continuous, around-theclock opioid analgesic is needed for an extended period
of time
1 year
DURAGESIC
LA OPIOIDS-PRE
1 year
20/ 30
days
KADIAN
LA OPIOIDS-PRE
moderate to severe pain when a continuous, around-theclock opioid analgesic is needed for an extended period
of time
moderate to severe pain when a continuous, around-theclock opioid analgesic is needed for an extended period
of time
1 year
LA
Trial of 1 month each of
2/ day
OPIOIDS- morphine sulfate cr tablets
PRE
(MS Contin) and oxymorphone
extended release (Opana ER)
BUTRANS
MORPHINE SUL ER
CAP/ BEADS
MORPHINE SUL ER TAB
12 HR
MS CONTIN
NUCYNTA
NUCYNTA ER
OPANA ER
OXYCONTIN
OXYMORPHONE ER
TRAMADOL HCL ER
ULTRAM ER
4/ 30 days
2/ day
4/ day
NUCYNTA Trial of 2 days of immediate
release oxycodone or
morphine
4/ day
6/ day
2/ day
4/ day
4/ day
4/ day
2/ day
2/ day
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
BUPRENORPHINE
TABLET
OPIOID DEPENDENCEPRE
opioid dependence
Prescriber provides verbal verification of patient’s current
and ongoing enrollment in an outpatient drug addiction
treatment program/ counseling (NSO)
Note: Medical literature does not support the concurrent
use of opioids/Tramadol as part of opioid drug
dependence treatment. Abstinence of opioids/Tramadol
is required both during and following therapy with
Suboxone/ Subutex/ Zubsolv/ Bunavail/ buprenorphine,
and will only be covered when determined to be medically
necessary**. Physicians can contact (855) 746-0013 with
any information related to the medical necessity for
opioid/Tramadol therapy.
6 months
For coverage of additional
quantities:
Member is pregnant or
breastfeeding (Up to 120
tablets in 30 days)
Member has a documented
contraindication or
intolerance or allergy to
buprenorphine-naloxone
sublingual tablet (allow up
to 90 tablets per month for
max length of approval of 6
months)
2 mg 24/
30 days
(for
induction
therapy);
8 mg 8/ 30
days (for
induction
therapy)
6 months
For coverage of additional
quantities:
Member’s dose is being
titrated by physician for 7
day induction therapy (max
dose 12 mg/daily for total of
42 tablets/films in 7 days)
2 mg/0.5
mg; 4
mg/1 mg;
8 mg/2 mg
3/ day (for
maintenan
ce
therapy);
12 mg/3
mg 2/ day
6 months
For coverage of additional
quantities:
Member’s dose is being
titrated by physician for 7
day induction therapy (max
dose 12 mg/daily for total of
42 tablets/films in 7 days)
2 mg/0.5
mg; 4
mg/1 mg;
8 mg/2 mg
3/ day (for
maintenan
ce
therapy);
12 mg/3
mg 2/ day
6 months
For coverage of additional
quantities:
Member’s dose is being
titrated by physician for 7
day induction therapy (max
dose 12 mg/daily for total of
42 tablets/films in 7 days)
2 mg/0.5
mg; 4
mg/1 mg;
8 mg/2 mg
3/ day (for
maintenan
ce
therapy);
12 mg/3
mg 2/ day
6 months
For coverage of additional ZUBSOLV- Trial of 1 month of
PRE
buprenorphine-naloxone
quantities:
sublingual tablet or Suboxone
Member’s dose is being
Film
titrated by physician for 7
day induction therapy (max
dose 8.4 mg/daily for total
of 42 tablets/films in 7 days)
3/ day (for
maintenan
ce
therapy)
1 year
STIMULAN Trial of 14 days each of 3 of
TS 1-PRE amphetamine/dextroampheta
mine/ sr, dexmethylphenidate/
sr, dextroamphetamine,
methamphetamine,
methylphenidate/ er/ sr,
Strattera, or Vyvanse
5 mg, 7.5
mg, 10
mg, 12.5
mg, 15
mg, 30 mg
2/day; 20
mg 3/ day
1 year
STIMULAN Trial of 14 days each of 3 of
TS 1-PRE amphetamine/dextroampheta
mine/ sr, dexmethylphenidate/
sr, dextroamphetamine,
methamphetamine,
methylphenidate/ er/ sr,
Strattera, or Vyvanse
5 mg, 10
mg, 15
mg, 20
mg, 25
mg, 30 mg
1/ day
**Medically necessary will be defined as:
BUPRENORPHINENALOXONE TABLET
OPIOID DEPENDENCEPRE
opioid dependence
1. Short-term use during and following opioid dependence
treatment: for the treatment of acute pain related to
surgery, dental procedure, or an emergency situation.
2. Long-term use following opioid dependence treatment:
for the treatment of chronic pain. In this case, 1) the
member must be treated by a pain management
specialist, 2) opioids will only be covered when prescribed
by the treating pain specialist, and 3) the treating pain
specialist is aware of past buprenorphine use for opioid
dependence treatment in which an opioid dependence
diagnosis (304.00) and enrollment in a drug addiction
Prescriber provides verbal verification of patient’s current
and ongoing enrollment in an outpatient drug addiction
treatment program/ counseling (NSO)
Note: Medical literature does not support the concurrent
use of opioids/Tramadol as part of opioid drug
dependence treatment. Abstinence of opioids/Tramadol
is required both during and following therapy with
Suboxone/ Subutex/ Zubsolv/ Bunavail/ buprenorphine,
and will only be covered when determined to be medically
necessary**. Physicians can contact (855) 746-0013 with
any information related to the medical necessity for
opioid/Tramadol therapy.
**Medically necessary will be defined as:
SUBOXONE FILM
OPIOID DEPENDENCEPRE
opioid dependence
1. Short-term use during and following opioid dependence
treatment: for the treatment of acute pain related to
surgery, dental procedure, or an emergency situation.
2. Long-term use following opioid dependence treatment:
for the treatment of chronic pain. In this case, 1) the
member must be treated by a pain management
specialist, 2) opioids will only be covered when prescribed
by the treating pain specialist, and 3) the treating pain
specialist is aware of past buprenorphine use for opioid
dependence treatment in which an opioid dependence
diagnosis (304.00) and enrollment in a drug addiction
Prescriber provides verbal verification of patient’s current
and ongoing enrollment in an outpatient drug addiction
treatment program/ counseling (NSO)
Note: Medical literature does not support the concurrent
use of opioids/Tramadol as part of opioid drug
dependence treatment. Abstinence of opioids/Tramadol
is required both during and following therapy with
Suboxone/ Subutex/ Zubsolv/ Bunavail/ buprenorphine,
and will only be covered when determined to be medically
necessary**. Physicians can contact (855) 746-0013 with
any information related to the medical necessity for
opioid/Tramadol therapy.
**Medically necessary will be defined as:
SUBOXONE TABLET
OPIOID DEPENDENCEPRE
opioid dependence
1. Short-term use during and following opioid dependence
treatment: for the treatment of acute pain related to
surgery, dental procedure, or an emergency situation.
2. Long-term use following opioid dependence treatment:
for the treatment of chronic pain. In this case, 1) the
member must be treated by a pain management
specialist, 2) opioids will only be covered when prescribed
by the treating pain specialist, and 3) the treating pain
specialist is aware of past buprenorphine use for opioid
dependence treatment in which an opioid dependence
diagnosis (304.00) and enrollment in a drug addiction
Prescriber provides verbal verification of patient’s current
and ongoing enrollment in an outpatient drug addiction
treatment program/ counseling (NSO)
Note: Medical literature does not support the concurrent
use of opioids/Tramadol as part of opioid drug
dependence treatment. Abstinence of opioids/Tramadol
is required both during and following therapy with
Suboxone/ Subutex/ Zubsolv/ Bunavail/ buprenorphine,
and will only be covered when determined to be medically
necessary**. Physicians can contact (855) 746-0013 with
any information related to the medical necessity for
opioid/Tramadol therapy.
**Medically necessary will be defined as:
ZUBSOLV TABLET
OPIOID DEPENDENCEPRE
opioid dependence
1. Short-term use during and following opioid dependence
treatment: for the treatment of acute pain related to
surgery, dental procedure, or an emergency situation.
2. Long-term use following opioid dependence treatment:
for the treatment of chronic pain. In this case, 1) the
member must be treated by a pain management
specialist, 2) opioids will only be covered when prescribed
by the treating pain specialist, and 3) the treating pain
specialist is aware of past buprenorphine use for opioid
dependence treatment in which an opioid dependence
diagnosis (304.00) and enrollment in a drug addiction
Prescriber provides verbal verification of patient’s current
and ongoing enrollment in an outpatient drug addiction
treatment program/ counseling (NSO)
Note: Medical literature does not support the concurrent
use of opioids/Tramadol as part of opioid drug
dependence treatment. Abstinence of opioids/Tramadol
is required both during and following therapy with
Suboxone/ Subutex/ Zubsolv/ Bunavail/ buprenorphine,
and will only be covered when determined to be medically
necessary**. Physicians can contact (855) 746-0013 with
any information related to the medical necessity for
opioid/Tramadol therapy.
**Medically necessary will be defined as:
ADDERALL
STIMULANTS 1-PRE
Attention deficit hyperactivity disorder (ADHD)
Narcolepsy
ADDERALL XR
STIMULANTS 1-PRE
Attention deficit hyperactivity disorder (ADHD)
Narcolepsy
1. Short-term use during and following opioid dependence
treatment: for the treatment of acute pain related to
surgery, dental procedure, or an emergency situation.
2. Long-term use following opioid dependence treatment:
for the treatment of chronic pain. In this case, 1) the
member must be treated by a pain management
specialist, 2) opioids will only be covered when prescribed
by the treating pain specialist, and 3) the treating pain
specialist is aware of past buprenorphine use for opioid
dependence treatment in which an opioid dependence
diagnosis (304.00) and enrollment in a drug addiction
AMPHETAMINE/DEXTR
OAMPHETAMINE
5 mg, 7.5
mg, 10
mg, 12.5
mg, 15
mg, 30 mg
2/day; 20
mg 3/ day
AMPHETAMINE/DEXTR
OAMPHETAMINE ER
5 mg, 10
mg, 15
mg, 20
mg, 25
mg, 30 mg
1/ day
4/ day
CLONIDINE ER
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
CONCERTA
STIMULANTS 1-PRE
Attention deficit hyperactivity disorder (ADHD)
Narcolepsy
1 year
STIMULAN Trial of 14 days each of 3 of
18 mg, 27
TS 1-PRE amphetamine/dextroampheta mg, 54 mg
mine/ sr, dexmethylphenidate/ 1/ day
sr, dextroamphetamine,
methamphetamine,
methylphenidate/ er/ sr,
Strattera, or Vyvanse
DAYTRANA
STIMULANTS 1-PRE
Attention deficit hyperactivity disorder (ADHD)
Narcolepsy
1 year
STIMULAN Trial of 14 days each of 3 of
36 mg 2/
TS 1-PRE amphetamine/dextroampheta day
mine/ sr, dexmethylphenidate/
sr, dextroamphetamine,
methamphetamine,
methylphenidate/ er/ sr,
Strattera, or Vyvanse
DESOXYN
STIMULANTS 1-PRE
Attention deficit hyperactivity disorder (ADHD)
Narcolepsy
1 year
STIMULAN Trial of 14 days each of 3 of
4/ day
TS 1-PRE amphetamine/dextroampheta
mine/ sr, dexmethylphenidate/
sr, dextroamphetamine,
methamphetamine,
methylphenidate/ er/ sr,
Strattera, or Vyvanse
DEXEDRINE
STIMULANTS 1-PRE
Attention deficit hyperactivity disorder (ADHD)
Narcolepsy
1 year
STIMULAN Trial of 14 days each of 3 of
TS 1-PRE amphetamine/dextroampheta
mine/ sr, dexmethylphenidate/
sr, dextroamphetamine,
methamphetamine,
methylphenidate/ er/ sr,
Strattera, or Vyvanse
DEXMETHYLPHENIDAT
E
DEXMETHYLPHENIDAT
E XR
DEXTROAMPHETAMINE
SOLN
DEXTROAMPHETAMINE
ER
DEXTROAMPHETAMINE STIMULANTS 1-PRE
TAB
3/ day (for
maintenan
ce
therapy)
2/ day
1/ day
40 ml/ day
3/ day
Attention deficit hyperactivity disorder (ADHD)
Narcolepsy
1 year
4/ day
FOCALIN
STIMULANTS 1-PRE
Attention deficit hyperactivity disorder (ADHD)
Narcolepsy
1 year
STIMULAN Trial of 14 days each of 3 of
2/ day
TS 1-PRE amphetamine/dextroampheta
mine/ sr, dexmethylphenidate/
sr, dextroamphetamine,
methamphetamine,
methylphenidate/ er/ sr,
Strattera, or Vyvanse
FOCALIN XR
STIMULANTS 1-PRE
Attention deficit hyperactivity disorder (ADHD)
Narcolepsy
1 year
STIMULAN Trial of 14 days each of 3 of
1/ day
TS 1-PRE amphetamine/dextroampheta
mine/ sr, dexmethylphenidate/
sr, dextroamphetamine,
methamphetamine,
methylphenidate/ er/ sr,
Strattera, or Vyvanse
INTUNIV
STIMULANTS 2-PRE
Attention deficit hyperactivity disorder (ADHD)
1 year
1/ day
STIMULAN Trial of 14 days each of 3 of
TS 2-PRE clonidine/ sr, guanfacine,
amphetamine/dextroampheta
mine/ sr, dexmethylphenidate/
sr, dextroamphetamine,
methamphetamine,
methylphenidate/ er/ sr,
Strattera, or Vyvanse
KAPVAY
STIMULANTS 2-PRE
Attention deficit hyperactivity disorder (ADHD)
1 year
4/ day; 1
STIMULAN Trial of 14 days each of 3 of
pack/ 30
TS 2-PRE clonidine/ sr, guanfacine,
amphetamine/dextroampheta days
mine/ sr, dexmethylphenidate/
sr, dextroamphetamine,
methamphetamine,
methylphenidate/ er/ sr,
Strattera, or Vyvanse
METADATE CD CAP
STIMULANTS 1-PRE
Attention deficit hyperactivity disorder (ADHD)
Narcolepsy
1 year
1/ day
STIMULAN Trial of 14 days each of 3 of
TS 1-PRE amphetamine/dextroampheta
mine/ sr, dexmethylphenidate/
sr, dextroamphetamine,
methamphetamine,
methylphenidate/ er/ sr,
Strattera, or Vyvanse
METADATE ER TAB
METHAMPHETAMINE
METHYLIN CHEW/
SOLN
STIMULANTS 1-PRE
Attention deficit hyperactivity disorder (ADHD)
Narcolepsy
1 year
STIMULAN Trial of 14 days each of 3 of
TS 1-PRE amphetamine/dextroampheta
mine/ sr, dexmethylphenidate/
sr, dextroamphetamine,
methamphetamine,
methylphenidate/ er/ sr,
Strattera, or Vyvanse
METHYLPHENIDATE
SOLN
METHYLPHENIDATE
TAB (generic Ritalin)
METHYLPHENIDATE ER
CAPS
METHYLPHENIDATE ER
CAPS (generic RITALIN
LA)
20 mg, 40
mg 1/ day;
30 mg 2/
day
4/ day
6/ day; 60
ml/ day
60 ml/ day
3/ day
3/ day
20 mg, 40
mg 1/ day;
30 mg 2/
day
18 mg, 27
mg, 54 mg
1/ day
3/ day
METHYLPHENIDATE ER
TAB (generic Concerta)
METHYLPHENIDATE ER
TAB (generic
METADATE ER,
RITALIN SR)
PROCENTRA
STIMULANTS 1-PRE
Attention deficit hyperactivity disorder (ADHD)
Narcolepsy
1 year
STIMULAN Trial of 14 days each of 3 of
40 ml/ day
TS 1-PRE amphetamine/dextroampheta
mine/ sr, dexmethylphenidate/
sr, dextroamphetamine,
methamphetamine,
methylphenidate/ er/ sr,
Strattera, or Vyvanse
QUILLIVANT XR
STIMULANTS 1-PRE
Attention deficit hyperactivity disorder (ADHD)
Narcolepsy
1 year
12 ml/ day
STIMULAN Trial of 14 days each of 3 of
TS 1-PRE amphetamine/dextroampheta
mine/ sr, dexmethylphenidate/
sr, dextroamphetamine,
methamphetamine,
methylphenidate/ er/ sr,
Strattera, or Vyvanse
RITALIN
STIMULANTS 1-PRE
Attention deficit hyperactivity disorder (ADHD)
Narcolepsy
1 year
STIMULAN Trial of 14 days each of 3 of
3/ day
TS 1-PRE amphetamine/dextroampheta
mine/ sr, dexmethylphenidate/
sr, dextroamphetamine,
methamphetamine,
methylphenidate/ er/ sr,
Strattera, or Vyvanse
RITALIN LA
STIMULANTS 1-PRE
Attention deficit hyperactivity disorder (ADHD)
Narcolepsy
1 year
STIMULAN Trial of 14 days each of 3 of
TS 1-PRE amphetamine/dextroampheta
mine/ sr, dexmethylphenidate/
sr, dextroamphetamine,
methamphetamine,
methylphenidate/ er/ sr,
Strattera, or Vyvanse
RITALIN SR
STIMULANTS 1-PRE
Attention deficit hyperactivity disorder (ADHD)
Narcolepsy
1 year
STIMULAN Trial of 14 days each of 3 of
3/ day
TS 1-PRE amphetamine/dextroampheta
mine/ sr, dexmethylphenidate/
sr, dextroamphetamine,
methamphetamine,
methylphenidate/ er/ sr,
Strattera, or Vyvanse
20 mg, 40
mg 1/ day;
30 mg 2/
day
STRATTERA
10 mg, 18
mg, 25
mg, 40
mg, 60 mg
2/ day; 80
mg, 100
mg 1/ day
VYVANSE
1/ day
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
ZENZEDI
2.5/7.5/10/20/30 MG
STIMULANTS 1-PRE
Attention deficit hyperactivity disorder (ADHD)
Narcolepsy
MODAFINIL
NARCOLEPSY-PRE
Narcolepsy
Obstructive sleep apnea/hypopnea syndrome (OSAHS)
NUVIGIL
NARCOLEPSY-PRE
Narcolepsy
Obstructive sleep apnea/hypopnea syndrome (OSAHS)
PROVIGIL
NARCOLEPSY-PRE
Narcolepsy
Obstructive sleep apnea/hypopnea syndrome (OSAHS)
1 year
STIMULAN Trial of 14 days each of 3 of
TS 1-PRE amphetamine/dextroampheta
mine/ sr, dexmethylphenidate/
sr, dextroamphetamine,
methamphetamine,
methylphenidate/ er/ sr,
Strattera, or Vyvanse
ZENZEDI 5/10 MG
Narcolepsy, confirmed by sleep lab evaluation OR
OSAHS) confirmed by polysomnography (a study on sleep
cycles and behavior) AND one of the following:
Member is currently using an oral/dental appliance
Member has undergone an uvulopalatopharyngoplasty
(UPPP)
Member is greater than or equal to 65 yrs of age
Member has already had an adequate therapeutic trial of
twelve weeks of continuous positive airway pressure
(CPAP)/ bilevel positive airway pressure (BiPAP)
treatment and meets ALL of the following:
Member is compliant with and currently using CPAP/BiPAP
treatment
Member is experiencing excessive sleepiness despite
Narcolepsy, confirmed by sleep lab evaluation OR
OSAHS) confirmed by polysomnography (a study on sleep
cycles and behavior) AND one of the following:
Member is currently using an oral/dental appliance
Member has undergone an uvulopalatopharyngoplasty
(UPPP)
Member is greater than or equal to 65 yrs of age
Member has already had an adequate therapeutic trial of
twelve weeks of continuous positive airway pressure
(CPAP)/ bilevel positive airway pressure (BiPAP)
treatment and meets ALL of the following:
Member is compliant with and currently using CPAP/BiPAP
treatment
Member is experiencing excessive sleepiness despite
Narcolepsy, confirmed by sleep lab evaluation OR
OSAHS) confirmed by polysomnography (a study on sleep
cycles and behavior) AND one of the following:
Member is currently using an oral/dental appliance
Member has undergone an uvulopalatopharyngoplasty
(UPPP)
Member is greater than or equal to 65 yrs of age
Member has already had an adequate therapeutic trial of
twelve weeks of continuous positive airway pressure
(CPAP)/ bilevel positive airway pressure (BiPAP)
treatment and meets ALL of the following:
Member is compliant with and currently using CPAP/BiPAP
treatment
Member is experiencing excessive sleepiness despite
5 mg, 10
mg 4/ day
2/ day
1 year
1 year
50 mg
2/day; 150
mg; 200
mg; 250
mg 1/ day
1 year
2/ day
TRIPTANS- Trial of 1 month of 3 of the
PRE
following: naratriptan,
rizatriptan, sumatriptan,
zolmitriptan (NSO)
ALSUMA
AMERGE
AXERT
TRIPTANS- Trial of 1 month of 3 of the
PRE
following: naratriptan,
rizatriptan, sumatriptan,
zolmitriptan (NSO)
TRIPTANS- Trial of 1 month of 3 of the
PRE
following: naratriptan,
rizatriptan, sumatriptan,
zolmitriptan (NSO)
FROVA
IMITREX TAB
IMITREX INJ
IMITREX SPR
MAXALT
MAXALT MLT
NARATRIPTAN HCL
RELPAX
TRIPTANS- Trial of 1 month of 3 of the
PRE
following: naratriptan,
rizatriptan, sumatriptan,
zolmitriptan (NSO)
RIZATRIPTAN
SUMATRIPTAN INJ
SUMATRIPTAN SPR
SUMATRIPTAN TAB
SUMAVEL DOSEPRO
TRIPTANS- Trial of 1 month of 3 of the
PRE
following: naratriptan,
rizatriptan, sumatriptan,
zolmitriptan (NSO)
TREXIME Trial of 1 month of 3 of the
T-PRE
following: naratriptan,
rizatriptan, sumatriptan,
zolmitriptan AND concurrent
use of prescription strength
naproxen >/= 500mg (NSO)
TREXIMET
ZOLMITRIPTAN
ZOLMITRIPTAN ODT
ZOMIG/ NASAL
ABSORICA
ISOTRETINOINS-PRE
severe recalcitrant nodular or cystic acne
Member is enrolled in the FDA iPLEDGE program
(females of childbearing potential ONLY)
6 months
AMNESTEEM
ISOTRETINOINS-PRE
severe recalcitrant nodular or cystic acne
Member is enrolled in the FDA iPLEDGE program
(females of childbearing potential ONLY)
6 months
CLARAVIS
ISOTRETINOINS-PRE
severe recalcitrant nodular or cystic acne
Member is enrolled in the FDA iPLEDGE program
(females of childbearing potential ONLY)
6 months
MYORISAN
ISOTRETINOINS-PRE
severe recalcitrant nodular or cystic acne
Member is enrolled in the FDA iPLEDGE program
(females of childbearing potential ONLY)
6 months
ZENATANE
ISOTRETINOINS-PRE
severe recalcitrant nodular or cystic acne
Member is enrolled in the FDA iPLEDGE program
(females of childbearing potential ONLY)
6 months
ALDARA
imiquimod cream
PICATO GEL
2.5 mg,
7.5 mg 4/
day; 13
mg, 20
mg, 30 mg
2/ day
TRIPTANS- Trial of 1 month of 3 of the
PRE
following: naratriptan,
rizatriptan, sumatriptan,
zolmitriptan (NSO)
ISOTRETI Trial of 1 generic oral
NOINSantibiotic prescribed for the
PRE
treatment of acne (i.e.,
minocycline or doxycycline)
ISOTRETI Trial of 1 generic oral
NOINSantibiotic prescribed for the
PRE
treatment of acne (i.e.,
minocycline or doxycycline)
ISOTRETI Trial of 1 generic oral
NOINSantibiotic prescribed for the
PRE
treatment of acne (i.e.,
minocycline or doxycycline)
ISOTRETI Trial of 1 generic oral
NOINSantibiotic prescribed for the
PRE
treatment of acne (i.e.,
minocycline or doxycycline)
ISOTRETI Trial of 1 generic oral
NOINSantibiotic prescribed for the
PRE
treatment of acne (i.e.,
minocycline or doxycycline)
4 kits (8
syringes)
in 30 days
9 tablets
in 30 days
6 tablets
in 30 days
9 tablets
in 30 days
10
cartridge(
s) per
month
6 sprays
in 30 days
9 tablets
in 30 days
12 tablets
in 30 days
12 tablets
in 30 days
9 tablets
in 30 days
6 tablets
in 30 days
12 tablets
in 30 days
10
cartridge(
s) per
month
6 sprays
in 30 days
9 tablets
in 30 days
6 (3 ml)
syringes
in 30 days
9 tablets
in 30 days
6 tablets
in 30 days
6 tablets
in 30 days
6 tablets/
sprays in
30 days
2/ day
2/ day
2/ day
2/ day
2/ day
16 weeks
of
treatment
per 365
days
16 weeks
of
treatment
per 365
days
0.015%
gel 18
tubes (6
boxes) per
year;
0.05% gel
12 tubes
(6 boxes)
per year
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
ZYCLARA
FREESTYLE
ONE TOUCH
PRECISION
All Other Test Strips
TEST
STRIPSPRE
Trial of 1 month each of 2 of
the preferred alternative test
strip products, Onetouch,
Freestyle Test Strips, or
Precision Xtra Test Strips
JANUMET
JANUMET XR
JANUVIA
JENTADUETO
KAZANO
DIABETES
type 2 diabetes mellitus in adults
1 year
KAZANOPRE
Trial of 1 month each of
Jentadueto AND Kombiglyze
XR AND Janumet or Janumet
XR
KOMBIGLYZE XR
NESINA
DIABETES
type 2 diabetes mellitus in adults
1 year
NESINAPRE
Trial of 1 month each of
metformin, AND Januvia AND
Onglyza AND Tradjeta
ONGLYZA
OSENI
DIABETES
type 2 diabetes mellitus in adults
1 year
OSENIPRE
TRADJENTA
ANDRODERM
TESTOSTERONE-PRE
Hypogonadism
female members
A. Testosterone replacement for androgen deficiency in men is
considered medically necessary only for persons with one or more
of the symptoms and signs listed: incomplete sexual development,
eunuchoidism, aspermia; reduced sexual desire (libido) and
activity; decreased spontaneous erections; breast discomfort,
gynecomastia; loss of body (axillary and pubic) hair, reduced
shaving; very small or shrinking testes; inability to father children,
low or zero sperm counts; height loss, low trauma fracture, low
bone mineral density; reduced muscle bulk and strength; or hot
flushes, sweats.
1 year
3.75%
cream
packets
56
packets of
treatment
per 365
days;
2.5%,
3.75%
cream
pump
dispenser
2 pumps
(15gm)
per 365
days
10/ day
10/ day
10/ day
10/ day
2/ day
1/ day
1/ day
2/ day
2/day
1/ day
1/ day
1/ day
Trial of 1 month each of
1/ day
metformin (single entity or
combination) AND pioglitazone
in combination with Januvia
AND Onglyza AND Tradjenta
1/ day
TESTOST Documentation of trial and failure 1/ day
of the preferred topical
ERONEtestosterone products (Testim and
PRE
Androgel) is required prior to
coverage of other topical products
(Androderm, Axiron, Fortesta,
Striant, Testosterone gel pump,
Vogelxo)
B. Member must be male with a symptomatic androgen deficiency
as defined by one of the follwoing:
- Having two consecutive low total fasting serum testosterone
levels (below the testing laboratory's reference range or below
300ng/dl if reference ranges are not available), OR
- For persons with low normal total testosterone levels (above 300
ng/dL but below 400 ng/dL), two consecutive low free or
bioavailable fasting serum testosterone levels (below the testing
laboratory's reference range or less than 225 picomoles per liter
(pmol/L) (6 ng/dL) if reference ranges are not available)
C. Two morning samples drawn between 7:00 a.m. and 10:00 a.m.
obtained on two consecutive days is required.
ANDROGEL
TESTOSTERONE-PRE
Hypogonadism
female members
A. Testosterone replacement for androgen deficiency in men is
considered medically necessary only for persons with one or more
of the symptoms and signs listed: incomplete sexual development,
eunuchoidism, aspermia; reduced sexual desire (libido) and
activity; decreased spontaneous erections; breast discomfort,
gynecomastia; loss of body (axillary and pubic) hair, reduced
shaving; very small or shrinking testes; inability to father children,
low or zero sperm counts; height loss, low trauma fracture, low
bone mineral density; reduced muscle bulk and strength; or hot
flushes, sweats.
1 year
1.62%
pump/ 2
month;
1.62%
packet
(20.25mg/
1.25gm)
1/ day;
1.62%
packet
(40.5mg/
2.5gm) 2/
day; 1%
pump 4/
month; 1%
packet
(25mg/
2.5gm) 1/
day; 1%
packet
(50mg/
5gm) 2
day
B. Member must be male with a symptomatic androgen deficiency
as defined by one of the follwoing:
- Having two consecutive low total fasting serum testosterone
levels (below the testing laboratory's reference range or below
300ng/dl if reference ranges are not available), OR
- For persons with low normal total testosterone levels (above 300
ng/dL but below 400 ng/dL), two consecutive low free or
bioavailable fasting serum testosterone levels (below the testing
laboratory's reference range or less than 225 picomoles per liter
(pmol/L) (6 ng/dL) if reference ranges are not available)
C. Two morning samples drawn between 7:00 a.m. and 10:00 a.m.
obtained on two consecutive days is required.
AXIRON
Hypogonadism
female members
A. Testosterone replacement for androgen deficiency in men is
considered medically necessary only for persons with one or more
of the symptoms and signs listed: incomplete sexual development,
eunuchoidism, aspermia; reduced sexual desire (libido) and
activity; decreased spontaneous erections; breast discomfort,
gynecomastia; loss of body (axillary and pubic) hair, reduced
shaving; very small or shrinking testes; inability to father children,
low or zero sperm counts; height loss, low trauma fracture, low
bone mineral density; reduced muscle bulk and strength; or hot
flushes, sweats.
1 year
2 pumps/
TESTOST Documentation of trial and
ERONEfailure of the preferred topical month
PRE
testosterone products (Testim
and Androgel) is required
prior to coverage of other
topical products (Androderm,
Axiron, Fortesta, Striant,
Testosterone gel pump,
Vogelxo)
1 year
TESTOST Trial of 1 month each of
ERONEAndroGel AND Testim
PRE
B. Member must be male with a symptomatic androgen deficiency
as defined by one of the follwoing:
- Having two consecutive low total fasting serum testosterone
levels (below the testing laboratory's reference range or below
300ng/dl if reference ranges are not available), OR
- For persons with low normal total testosterone levels (above 300
ng/dL but below 400 ng/dL), two consecutive low free or
bioavailable fasting serum testosterone levels (below the testing
laboratory's reference range or less than 225 picomoles per liter
(pmol/L) (6 ng/dL) if reference ranges are not available)
C. Two morning samples drawn between 7:00 a.m. and 10:00 a.m.
obtained on two consecutive days is required.
FORTESTA
TESTOSTERONE-PRE
Hypogonadism
female members
A. Testosterone replacement for androgen deficiency in men is
considered medically necessary only for persons with one or more
of the symptoms and signs listed: incomplete sexual development,
eunuchoidism, aspermia; reduced sexual desire (libido) and
activity; decreased spontaneous erections; breast discomfort,
gynecomastia; loss of body (axillary and pubic) hair, reduced
shaving; very small or shrinking testes; inability to father children,
low or zero sperm counts; height loss, low trauma fracture, low
bone mineral density; reduced muscle bulk and strength; or hot
flushes, sweats.
B. Member must be male with a symptomatic androgen deficiency
as defined by one of the follwoing:
- Having two consecutive low total fasting serum testosterone
levels (below the testing laboratory's reference range or below
300ng/dl if reference ranges are not available), OR
- For persons with low normal total testosterone levels (above 300
ng/dL but below 400 ng/dL), two consecutive low free or
bioavailable fasting serum testosterone levels (below the testing
laboratory's reference range or less than 225 picomoles per liter
(pmol/L) (6 ng/dL) if reference ranges are not available)
C. Two morning samples drawn between 7:00 a.m. and 10:00 a.m.
obtained on two consecutive days is required.
2
canisters/
month
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
STRIANT
TESTOSTERONE-PRE
Hypogonadism
female members
A. Testosterone replacement for androgen deficiency in men is
considered medically necessary only for persons with one or more
of the symptoms and signs listed: incomplete sexual development,
eunuchoidism, aspermia; reduced sexual desire (libido) and
activity; decreased spontaneous erections; breast discomfort,
gynecomastia; loss of body (axillary and pubic) hair, reduced
shaving; very small or shrinking testes; inability to father children,
low or zero sperm counts; height loss, low trauma fracture, low
bone mineral density; reduced muscle bulk and strength; or hot
flushes, sweats.
1 year
TESTOST Documentation of trial and
2/ day
ERONEfailure of the preferred topical
PRE
testosterone products (Testim
and Androgel) is required
prior to coverage of other
topical products (Androderm,
Axiron, Fortesta, Striant,
Testosterone gel pump,
Vogelxo)
1 year
2/ day
1 year
50mg/
5gm
packet/
tube 2/
day;
12.5mg/
pump
actuation
4 pumps/
month
B. Member must be male with a symptomatic androgen deficiency
as defined by one of the follwoing:
- Having two consecutive low total fasting serum testosterone
levels (below the testing laboratory's reference range or below
300ng/dl if reference ranges are not available), OR
- For persons with low normal total testosterone levels (above 300
ng/dL but below 400 ng/dL), two consecutive low free or
bioavailable fasting serum testosterone levels (below the testing
laboratory's reference range or less than 225 picomoles per liter
(pmol/L) (6 ng/dL) if reference ranges are not available)
C. Two morning samples drawn between 7:00 a.m. and 10:00 a.m.
obtained on two consecutive days is required.
TESTIM
TESTOSTERONE-PRE
Hypogonadism
female members
A. Testosterone replacement for androgen deficiency in men is
considered medically necessary only for persons with one or more
of the symptoms and signs listed: incomplete sexual development,
eunuchoidism, aspermia; reduced sexual desire (libido) and
activity; decreased spontaneous erections; breast discomfort,
gynecomastia; loss of body (axillary and pubic) hair, reduced
shaving; very small or shrinking testes; inability to father children,
low or zero sperm counts; height loss, low trauma fracture, low
bone mineral density; reduced muscle bulk and strength; or hot
flushes, sweats.
B. Member must be male with a symptomatic androgen deficiency
as defined by one of the follwoing:
- Having two consecutive low total fasting serum testosterone
levels (below the testing laboratory's reference range or below
300ng/dl if reference ranges are not available), OR
- For persons with low normal total testosterone levels (above 300
ng/dL but below 400 ng/dL), two consecutive low free or
bioavailable fasting serum testosterone levels (below the testing
laboratory's reference range or less than 225 picomoles per liter
(pmol/L) (6 ng/dL) if reference ranges are not available)
C. Two morning samples drawn between 7:00 a.m. and 10:00 a.m.
obtained on two consecutive days is required.
Testosterone Gel
(generic)
TESTOSTERONE-PRE
Hypogonadism
female members
A. Testosterone replacement for androgen deficiency in men is
considered medically necessary only for persons with one or more
of the symptoms and signs listed: incomplete sexual development,
eunuchoidism, aspermia; reduced sexual desire (libido) and
activity; decreased spontaneous erections; breast discomfort,
gynecomastia; loss of body (axillary and pubic) hair, reduced
shaving; very small or shrinking testes; inability to father children,
low or zero sperm counts; height loss, low trauma fracture, low
bone mineral density; reduced muscle bulk and strength; or hot
flushes, sweats.
B. Member must be male with a symptomatic androgen deficiency
as defined by one of the follwoing:
- Having two consecutive low total fasting serum testosterone
levels (below the testing laboratory's reference range or below
300ng/dl if reference ranges are not available), OR
- For persons with low normal total testosterone levels (above 300
ng/dL but below 400 ng/dL), two consecutive low free or
bioavailable fasting serum testosterone levels (below the testing
laboratory's reference range or less than 225 picomoles per liter
(pmol/L) (6 ng/dL) if reference ranges are not available)
C. Two morning samples drawn between 7:00 a.m. and 10:00 a.m.
obtained on two consecutive days is required.
VOGELXO
TESTOSTERONE-PRE
Hypogonadism
female members
A. Testosterone replacement for androgen deficiency in men is
considered medically necessary only for persons with one or more
of the symptoms and signs listed: incomplete sexual development,
eunuchoidism, aspermia; reduced sexual desire (libido) and
activity; decreased spontaneous erections; breast discomfort,
gynecomastia; loss of body (axillary and pubic) hair, reduced
shaving; very small or shrinking testes; inability to father children,
low or zero sperm counts; height loss, low trauma fracture, low
bone mineral density; reduced muscle bulk and strength; or hot
flushes, sweats.
1 year
TESTOST Documentation of trial and
ERONEfailure of the preferred topical
PRE
testosterone products (Testim
and Androgel) is required
prior to coverage of other
topical products (Androderm,
Axiron, Fortesta, Striant,
Testosterone gel pump,
Vogelxo)
50mg/
5gm
packet/
tube 2/
day;
12.5mg/
pump
actuation
2/ month
B. Member must be male with a symptomatic androgen deficiency
as defined by one of the follwoing:
- Having two consecutive low total fasting serum testosterone
levels (below the testing laboratory's reference range or below
300ng/dl if reference ranges are not available), OR
- For persons with low normal total testosterone levels (above 300
ng/dL but below 400 ng/dL), two consecutive low free or
bioavailable fasting serum testosterone levels (below the testing
laboratory's reference range or less than 225 picomoles per liter
(pmol/L) (6 ng/dL) if reference ranges are not available)
C. Two morning samples drawn between 7:00 a.m. and 10:00 a.m.
obtained on two consecutive days is required.
BYDUREON
BYETTA
TANZEUM
TANZEUM
Type II diabetes
no personal or family history of medullary thyroid
carcinoma (MTC) or Multiple Endocrine Neoplasia
syndrome type 2 (MEN 2)
1 year
Trial of 1 month each of
Bydureon and Victoza
VICTOZA
INVOKANA
INVOKAMET
FARXIGA
XIGDUO
Trial of 1 month of metformin
Trial of 1 month of metformin
Trial of 1 month of metformin
Trial of 1 month of metformin
JARDIANCE
Trial of 1 month of metformin
AND Invokana
ACTIVELLA
ANGELIQ
CENESTIN
FEMHRT
MIMVEY
NORETHINDRONE
PREFEST
ALORA
CLIMARA
CLIMARA PRO
COMBIPATCH
ELESTRIN
ESTRADIOL PATCH
ESTRASORB
ESTROGEL
EVAMIST
MENOSTAR
MINIVELLE
VIVELLE-DOT
FEMRING
balsalazide
CANASA suppository
COLAZAL
1.2 mg 2
/month;
1.8mg 3/
30 days
1/ day
2/ day
1/day
5/500 mg:
1/day,
5/1000 mg:
2/day,
10/500 mg:
1/day,
10/1000mg
: 1/day
1/day
1/ day
1/ day
0.3mg,
0.45mg,
0.625mg,
0.9mg 1
per day;
1.25mg
2/day
1/ day
0.3mg,
0.45mg,
0.625mg,
0.9mg 1
per day;
1.25mg
2/day
1/ day
1/ day
2/ day
1/ day
8/ month
1/ week
1/ week
8/ month
1/ fill
1/ week
2/ day
1/ fill
1/ fill
1/ week
8/ month
8/ month
1/ 90 days
DUAVEE
ENJUVIA
APRISO
ASACOL
ASACOL HD
AZULFIDINE/ EN TABS
4/ month
1/ month
4/ month
5ASAPRE
Trial of 1 month of Apriso,
Asacol, Asacol HD, Delzicol,
Lialda, or Pentasa (NSO)
5ASAPRE
Trial of 1 month of Apriso,
Asacol, Asacol HD, Delzicol,
Lialda, or Pentasa (NSO)
4/ day
12/ day
6/ day
8/ day
9/ day
1/ day
9/ day
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
DELZICOL
DIPENTUM
5ASAPRE
GIAZO
ulcerative colitis
female members
covered in
patients 18
years of age
and older
1 year
5ASAPRE
Trial of 1 month of Apriso,
Asacol, Asacol HD, Delzicol,
Lialda, or Pentasa (NSO)
Trial of 1 month of Apriso,
Asacol, Asacol HD, Delzicol,
Lialda, or Pentasa (NSO)
LIALDA
PENTASA
Sulfasalazine
sulfasalazine DR
sulfazine
sulfazine EC
AMITIZA
Trial of 1 month of 1
prescription generic laxative
alternative (i.e., lactulose)
(NSO)
LINZESS
Cialis 2.5/5 MG
Trial of 1 month of 1
prescription generic laxative
alternative (i.e., lactulose)
(NSO)
CIALIS_BPH-PRE
For BPH (Benign Prostatic Hyperplasia)
Member has diagnosis of BPH (Benign Prostatic
Hyperplasia)
AND ALL of the following:
Member is not currently on nitrite/nitrate therapy **
Member is not currently on another phosphodiesterase5 inhibitor
Member has a documented contraindication or
intolerance or allergy or failure of a one month trial of
one of the preferred drugs alfuzosin, finasteride,
tamsulosin, Avodart, Jalyn or Rapaflo
1 year
Cialis 10/20 MG
1 year
Levitra
1 year
Staxyn
1 year
Stendra
1 year
For Fully Insured members
of contract state New York:
A documented primary
diagnosis of erectile
dysfunction in adult males
over 18 years of age AND a
documented secondary
diagnosis of one of the
following:
Diabetes
Hypertension
Spinal cord injury
Multiple sclerosis
Stroke
Radical surgery of genital
tract, urinary tract, or
rectum
Hypogonadism
AND
Member is not receiving any
of the following organic
nitrate product: Isosorbide
mononitrate (Ismo),
isosorbide dinitrate
(Sorbitrate, Isordil, DilatrateSR), Nitroglycerin (NTG,
For Fully Insured members
of contract state New York:
A documented primary
diagnosis of erectile
dysfunction in adult males
over 18 years of age AND a
documented secondary
diagnosis of one of the
following:
Diabetes
Hypertension
Spinal cord injury
Multiple sclerosis
Stroke
Radical surgery of genital
tract, urinary tract, or
rectum
Hypogonadism
AND
Member is not receiving any
of the following organic
nitrate product: Isosorbide
mononitrate (Ismo),
isosorbide dinitrate
(Sorbitrate, Isordil, DilatrateSR), Nitroglycerin (NTG,
For Fully Insured members
of contract state New York:
A documented primary
diagnosis of erectile
dysfunction in adult males
over 18 years of age AND a
documented secondary
diagnosis of one of the
following:
Diabetes
Hypertension
Spinal cord injury
Multiple sclerosis
Stroke
Radical surgery of genital
tract, urinary tract, or
rectum
Hypogonadism
AND
Member is not receiving any
of the following organic
nitrate product: Isosorbide
mononitrate (Ismo),
isosorbide dinitrate
(Sorbitrate, Isordil, DilatrateSR), Nitroglycerin (NTG,
For Fully Insured members
of contract state New York:
A documented primary
diagnosis of erectile
dysfunction in adult males
over 18 years of age AND a
documented secondary
diagnosis of one of the
following:
Diabetes
Hypertension
Spinal cord injury
Multiple sclerosis
Stroke
Radical surgery of genital
tract, urinary tract, or
rectum
Hypogonadism
AND
Member is not receiving any
of the following organic
nitrate product: Isosorbide
mononitrate (Ismo),
isosorbide dinitrate
(Sorbitrate, Isordil, DilatrateSR), Nitroglycerin (NTG,
For Fully Insured members
of contract state New York:
A documented primary
diagnosis of erectile
dysfunction in adult males
over 18 years of age AND a
documented secondary
diagnosis of one of the
following:
Diabetes
Hypertension
Spinal cord injury
Multiple sclerosis
Stroke
Radical surgery of genital
tract, urinary tract, or
rectum
Hypogonadism
AND
Member is not receiving any
of the following organic
nitrate product: Isosorbide
mononitrate (Ismo),
isosorbide dinitrate
(Sorbitrate, Isordil, DilatrateSR), Nitroglycerin (NTG,
Trial of 1 month of Cialis
(NSO, if ED rider applies to
plan)
Trial of 1 month of Cialis
(NSO, if ED rider applies to
plan)
Trial of 1 month of Cialis
(NSO, if ED rider applies to
plan)
12/ day
4/ day
6/ day
4/ day
250mg 16/
day;
500mg 8/
day
8/ day
8/ day
8/ day
8/ day
2/ day
1/ day
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
Viagra
1 year
DETROL
DETROL LA
DITROPAN XL
ENABLEX
GELNIQUE 3%
GELNIQUE 10%
MYRBETRIQ
SANCTURA/ XR
TOVIAZ
VESICARE
For Fully Insured members
of contract state New York:
A documented primary
diagnosis of erectile
dysfunction in adult males
over 18 years of age AND a
documented secondary
diagnosis of one of the
following:
Diabetes
Hypertension
Spinal cord injury
Multiple sclerosis
Stroke
Radical surgery of genital
tract, urinary tract, or
rectum
Hypogonadism
AND
Member is not receiving any
of the following organic
nitrate product: Isosorbide
mononitrate (Ismo),
isosorbide dinitrate
(Sorbitrate, Isordil, DilatrateSR), Nitroglycerin (NTG,
Trial of 1 month of Cialis
(NSO, if ED rider applies to
plan)
OAB-PRE Trial of 1 month of 1 of
trospium/ er, tolteridine/ er
AND 1 of Enablex, Myrbetriq,
Vesicare
OAB-PRE Trial of 1 month of 1 of
trospium/ er, tolteridine/ er
AND 1 of Enablex, Myrbetriq,
Vesicare
OAB-PRE Trial of 1 month of 1 of
trospium/ er, tolteridine/ er
AND 1 of Enablex, Myrbetriq,
Vesicare
OAB-PRE Trial of 1 month of 1 of
trospium/ er, tolteridine/ er
AND 1 of Enablex, Myrbetriq,
Vesicare
OAB-PRE Trial of 1 month of 1 of
trospium/ er, tolteridine/ er
AND 1 of Enablex, Myrbetriq,
Vesicare
OAB-PRE Trial of 1 month of 1 of
trospium/ er, tolteridine/ er
AND 1 of Enablex, Myrbetriq,
Vesicare
OAB2Trial of 1 month of trospium/
PRE
er or tolteridine/ er
OAB-PRE Trial of 1 month of 1 of
trospium/ er, tolteridine/ er
AND 1 of Enablex, Myrbetriq,
Vesicare
OAB-PRE Trial of 1 month of 1 of
trospium/ er, tolteridine/ er
AND 1 of Enablex, Myrbetriq,
Vesicare
OAB2Trial of 1 month of trospium/
PRE
er or tolteridine/ er
latanoprost
LUMIGAN
RESCULA
OPHTHPRE
Trial of 1 week of latanoprost
AND 1 week of Travatan Z
OPHTHPRE
OPHTHPRE
ANOROPRE
Trial of 1 week of latanoprost
AND 1 week of Travatan Z
Trial of 1 week of latanoprost
AND 1 week of Travatan Z
Trial of 1 month of Symbicort
AND Spiriva
TRAVATAN Z
travoprost
XALATAN
ZIOPTAN
ANORO ELLIPTA
COPD
Chronic Ostructive Pulmonary Disease (COPD)
1 year
SPIRIVA
TUDORZA
COPD
Chronic Ostructive Pulmonary Disease (COPD)
1 year
AEROSPAN
ALVESCO
BUDESONIDE
INHALATION SUS
(Respules)
FLOVENT DISKUS
FLOVENT HFA
PULMICORT
FLEXHALER
PULMICORT RESPULES
QVAR
ADVAIR DISKUS
ADVAIR HFA
BREO
TUDORZA- Trial of 1 month of Spiriva
PRE
ICS-PRE Trial of 1 month of Asmanex,
Qvar, or Flovent/HFA
ICS-PRE Trial of 1 month of Asmanex,
Qvar, or Flovent/HFA
ICS-PRE
COPD
Chronic Ostructive Pulmonary Disease (COPD)
1 year
Trial of 1 month of Asmanex,
Qvar, or Flovent/HFA
BREOPRE
Trial of 1 month of Symbicort
AND Spiriva
NASAL
SPRAYSPRE
Trial of 2 weeks each of 2 of
Nasonex, Veramyst,
budesonide, flunisolide,
fluticasone, or triamcinolone
Trial of 2 weeks each of 2 of
Nasonex, Veramyst,
budesonide, flunisolide,
fluticasone, or triamcinolone
Trial of 2 weeks each of 2 of
Nasonex, Veramyst,
budesonide, flunisolide,
fluticasone, or triamcinolone
ZETONNA
NASAL
SPRAYSPRE
COPD
COPD
Chronic Ostructive Pulmonary Disease (COPD)
Chronic Ostructive Pulmonary Disease (COPD)
1 year
1 year
COPD
Chronic Ostructive Pulmonary Disease (COPD)
1 year
COPDPRE
Trial of 1 month each of
Foradil AND Serevent
COPDPRE
Trial of 1 month each of
Foradil AND Serevent
FORADIL
VENTOLIN HFA
XOPENEX HFA
1/ month
1/ fill
1/ fill
1/ fill
1/ fill
1/ fill
1/ fill
1/ fill
1/ fill
1/ fill
1/ fill
1/ month
1/ fill
1/ fill
NASAL
SPRAYSPRE
SEREVENT
PROAIR HFA
PROVENTIL HFA
1/ day
1/ fill
NASACORT AQ
PERFOROMIST
90 days
max/ fill
3ml/ fill
3ml/ fill
1/ fill
DULERA
SYMBICORT
BECONASE AQ
ARCAPTA
BROVANA
3ml/ fill
3ml/
month
1/ day
PROVENT Trial of 1 week each of
IL HFAVentolin HFA AND Proair
PRE
PROVENT Trial of 1 week each of
IL HFAVentolin HFA AND Proair
PRE
1/ day
60vials/ fill
2caps/
day
60vials/ fill
1/ fill
2/ fill
2/ fill
2/ fill
2/ fill
Cervical Caps (Femcap,
Prentif)
Combination
Contraceptives - Oral
Combination
Contraceptives Transdermal (OrthoEvra)
Combination
Contraceptives - Vaginal
(Nuvaring)
Contraceptive Sponge
Diaphragms (Ortho-Flex,
Wideseal,Omniflex)
1/ year
Emergency
Contraceptives(Ella,
Plan B)
Female Condoms
(Reality, FC Female)
Intrautarine Device -IUD
(Paragard, )
Progenstin
contraceptives -Oral
Progestin
Contraceptives Implants
(Implanon,Nexplanon)
Progestin
Contraceptives Injectable - (DepoProvera)
Progestin
Contraceptives - IUD
(Mirena, Skyla)
Spermicides
Bupropion
Chantix 0.5 and 1 mg
Nicotine Inhaler
(Nicotrol)
2/ fill
1.5/ day
12/ year
12/ year
15/ month
1/ year
15/ month
1/ year
1/5/ day
1/ year
4/ year
1/ year
15/ month
2/ day
2/ day
3units/
month
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
Nicotine Nasal Solution
(Nicotrol NS)
Nicotine polacrilex Gum
(Nicorette)
Nicotine polacrilex
Lozenge (Nicorette)
Transdermal Nicotine
Patch (Nicoderm)
Zyban
LOVAZA
12/ month
24/ day
20/ day
1/ day
omega-3-acid
Lunesta
Insomnia, in members over age 18
Eszopiclone
Insomnia, in members over age 18
not covered <
18 years of
age
not covered <
18 years of
age
1 year
>5
1 year
1 year
Actonel
RISEDRONATE SODIUM
TAB 150 MG (Active)
EPANED
ATRALIN
RETIN-A
TRETIN-X
VELTIN
FABIOR
ACEI-PRE
Acne-PRE
hypertension
Acne vulgaris
A documented diagnosis of hypertension (HTN), AND
Member has a documented inability to swallow a tablet or
capsule and no other route of administration exists (i.e.,
NG-tube, G-tube, J-tube)
A documented diagnosis of any one of the following: Acne vulgaris (includes comedonal, cystic, nodular &
papular acne)
-Actinic keratoses AND Lesions are on the face OR
Lesions are not on the face and therapy includes the use
of 5-fluorouracil in conjunction with tretinoin
>35
1 year
>35
1 year
-Hypertrophic scars or keloids AND Intralesional injection
of corticosteroids is ineffective or not tolerated
avita
ZIANA
EPIDUO
RETIN-A MICRO
tretinoin
2/ day
Trial of 1 month of fenofibrate 4/ day
or Vascepa
4/ day
LUNESTA- Trial of 1 month of a generic
1/ day
PRE
hypnotic, i.e., zolpidem,
temazepam, triazolam
LUNESTA- Trial of 1 month of a generic
1/ day
PRE
hypnotic, i.e., zolpidem,
temazepam, triazolam
35 mg 4/
month; 75
mg 2/
month;
150 mg 1/
month
35 mg 4/
month; 75
mg 2/
month;
150 mg 1/
month
1200 ml in
EPANED- A documented trial of one
30
days
PRE
month each of three preferred
generic alternative
angiotensin-converting
enzyme inhibitors (ACEI) or
hydrochlorothiazide
combinations (ACEI/ HCTZ)
LOVAZAPRE
Acne-PRE
Acne vulgaris
-Keratosis follicularis (Darier's disease, Darier-White
disease)
-Facial flat warts
-Multiple flat warts (includes common warts and plantar
warts)
A documented diagnosis of any one of the following: Acne vulgaris (includes comedonal, cystic, nodular &
papular acne)
-Actinic keratoses AND Lesions are on the face OR
Lesions are not on the face and therapy includes the use
of 5-fluorouracil in conjunction with tretinoin
ACNEPRE
Note: Trial of a single entity
ACEI and its own
hydrochlorothiazide
combination does not qualify
for meeting the requirement of
trying three alternatives. Trial
requires three different drugs
(different chemical entities),
either as single entity or in
combination.
A documented trial of one
month tretinoin and one of
the following: adapalene,
benzoyl peroxide, topical
clindamycin, topical
erythromycin, sulfacetamide
w/sulfur, DIFFERIN 0.3% GEL
or EPIDUO or RETIN-A MICRO
or ZIANA
-Hypertrophic scars or keloids AND Intralesional injection
of corticosteroids is ineffective or not tolerated
PLEXION
ARALAST
ARALAST NP
GLASSIA
PROLASTIN
PROLASTIN-C
ZEMAIRA
PLEXION-PRE
ARALAST-PRE
acne or seborrheic dermatitis
alpha 1-antitrypsin (AAT) inhibitor therapy
-Keratosis follicularis (Darier's disease, Darier-White
disease)
-Facial flat warts
-Multiple flat warts (includes common warts and plantar
warts)
A documented diagnosis of acne or seborrheic dermatitis
AND
A documented contraindication or intolerance or allergy or
failure of an adequate trial of one month each of two
preferred generic sulfacetamide sodium with sulfur
products
Aetna considers alpha 1-antitrypsin (AAT) inhibitor
therapy (e.g., Aralast NP, Glassia, Prolastin-C, and
Zemaira) medically necessary for selected adult members
with emphysema due to AAT deficiency when all of the
following criteria are met:
1.
Member has a low serum concentration of AAT less than
80 mg/dL or less than 11 uM/L or less than 0.8 g/L (35 %
of normal), which is considered the threshold thought to
protect against emphysema; and
1 year
PLEXION- A documented trial of one month
each of two preferred generic
PRE
sulfacetamide sodium with sulfur
products
1 year
2.
Member has PiZZ, PiZ(null) or Pi(null, null) phenotype
(homozygous) AAT deficiency or other phenotypes
associated with serum AAT concentrations of less than 80
mg per deciliter (mg/dL). (AAT inhibitor is considered not
medically necessary for use in individuals with the PiMZ or
PiMS phenotypes of AAT deficiency because these
individuals appear to be at small risk of developing
panacinar emphysema); and
3.
Member has progressive panacinar emphysema with a
documented rate of decline in forced expiratory volume in
1 second (FEV1); and
RILUTEK
RILUTEK-PRE
amyotrophic lateral sclerosis (ALS)
A documented diagnosis of amyotrophic lateral sclerosis
(ALS) AND
A documented contraindication or intolerance or allergy or
failure of an adequate trial of one month of the preferred
generic quivalent alternative, riluzole
1 year
RILUTEKPRE
A documented trial of one
month of the preferred generic
quivalent alternative, riluzole
A documented diagnosis of amyotrophic lateral sclerosis
(ALS)
A documented diagnosis of one of the following:
-Hypertension AND
-A documented contraindication or intolerance or allergy
or failure of an adequate trial of one month each of any
three preferred generic alternatives from the following as
a single entity or hydrochlorothiazide combination product:
candesartan, eprosartan, irbesartan, losartan, valsartan,
OR telmisartan
OR
-Heart failure AND
-A documented contraindication or intolerance or allergy
or failure of an adequate trial of one month of the
preferred generic alternative, candesartan
A documented diagnosis of hypertension, AND
A documented contraindication or intolerance or allergy or
failure of an adequate trial of one month each of any
three preferred alternatives from the following:
candesartan/hctz, eprosartan/hctz, irbesartan/hctz,
losartan/hctz, telmisartan/hctz, OR valsartan/hctz
1 year
riluzolePRE
ATACAND- A documented trial of one
2
tablets/da
PRE
month each of any three
preferred alternatives from the y
following as a single entity or
hydrochlorothiazide
combination product:
candesartan
eprosartan
irbesartan
losartan
valsartan
telmisartan
riluzole
riluzole-PRE
myotrophic lateral sclerosis (ALS)
ATACAND
DIOVAN
ATACAND-PRE
hypertension
Atacand HCT
Atacand HCT -PRE
hypertension
Azor
Twynsta
Azor-PRE
hypertension
A documented diagnosis of hypertension, ANDA
documented contraindication or intolerance or allergy or
failure of an adequate trial of one month each of any two
preferred alternatives from the following: candesartan, in
combination with amlodipine, eprosartan, in combination
with amlodipine, irbesartan, in combination with
amlodipine, losartan, in combination with amlodipine,
valsartan, in combination with amlodipine, telmisartan, in
combination with amlodipine, telmisartan/ amlodipine OR
Exforge
1 year
1 year
2
Atacand
A documented trial of one
HCT -PRE month each of any three
tablets/da
preferred alternatives from the y
following: candesartan/hctz,
eprosartan/hctz,
irbesartan/hctz, losartan/hctz,
telmisartan/hctz, OR
valsartan/hctz
1 year
Azor-PRE A documented trial of one
1
month each of any two
tablet/day
preferred alternatives from the
following: candesartan, in
combination with amlodipine,
eprosartan, in combination
with amlodipine, irbesartan, in
combination with amlodipine,
losartan, in combination with
amlodipine, valsartan, in
combination with amlodipine,
telmisartan, in combination
with amlodipine, telmisartan/
amlodipine OR Exforge
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
Tribenzor
Tribenzor-PRE
hypertension
1 year
1
Tribenzor- A documented trial of one
tablet/day
PRE
month each of any two
preferred alternatives from the
following: candesartan/hctz, in
combination with amlodipine,
eprosartan/hctz, in
combination with amlodipine,
irbesartan/hctz, in combination
with amlodipine, losartan/hctz,
in combination with
amlodipine, telmisartan/hctz in
combination with amlodipine,
valsartan/hctz in combination
with amlodipine, telmisartan/
amlodipine in combination with
hctz OR Exforge HCT
A documented diagnosis of hypertension, AND
A documented contraindication or intolerance or allergy or
failure of an adequate trial of one month each of any two
preferred alternatives from the following: candesartan/hctz, in
combination with amlodipine, eprosartan/hctz, in combination
with amlodipine, irbesartan/hctz, in combination with
amlodipine, losartan/hctz, in combination with amlodipine,
telmisartan/hctz in combination with amlodipine, valsartan/hctz
in combination with amlodipine, telmisartan/ amlodipine in
combination with hctz OR Exforge HCT
Benicar-PRE
hypertension
o A documented diagnosis of hypertension, AND
o A documented contraindication or intolerance or allergy
or failure of an adequate trial of one month each of any
three preferred generic alternatives from the following as
a single entity or hydrochlorothiazide combination product:
candesartan, eprosartan, irbesartan, losartan, valsartan,
OR telmisartan
1 year
BenicarPRE
Avapro
Avapro-PRE
hypertension
A documented diagnosis of one of the following:
Hypertension AND
A documented contraindication or intolerance or allergy or
failure of an adequate trial of one month each of any
three preferred generic alternatives from the following as
a single entity or hydrochlorothiazide combination product:
candesartan, eprosartan, irbesartan, losartan, valsartan,
OR telmisartan
OR
Diabetic nephropathy AND
A documented contraindication or intolerance or allergy or
failure of an adequate trial of one month each of the
preferred generic alternatives, irbesartan and losartan
1 year
Note: Trial of a single entity Avaprofrom the above and its own PRE
hydrochlorothiazide
combination does not
qualify for meeting the
requirement of trying two
alternatives. Trial requires
two different drugs
(different chemical entities),
either as single entity or in
combination.
Benicar HCT
Diovan HCT
Edarbyclor
Avalide
Micardis HCT
Benicar HCT-PRE
hypertension
A documented diagnosis of hypertension, AND
A documented contraindication or intolerance or allergy or
failure of an adequate trial of one month each of any
three preferred alternatives from the following:
candesartan/hctz, eprosartan/hctz, irbesartan/hctz,
losartan/hctz, telmisartan/hctz, OR valsartan/hctz
1 year
Benicar
A documented trial of one
1
HCT-PRE month each of any three
tablet/day
preferred alternatives from the
following: candesartan/hctz,
eprosartan/hctz,
irbesartan/hctz, losartan/hctz,
telmisartan/hctz, OR
valsartan/hctz
Teveten HCT
Teveten HCT-PRE
hypertension
A documented diagnosis of hypertension, AND
A documented contraindication or intolerance or allergy or
failure of an adequate trial of one month each of any
three preferred alternatives from the following:
candesartan/hctz, eprosartan/hctz, irbesartan/hctz,
losartan/hctz, telmisartan/hctz, OR valsartan/hctz
1 year
Teveten
A documented trial of one
HCT-PRE month each of any three
preferred alternatives from the
following: candesartan/hctz,
eprosartan/hctz,
irbesartan/hctz, losartan/hctz,
telmisartan/hctz, OR
valsartan/hctz
Tevten
Tevten-PRE
hypertension
o A documented diagnosis of hypertension, AND
o A documented contraindication or intolerance or allergy
or failure of an adequate trial of one month each of any
three preferred generic alternatives from the following as
a single entity or hydrochlorothiazide combination product:
candesartan, eprosartan, irbesartan, losartan, valsartan,
OR telmisartan
1 year
TevtenPRE
Cozaar
Cozaar-PRE
hypertension
A documented diagnosis of one of the following:
Hypertension AND
A documented contraindication or intolerance or allergy or
failure of an adequate trial of one month each of any
three preferred generic alternatives from the following as
a single entity or hydrochlorothiazide combination product:
candesartan, eprosartan, irbesartan, losartan, valsartan,
OR telmisartan
OR
Diabetic nephropathy AND
A documented contraindication or intolerance or allergy or
failure of an adequate trial of one month each of the
preferred generic alternatives, irbesartan and losartan
1 year
Note: Trial of a single entity Cozaarfrom the above and its own PRE
hydrochlorothiazide
combination does not
qualify for meeting the
requirement of trying two
alternatives. Trial requires
two different drugs
(different chemical entities),
either as single entity or in
combination.
XOLAIR
XOLAIR-PRE
IgE-mediated allergic asthma
6 months
APTIOM
APTIOM-PRE
partial-onset seizures
Moderate-to-severe persistent allergic asthma for at least
3 months, as second line treatment for children 6 years of
age and older, adolescents, and adults, who meet all of
the criteria below: Member demonstrates atopy (has a
positive skin test or in-vitro reactivity (e.g., positive
radioallergosorbent (RAST) test)) to a perennial
aeroallergen; and
Member's baseline serum IgE level is between 30 and
1500 IU/ml; and
Member's symptoms are inadequately controlled with a
moderate dose of inhaled corticosteroids (e.g., Asmanex,
QVAR) plus long-acting beta-agonists (LABAs)* or
leukotriene inhibitors for at least 3 months; and
Member has daily symptoms (e.g., coughing, wheezing,
and dyspnea) and/or exacerbations affecting activity (e.g.,
exercise) and sleep; and
Members who smoke are engaged in smoking cessation
efforts; and
Member exhibits any of the following signs of poor asthma
control: Daily use of short-acting inhaled beta2-agonists;
or
Diurnal variation in peak expiratory flow (PEF) of greater
than 30 %; or
Forced expiratory volume in 1 second (FEV1) less than 60
% predicted; or
PEF less than 80 % of personal best; or
A documented diagnosis of partial-onset seizures AND
Documented concurrent therapy with one of the following:
carbamazepine, divalproex dr/er/sprinkle, gabapentin,
lamotrigine, levetiracetam/ER, oxcarbazepine, phenytoin,
topiramate, valproic acid, or zonisamide
1 year
For coverage of additional
quantities, a member's
treating physician must
request prior authorization
through the Pharmacy
Management
Precertification Unit. A prior
authorization will be granted
for coverage of additional
quantities of Aptiom,
Fycompa, gabapentin,
Lyrica (capsules only),
Neurontin, Potiga, Qudexy,
Sabril, and Vimpat for those
members who meet the
following criterion:
Member's dose is being
titrated by physician (3
month limit) OR
BANZEL
ONFI
BANZEL-PRE
Lennox-Gastaut syndrome
A documented diagnosis of seizures associated with
Lennox-Gastaut syndrome or refractory (therapy
resistant) epilepsy AND
Concomitant use of an anticonvulsant drug
1 year
Member is taking Neurontin
or gabapentin 300mg
caps/tabs, using three
caps/tabs, three times daily
A documented trial of one
month each of any three
preferred alternatives from the
following as a single entity or
hydrochlorothiazide
combination product:
candesartan
eprosartan
irbesartan
losartan
valsartan
telmisartan
A documented trial of one
month each of any three
preferred alternatives from the
following as a single entity or
hydrochlorothiazide
combination product:
candesartan
eprosartan
irbesartan
losartan
valsartan
telmisartan
1
tablet/day
Benicar
Edarbi
Micardis
A documented trial of one
month each of any three
preferred alternatives from the
following as a single entity or
hydrochlorothiazide
combination product:
candesartan
eprosartan
irbesartan
losartan
valsartan
telmisartan
A documented trial of one
month each of any three
preferred alternatives from the
following as a single entity or
hydrochlorothiazide
combination product:
candesartan
eprosartan
irbesartan
losartan
valsartan
telmisartan
75 mg and
150 mg =
1
tablets/da
y
2
tablets/da
y
25 mg and
50 mg = 2
tablets/da
y
200 mg,
400 mg,
800 mg:
1/day
600 mg:
2/day
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
VIMPAT
VIMPAT-PRE
partial-onset seizures
A documented diagnosis of partial-onset seizures
1 year
For coverage of additional
quantities, a member's
treating physician must
request prior authorization
through the Pharmacy
Management
Precertification Unit. A prior
authorization will be granted
for coverage of additional
quantities of Aptiom,
Fycompa, gabapentin,
Lyrica (capsules only),
Neurontin, Potiga, Qudexy,
Sabril, and Vimpat for those
members who meet the
following criterion:
50mg
6/day,
100, 150,
200mg
2/day,
10mg/mL
40mL/day
Member's dose is being
titrated by physician (3
month limit) OR
FYCOMPA
POTIGA
FYCOMPA-PRE
partial-onset seizures
A documented diagnosis of partial-onset seizures AND
Documented concurrent therapy with one of the following:
carbamazepine, divalproex dr/er/sprinkle, gabapentin,
lamotrigine, levetiracetam/ER, oxcarbazepine, phenytoin,
topiramate, valproic acid, or zonisamide
1 year
Member is taking Neurontin
or gabapentin 300mg
caps/tabs, using three
caps/tabs, three times daily
For coverage of additional
quantities, a member's
treating physician must
request prior authorization
through the Pharmacy
Management
Precertification Unit. A prior
authorization will be granted
for coverage of additional
quantities of Aptiom,
Fycompa, gabapentin,
Lyrica (capsules only),
Neurontin, Potiga, Qudexy,
Sabril, and Vimpat for those
members who meet the
following criterion:
Member's dose is being
titrated by physician (3
month limit) OR
Gabitril
tiagabine
Gabitril-PRE
partial-onset seizures
A documented diagnosis of partial-onset seizures AND
Concomitant use of an anticonvulsant drug
1 year
Sabril tablets
Sabril-PRE
refractory complex partial seizures
A documented diagnosis of refractory complex partial
seizures AND
Documented concurrent therapy with one of the following:
carbamazepine, divalproex dr/er/sprinkle, gabapentin,
lamotrigine, levetiracetam/ER, oxcarbazepine, phenytoin,
topiramate, valproic acid, or zonisamide
1 year
Member is taking Neurontin
or gabapentin 300mg
caps/tabs, using three
caps/tabs, three times daily
For coverage of additional
quantities, a member's
treating physician must
request prior authorization
through the Pharmacy
Management
Precertification Unit. A prior
authorization will be granted
for coverage of additional
quantities of Aptiom,
Fycompa, gabapentin,
Lyrica (capsules only),
Neurontin, Potiga, Qudexy,
Sabril, and Vimpat for those
members who meet the
following criterion:
Member's dose is being
titrated by physician (3
month limit) OR
BRISDELLE
BRISDELLE-PRE
menopause,
ALOXI
ANZEMET injectable
EMEND injectable
Antiemetic Inj.-PRE
Chemotherapy-induced nausea and vomiting
Postoperative nausea and vomiting
Brisdelle is not indicated for A documented diagnosis of moderate to severe
the treatment of any
vasomotor symptoms associated with menopause, AND
psychiatric condition.
A documented contraindication to menopausal hormone
therapy (i.e., estradiol, Premarin), such as current, past or
suspected breast cancer, estrogen-dependent neoplasia,
genital bleeding, endometrial hyperplasia, thromboembolic
disease, liver dysfunction, hypersensitivity to menopausal
hormone therapy, or porphyria cutanea tarda, AND
A documented contraindication or intolerance or allergy to
the preferred generic alternative, paroxetine
I.
Cancer Chemotherapy:
1 year
Member is taking Neurontin
or gabapentin 300mg
caps/tabs, using three
caps/tabs, three times daily
BRISDELL A documented trial of one
7.5mg: 1
E-PRE
month of the preferred generic capsule/d
alternative, paroxetine
ay
1 year
Aetna considers palonosetron (Aloxi) or fosaprepitant
dimeglumine (Emend) antiemetic intravenous therapy
medically necessary for the following indications: (i) the
prevention of acute nausea or vomiting associated with
initial and repeat courses of moderately and highly
emetogenic cancer chemotherapy, including high-dose
cisplatin; and (ii) for treatment of chemotherapy-induced
nausea or vomiting from low or minimally emetogenic
cancer chemotherapy in persons who have an inadequate
response or contraindication to intravenous granisetron
(Kytril) or ondansetron (Zofran) at the Food and Drug
Administration (FDA) recommended dose (see table in
Appendix).
DICLEGIS
DICLEGIS-PRE
Nausea and vomiting
MARINOL
dronabinol
MARINOL-PRE
Chemotherapy-induced nausea and vomiting
Aetna considers granisetron (Kytril) and ondansetron
(Zofran) antiemetic intravenous therapy medically
necessary for the following indications: (i) prevention of
acute and delayed nausea and/or vomiting associated
with initial and repeat courses of moderately and highly
emetogenic cancer chemotherapy including high-dose
displatin; and (ii) for treatment of chemotherapy-induced
nausea and/or vomiting of low or minimally emetogenic
cancer chemotherapy in persons who have an inadequate
A documented diagnosis of nausea and vomiting in
pregnant women who do not respond to conservative
management (i.e. trigger avoidance, small frequent meals,
etc) AND
A documented contraindication or intolerance or allergy or
failure of an adequate trial of one week of any of the
following: otc doxylamine, or otc pyridoxine (vit B6), or
metoclopramide, or promethazine, or ondansetron
A documented diagnosis of one of the following: Nausea
and vomiting associated with cancer chemotherapy
following previous failure of ondansetron or granisetron
OR
Anorexia associated with weight loss in patients with AIDS
following failure (one month trial) of megestrol or
oxandrolone
1 year
1 year
DICLEGIS- A documented trial of one
4/day
PRE
week of any of the following:
otc doxylamine, or otc
pyridoxine (vit B6), or
metoclopramide, or
promethazine, or ondansetron
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
JUXTAPID
JUXTAPID-PRE
homozygous familial hypercholesterolemia (HoFH)
KYNAMRO
KYNAMRO-PRE
homozygous familial hypercholesterolemia (HoFH)
VECAMYL
VECAMYL-PRE
severe essential hypertension
uncomplicated malignant hypertension
A documented diagnosis of homozygous familial
hypercholesterolemia (HoFH) in patients 18 years of age
or older AND documentation of ALL of the following:
Total LDL >/= 300mg/dl while on a maximum tolerated
dose of atorvastatin OR Crestor, both taken in
combination with any of the following: Zetia (ezetimibe), or
a bile acid sequestrant (cholestyramine, Welchol
(colesevelam), or colestipol), or niacin
Juxtapid will be taken in combination with a maximum
tolerated dose of atorvastatin OR Crestor, both taken in
combination with any of the following: Zetia (ezetimibe), or
a bile acid sequestrant (cholestyramine, Welchol
(colesevelam), or colestipol), or niacin
Verbal confirmation that appropriate dietary counseling
has/will be provided to the patient that includes all of the
following: Starting/maintaining a low-fat diet (<20%
calories from fat)
Concomitant vitamin supplementation (i.e., 400
international units vitamin E, 210 mg alpha-linolenic acid
(ALA), 200 mg linoleic acid, 110 mg eicosapentaenoic
acid (EPA), and 80 mg docosahexaenoic acid (DHA))
Avoidance of grapefruit juice during therapy
Prescriber
is a
cardiologist
enrolled in
REMS
program
and is
certified to
prescribe
Juxtapid
Juxtapid 5mg:
2 week
approval at a
time
(additional
approval will
require call in
to verify 5 mg
is still
needed;
approvals will
be only for 2
weeks at a
time)
Verbal confirmation of
patient enrollment in a lipid
clinic or disease
management program
Negative pregnancy test, if
female
Confirmation that patient is
not starting/currently on or
has discontinued or will be
discontinuing therapy if they
are on any of the drugs
listed below before initiating
therapy with Juxtapid:
Agenerase (amprenavir)
Biaxin (clarithromycin)
Juxtapid
Calan SR, Isoptin SR
10mg and
(verapamil)
20mg: 4
Cardizem, Tiazac (diltiazem)
weeks
Cipro (ciprofloxacin)
(approvals
Crixivan (indinavir)
will only be
Diflucan (fluconazole)
for 4 weeks, Emend (aprepitant)
pending liver Ery-tab (erythromycin)
function test Gleevec (imatinib)
results)
Incivek (telaprevir)
Invirase (saquinavir)
Prescriber
4 weeks
Verbal confirmation of
is a
(approvals
patient enrollment in a lipid
cardiologist will only be
clinic or disease
enrolled in for 4 weeks, management program
REMS
pending liver
program
function test AND
and is
results)
certified to
A documented
prescribe
contraindication or
Kynamro
intolerance or allergy or
failure of an adequate trial
of one month each of the
maximum tolerated dose of
atorvastatin AND Crestor,
both taken in combination
with any of the following:
Zetia (ezetimibe), or a bile
acid sequestrant
(cholestyramine, Welchol
(colesevelam), or
colestipol), or niacin
Liver function tests (alanine aminotransferase (ALT),
aspartate aminosferase (AST), alkaline phosphastase,
and total bilirubin level) should be performed at all of the
A documented diagnosis of homozygous familial
hypercholesterolemia (HoFH) in patients 18 years of age
or older AND documentation of ALL of the following:
Total LDL >/= 300mg/dl while on a maximum tolerated
dose of atorvastatin OR Crestor, both taken in
combination with any of the following: Zetia (ezetimibe), or
a bile acid sequestrant (cholestyramine, Welchol
(colesevelam), or colestipol), or niacin
Kynamro will be taken in combination with a maximum
tolerated dose of atorvastatin OR Crestor, both taken in
combination with any of the following: Zetia (ezetimibe), or
a bile acid sequestrant (cholestyramine, Welchol
(colesevelam), or colestipol), or niacin
Kynamro will not be given as an adjunct to LDL apheresis
therapy
Liver function tests (alanine aminotransferase (ALT),
aspartate aminosferase (AST), alkaline phosphastase,
and total bilirubin level) should be performed at all of the
following stages: Prior to initiation of therapy of Kynamro
to rule out active liver disease
Monthly for the first year of Kynamro therapy
Every 3 months thereafter
JUXTAPID- A documented trial of one
PRE
month each of maximum
tolerated doses of atorvastatin
AND Crestor, both taken in
combination with any of the
following: Zetia (ezetimibe), or
a bile acid sequestrant
(cholestyramine, Welchol
(colesevelam), or colestipol),
or niacin
KYNAMR
O-PRE
5 mg = 14
tablets/14
days, 10
mg = 28
tablets/28
days, 20
mg = 84
tablets/28
days
4 vials/28
days
A documented trial of one
month each of maximum
tolerated doses of atorvastatin
AND Crestor, both taken in
combination with any of the
following: Zetia (ezetimibe), or
a bile acid sequestrant
(cholestyramine, Welchol
(colesevelam), or colestipol),
or niacin
Lipid panel every 3 months
1 year
A documented diagnosis of moderately severe to severe
essential hypertension or uncomplicated malignant
hypertension AND
A documented contraindication or intolerance or allergy or
failure of an adequate trial of one month of a triple-drug
combination from the preferred alternatives from the
following classes: Diuretics
Angiotensin-Converting Enzyme Inhibitors
Angiotensin II Receptor Antagonists
Beta-Adrenergic Blockers
Calcium Channel Blockers
Note: Selection of three medications must each be from a
different class.
TAZORAC
TAZORAC-PRE
acne vulgaris
plaque psoriasis
A documented diagnosis of acne vulgaris, OR
A documented diagnosis of plaque psoriasis
STRIBILD
STRIBILD-PRE
human immunodeficiency virus (HIV)
A documented diagnosis of human immunodeficiency
virus (HIV)
A documented resistance test within the past 3 months
demonstrating virologic susceptibility to all of the following
components of Stribild: elvitegravir, emtricitabine, and
tenofovir AND A documented contraindication or
intolerance or allergy or failure of an adequate trial of one
month of Atripla (efavirenz-emtricitabine-tenofovir) or a
documented resistance test within the past 3 months
demonstrating virologic resistance to efavirenz OR
A documented contraindication or intolerance or allergy or
failure of an adequate trial of one month of Truvada,
Reyataz, and Norvir (emtricitabine-tenofovir, atazanavir,
ritonavir) in combination or documented resistance test
within the past 3 months demonstrating virological
resistance to atazanavir OR
10/day
VECAMYL- A documented trial of one
PRE
month of a triple-drug
combination from the
preferred alternatives from the
following classes: Diuretics
Angiotensin-Converting
Enzyme Inhibitors
Angiotensin II Receptor
Antagonists
Beta-Adrenergic Blockers
Calcium Channel Blockers
Note: Selection of three
medications must each be
from a different class.
>35 years old
1 year
1 year
A documented viral load assay AND CD4 count indicating
that the patient is stable on Stribild (stable or increase in
CD4 counds AND viral load <50 copies/ml) (FOR renewals
ONLY)
TRUVADA
TRUVADA-PRE
human immunodeficiency virus (HIV)
A documented diagnosis of human immunodeficiency
virus (HIV) OR
A documented diagnosis of initiating therapy for preexposure prophylaxis (PrEP) to reduce the risk of sexually
acquired HIV-1 in adults at high risk AND documentation
of all of the following: A negative HIV antibody test taken:
Immediately before starting Truvada for PrEP AND
Every 3 months thereafter while on therapy
Confirmation that creatinine clearance value >/=60 mL/min
before initiating Truvada for PrEP AND Serum creatinine
and calculate creatinine clearance checks performed at 3
months after initiation and then every 6 months thereafter
(PrEP
diagnosis) - 3
months
(renewals
approved
pending HIV
testing and
creatinine
clearance
value)
(HIV
diagnosis) one year
NOTE: Members may receive a 30 days’ supply of
medication upon initial request of Truvada for PrEP
diagnosis. After 30 days, above criteria must be met.
ARAVA
leflunomide
ARAVA-PRE
rheumatoid arthritis
psoriatic arthritis
A documented diagnosis of rheumatoid arthritis OR
A documented diagnosis of psoriatic arthritis
6 months
AND
A negative pregnancy test for females of childbearing age
within the last 14 days, unless it is documented that the
member is sterile (e.g. hysterectomy, unable to achieve
pregnancy) or in menopause
OTREXUP
OTREXUP-PRE
Juvenile idiopathic arthritis
Psoriasis
Rheumatoid arthritis
A documented diagnosis of one of the following: A
documented diagnosis of severe, active rheumatoid
arthritis (RA) in adults who have had an insufficient
therapeutic response to, or are intolerant of, an adequate
trial of first-line therapy including full dose non-steroidal
anti-inflammatory agents (NSAIDs) OR
A documented diagnosis of active polyarticular juvenile
idiopathic arthritis (pJIA) in children who have had an
insufficient therapeutic response to, or are intolerant of,
an adequate trial of first-line therapy including full dose
non-steroidal anti-inflammatory agents (NSAIDs) OR
A documented diagnosis of severe, recalcitrant, disabling
psoriasis that has been established, as by biopsy and/or
after dermatologic consultation, and is not adequately
responsive to other forms of therapy
AND
A documented failure of an adequate trial of one month of
a preferred generic alternative methotrexate OR
A documented mental or physical handicap or other
clinical reason preventing the reasonable use of an
available generic injectable or oral methotrexate
medication
1 year
OTREXUP- A documented trial of one
PRE
month of a preferred generic
alternative methotrexate
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
ADOXA
Dynacin
Minocin
Monodox
ADOXA-PRE
Acinetobacter infection
Rosacea
Acne vulgaris
Documented to be 8 years of age or older (Note: see
>8 years old
section above under ALL tetracyclines if less than 8 years
of age) AND ONE of the following:
1 year
A documented diagnosis of acne or rosacea and a
documented contraindication or intolerance or allergy or
failure of an adequate trial of one month of the preferred
generic alternative, doxycycline (for Adoxa or Monodox) or
minocycline (for Dynacin or Minocin) OR
A documented diagnosis of infection other than acne or
rosacea and a documented contraindication or
intolerance or allergy or failure of an adequate trial of
three days of the preferred generic alternative,
doxycycline (for Adoxa or Monodox) or minocycline (for
Dynacin or Minocin)
DIFICID
DIFICID-PRE
Clostridium difficile infection
Dificid (A AND B OR C) AND D
1 month
(If less than 8 years of age)
A documented rare
infectious diagnosis that
requires use of
tetracyclines in young
children (examples include
juvenile periodontitis or
Mediterranean spotted
fever)
(Note: Tetracyclines should
not be used in children
younger than 8 years of
age unless other
appropriate drugs are
ineffective or are
contraindicated. American
Academy of Pediatrics
(AAP), US Centers for
Disease Control and
Prevention (CDC), and
Infectious Diseases Society
of America (IDSA) state that
use of tetracyclines in
children younger than 8
20 tablets/
30 day
supply
A. A documented diagnosis of Clostridium difficile
associated diarrhea in adults > 18 years of age
AND
B. A documented:
Contraindication to preferred agents metronidazole or oral
vancomycin hydrochloride indicated for the member's
condition OR
Intolerance to metronidazole or oral vancomycin
hydrochloride indicated for member’s condition OR
Allergy to metronidazole or oral vancomycin hydrochloride
indicated for the member's condition OR
Failure of an adequate trial of 10 days of metronidazole or
7 days of oral vancomycin hydrochloride
OR
C. Discharge from hospital or medical facility due to a
documented diagnosis from A above AND documented
initial treatment with Dificid while in the hospital/medical
facility.
AND
avidoxy
DORYX
ORAXYL
demeclocycline
DORYX
doxycycline
DYNACIN
MINOCIN
minocycline
MONODOX
SOLODYN
tetracycline
vibramycin
DORYX-PRE
Infection
For ALL tetracyclines
ORACEA
ORACEA-PRE
Rosacea,
Avelox
Cipro
Cipro XR
Ciprofloxacin
ciprofloxacin er
Factive
Levaquin
Levofloxacin
Moxifloxacin
Noroxin
ofloxacin
Avelox-PRE
Infection
A documented diagnosis of cystic fibrosis with pulmonary < 10 years
infection due to P. aeruginosa, OR
old
A documented diagnosis of a life-threatening infection due
to P. aeruginosa untreatable by other first line antibiotics,
OR
A documented diagnosis of recurrent resistant urinary
tract infection due to P. aeruginosa, OR
Member needs prophylaxis or treatment of anthrax after
known or suspected exposure (Cipro/ ciprofloxacin only),
OR
A documented diagnosis of complicated UTI and
Pyelonephritis due to E. coli and is being used as second
line treatment (Cipro/ ciprofloxacin only) ^
30days
Member’s physician provides documentation (controlled
clinical trial) from the peer-reviewed medical literature for
medical use in females
Female Members- A AND (B OR C)
1 year
^ Note: Cipro tablets or oral
suspension received FDA
approval as second-line
treatment of complicated
urinary tract infections
(cUTI) and pyelonephritis in
pediatric patients 1 to 17
years of age. Per the
manufacturer's package
labeling, Cipro is not a drug
of first choice in the
pediatric population due to
an increased incidence of
adverse events related to
joints and/or surrounding
tissues.
Member is female
1 year
Member is female
1 year
Member is female
< 8 years old
1 year
(If less than 8 years of age)
A documented rare infectious diagnosis that requires use
of tetracyclines in young children (examples include
juvenile periodontitis or Mediterranean spotted fever)
alfuzosin
alfuzosin-PRE
Benign prostatic hyperplasia
CASODEX
bicalutamide
CASODEX-PRE
Metastatic prostate cancer
(Note: Tetracyclines should not be used in children
younger than 8 years of age unless other appropriate
drugs are ineffective or are contraindicated. American
Academy of Pediatrics (AAP), US Centers for Disease
Control and Prevention (CDC), and Infectious Diseases
Society of America (IDSA) state that use of tetracyclines in
children younger than 8 years of age can be considered
in certain circumstances when the benefits outweigh the
risks)
>8 years old
A documented diagnosis of Rosacea, AND
Age > 8 years old, AND
A documented contraindication or intolerance or allergy or
failure of an adequate trial of fourteen days of the
preferred alternative topical metronidazole OR generic
doxycycline
1 year
1
capsule/d
ay
A. Member is NOT pregnant
AND
B. Documented diagnosis of hirsutism secondary to
ovarian or adrenal dysfunction (for example, polycystic
ovary syndrome, adrenal or ovarian tumor)
OR
AVODART
Jalyn
AVODART-PRE
Benign prostatic hyperplasia
Proscar
Finasteride
Proscar-PRE
Benign prostatic hyperplasia
C. Member's physician provides documentation
(controlled clinical trial) from the peer-reviewed medical
literature for medical use in females
Member is NOT pregnant
AND
Member’s physician provides documentation (controlled
clinical trial) from the peer-reviewed medical literature for
medical use in females.
(Member is male)
Age > 50 yrs old
OR
Member has diagnosis of BPH (Benign Prostatic
Hyperplasia)
1 year
(Member is female)
Member is NOT pregnant
AND Member has documented diagnosis of hirsutism
secondary to ovarian or adrenal dysfunction (for example,
polycystic ovary syndrome, adrenal or ovarian tumor)
OR
Member’s physician provides documentation (controlled
clinical trial) from the peer-reviewed medical literature for
medical use in females
Flomax
Flomax-PRE
Benign prostatic hyperplasia
Uroxatral
RAPAFLO-PRE
Benign prostatic hyperplasia
RAPAFLO
alfuzosin
RAPAFLO-PRE
Benign prostatic hyperplasia
Member has documented diagnosis of Urethral syndrome
(urinary hesitancy, frequency, and dysuria)
OR
Member has documented diagnosis of intractable
micturition difficulties (difficulty passing urine)
OR
Member has documented diagnosis of Ureteral
calculi/Kidney stones
OR
Member’s physician provides documentation (controlled
clinical trial) from the peer-reviewed medical literature for
medical use in females
Member’s physician provides documentation (controlled
clinical trial) from the peer-reviewed medical literature for
medical use in females
Member’s physician provides documentation (controlled
clinical trial) from the peer-reviewed medical literature for
medical use in females
1 year
Member is female
FlomaxPRE
A documented trial of one
month of the drug’s generic
equivalent tamsulosin
1 year
Member is female
Uroxatral- A documented trial of one
PRE
month of the drug’s generic
equivalent alfuzosin
1 year
Member is female
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
tamsulosin
Flomax-PRE
Benign prostatic hyperplasia
Member has documented diagnosis of Urethral syndrome
(urinary hesitancy, frequency, and dysuria)
OR
Member has documented diagnosis of intractable
micturition difficulties (difficulty passing urine)
OR
Member has documented diagnosis of Ureteral
calculi/Kidney stones
OR
Member’s physician provides documentation (controlled
clinical trial) from the peer-reviewed medical literature for
medical use in females
A documented diagnosis of hypertension AND
A documented contraindication or intolerance or allergy or
failure of an adequate trial of one month of the preferred
generic alternative, propanolol
1 year
INDERAL XL
INDERAL XL-PRE
Hypertension
Hemangeol
Hemangeol-PRE
Proliferating infantile hemangioma
A documented diagnosis of proliferating infantile
hemangioma requiring systemic therapy AND documented
all of the following: Member was not born prematurely with
a corrected age of less than 5 weeks AND
Member does not weigh less than 2kg, have sustained
heart rate < 80 beats per minute, have greater than first
degree heart block, or have decompensated heart failure
AND
Member does not have sustained blood pressure < 50/
30mmHg AND
A documented contraindication or intolerance or allergy or
failure of an adequate trial of one month of the preferred
generic alternative, propranolol
1 year
ACTEMRA
ACTEMRA-PRE
Rheumatoid arthritis
Juvenile idiopathic arthritis
Polyarticular juvenile rheumatoid arthritis
6 months
AMEVIVE
AMEVIVE-PRE
Plaque psoriasis
Adult Moderate to Severe Active Rheumatoid Arthritis AND
A documented Contraindication or Intolerance or Allergy
or an inadequate response to a trial of one month each of
two preferred alternatives indicated for Rheumatoid
Arthritis one of which must include Remicade and one
from the following: Enbrel or Humira or Simponi or Simponi
ARIA (IV and SQ formulations)
Active systemic onset juvenile idiopathic arthritis in
patients with a disease duration of 6 or more months, who
have had an inadequate response to high-dose
corticosteroids and non-steroidal anti-inflammatory drugs
(IV formulation ONLY)
Moderate to severely active polyarticular juvenile
idiopathic arthritis (juvenile rheumatoid arthritis) in
persons 2 years of age and older (IV formulation ONLY)
A documented Diagnosis of Chronic Moderate to Severe
Plaque psoriasis in adults aged 18 years and older AND
documented to be a candidate for systemic therapy or
phototherapy when the following selection criteria are met:
10 % or more body surface area is affected by plaque
psoriasis (or 5 percent or more of body surface area if
psoriasis involves sensitive areas (hands, feet, face, or
genitals)) or member has a Psoriasis Area and Severity
Index (PASI) score of 10 or more AND
Member has failed to adequately respond to or is
intolerant to a 3-month trial of one of the following
phototherapies (unless contraindicated) Psoralens
(methoxsalen, trioxsalen) with UVA light (PUVA)
UVB with coal tar or dithranol
UVB (standard or narrow-band)
1 year
6 months
AND
A documented Contraindication or Intolerance or Allergy
or an inadequate response to a trial of one month each of
two preferred alternatives indicated for Plaque Psoriasis
such as Enbrel or Humira or Remicade or Stelara
CIMZIA
CIMZIA-PRE
Ankylosing spondylitis
Crohn's disease
Psoriatic arthritis
Rheumatoid arthritis
ENBREL
ENBREL-PRE
Ankylosing spondylitis
Juvenile idiopathic arthritis
Plaque psoriasis
Psoriatic arthritis
Rheumatoid arthritis
ENTYVIO
ENTYVIO-PRE
Crohn's disease
Ulcerative colitis
A documented Diagnosis of one of the following:
Active Crohn’s Disease that has remained active despite
treatment with either 6-mercaptopurine, azathioprine, or
corticosteroids AND A documented Contraindication or
Intolerance or Allergy or an inadequate response to a trial
of one month each of two preferred alternatives indicated
for Crohn’s Disease such as Humira and Remicade
Adult Moderate to Severe Active Rheumatoid Arthritis as
monotherapy or in combination with methotrexate (MTX)
AND A documented Contraindication or Intolerance or
Allergy or an inadequate response to a trial of one month
each of two preferred alternatives indicated for
Rheumatoid Arthritis such as Enbrel, Humira, Remicade,
Simponi, or Simponi ARIA
Active non-axial psoriatic arthritis AND a documented
failure of two or more non-biologic disease-modifying antirheumatic drugs (DMARDs) (e.g., anti-malarials,
cyclosporine, gold compounds, methotrexate, or
sulfasalazine) AND a documented contraindication or
intolerance or allergy or an inadequate response to a trial
of one month each of two preferred alternatives indicated
for active psoriatic arthritis such as Enbrel, Humira,
Remicade, Simponi, or Stelara
Active axial psoriatic arthritis and an inadequate response
to 2 or more NSAIDs AND a documented contraindication
or intolerance or allergy or an inadequate response to a
documented Diagnosis of one of the following:
Active non-axial psoriatic arthritis AND a documented
failure of two or more non-biologic disease-modifying antirheumatic drugs (DMARDs) (e.g., anti-malarials,
cyclosporine, gold compounds, methotrexate, or
sulfasalazine)
Active axial psoriatic arthritis and an inadequate response
to 2 or more NSAIDs
Adult Moderate to Severe Active Rheumatoid Arthritis
Ankylosing spondylitis AND a documented failure of two
or more non-steroidal anti-inflammatory drugs (NSAID)
(e.g. naproxen, ibuprofen, meloxicam)
Behcet’s Disease AND documented refractory to
glucocorticoids and azathioprine
Chronic Moderate to Severe Plaque psoriasis in adults
aged 18 years and older AND documented to be a
candidate for systemic therapy or phototherapy when the
following selection criteria are met: 10 % or more body
surface area is affected by plaque psoriasis (or 5 percent
or more of body surface area if psoriasis involves
sensitive areas (hands, feet, face, or genitals)) or member
has a Psoriasis Area and Severity Index (PASI) score of
10 or more AND
Member has failed to adequately respond to or is
intolerant to a 3-month trial of one of the following
phototherapies (unless contraindicated) Psoralens
A documented diagnosis of one of the following:
Moderately to severely active Ulcerative Colitis (UC) in
adults 18 years of age or older who meet either of the
following criteria: Member is hospitalized with fulminant
ulcerative colitis (i.e., persons with severe ulcerative colitis
who have more than 10 stools per day, continuous
bleeding, abdominal pain, and distension, and acute,
severe toxic symptoms including fever and anoxia); or
Member has moderate-to-severe active ulcerative colitis
and meets all of the following criteria: Member is refractory
to or requires continuous immunosuppression with
corticosteroids (e.g., methylprednisolone, prednisone) at
a dose of prednisone 40 to 60 mg/day (or equivalent) for
30 days for oral therapy or 7 to 10 days for IV therapy);
and
Member is refractory to or has a contraindication to 5aminosalicylic acid agents (e.g., balsalazide, mesalamine,
sulfasalazine); and
Member is refractory to or has a contraindication to
immunosuppressants (azathioprine and 6mercaptopurine).
AND
A documented contraindication or intolerance or allergy or
6 months
6 months
6 months
Member is female
INDERAL
XL-PRE
A documented trial of one
month of the preferred generic
alternative, propanolol
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
Otezla
Otezla-PRE
Plaque psoriasis
Psoriatic arthritis
Active non-axial psoriatic arthritis AND a documented
failure of two or more non-biologic disease-modifying antirheumatic drugs (DMARDs) (e.g., anti-malarials,
cyclosporine, gold compounds, methotrexate, or
sulfasalazine) AND a documented contraindication or
intolerance or allergy or an inadequate response to a trial
of one month each of two preferred alternatives indicated
for active psoriatic arthritis such as Enbrel, Humira,
Remicade, Simponi, or Stelara
Active axial psoriatic arthritis and an inadequate response
to 2 or more NSAIDs AND a documented contraindication
or intolerance or allergy or an inadequate response to a
trial of one month each of two preferred alternatives
indicated for active psoriatic arthritis such as Enbrel,
Humira, Remicade, Simponi, or Stelara
6 months
ENTYVIO
ENTYVIO-PRE
Crohn's disease
Ulcerative colitis
A documented diagnosis of one of the following:
Moderately to severely active Ulcerative Colitis (UC) in
adults 18 years of age or older who meet either of the
following criteria: Member is hospitalized with fulminant
ulcerative colitis (i.e., persons with severe ulcerative colitis
who have more than 10 stools per day, continuous
bleeding, abdominal pain, and distension, and acute,
severe toxic symptoms including fever and anoxia); or
Member has moderate-to-severe active ulcerative colitis
and meets all of the following criteria: Member is refractory
to or requires continuous immunosuppression with
corticosteroids (e.g., methylprednisolone, prednisone) at
a dose of prednisone 40 to 60 mg/day (or equivalent) for
30 days for oral therapy or 7 to 10 days for IV therapy);
and
Member is refractory to or has a contraindication to 5aminosalicylic acid agents (e.g., balsalazide, mesalamine,
sulfasalazine); and
Member is refractory to or has a contraindication to
immunosuppressants (azathioprine and 6mercaptopurine).
6 months
HUMIRA
HUMIRA-PRE
Ankylosing spondylitis
Crohn's disease
Juvenile idiopathic arthritis
Plaque psoriasis
Psoriatic arthritis
Rheumatoid arthritis
KINERET
KINERET-PRE
Chronic infantile neurologica
Rheumatoid arthritis
ORENCIA
ORENCIA-PRE
Juvenile idiopathic arthritis
Rheumatoid arthritis
AND
A documented contraindication or intolerance or allergy or
A documented Diagnosis of one of the following:
Active Crohn’s disease that has remained active despite
treatment with either 6-mercaptopurine, azathioprine, or
corticosteroids
Active Crohn's disease in children and adolescents who
do not respond to Remicade (infliximab) or develop
infusion reactions to Remicade (infliximab)
Active non-axial psoriatic arthritis AND a documented
failure of two or more non-biologic disease-modifying antirheumatic drugs (DMARDs) (e.g., anti-malarials,
cyclosporine, gold compounds, methotrexate, or
sulfasalazine)
Active axial psoriatic arthritis and an inadequate response
to 2 or more NSAIDs
Adult Moderate to Severe Active Rheumatoid Arthritis as
monotherapy or in combination with methotrexate or in
combination with non-biologic disease-modifying antirheumatic drugs (DMARDs)
Ankylosing spondylitis AND a documented failure of two or
more non-steroidal anti-inflammatory drugs (NSAID) (e.g.
naproxen, ibuprofen, meloxicam)
Chronic Moderate to Severe Plaque psoriasis in adults
aged 18 years and older AND documented to be a
candidate for systemic therapy or phototherapy when the
following selection criteria are met: 10 % or more body
surface area is affected by plaque psoriasis (or 5 percent
documented Diagnosis of one of the following:
Adult Moderate to Severe Active Rheumatoid Arthritis as
monotherapy or in combination with DMARDs other than
tumor necrosis factor (TNF) blocking agents AND A
documented Contraindication or Intolerance or Allergy or
an inadequate response to a trial of one month each of
two preferred alternatives indicated for Rheumatoid
Arthritis such as Enbrel, Humira, Remicade, Simponi, or
Simponi ARIA
Neonatal-onset multisystem inflammatory disease
(NOMID)
Adult-onset Still's disease when after failure of
glucocorticoids, methotrexate and a TNF-alpha inhibitor
Systemic onset juvenile idiopathic arthritis with active
systemic features and varying degrees of synovitis in
patients who have failed to respond to systemic
glucocorticoid monotherapy or non-steroidal antiinflammatory drug (NSAID) monotherapy
Systemic onset juvenile idiopathic arthritis without active
systemic features and with varying degrees of active
synovitis in patients who have failed intra-articular
injection or NSAID monotherapy (for individuals with an
active joint count (AJC) greater than 4) or have failed
methotrexate or leflunomide (for individuals with an AJC
A documented Diagnosis of one of the following:
6 months
6 months
6 months
Adult Moderate to Severe Active Rheumatoid Arthritis AND
a documented Contraindication or Intolerance or Allergy
or an inadequate response to a trial of one month each of
two preferred alternatives indicated for Rheumatoid
Arthritis (note: for Orencia IV, one preferred alternative
must include Remicade; and one from the following:
Enbrel, Humira, Simponi, or Simponi ARIA)
Moderate or Severely active polyarticular juvenile
rheumatoid arthritis (juvenile idiopathic arthritis) AND a
documented Contraindication or Intolerance or Allergy or
an inadequate response to a trial of one month each of
two preferred alternatives indicated for juvenile
rheumatoid arthritis (note: for Orencia IV, one preferred
alternative must include Remicade; and one from the
following: Enbrel or Humira)
REMICADE
REMICADE-PRE
Ankylosing spondylitis
Crohn's disease
Plaque psoriasis
Psoriatic arthritis
Rheumatoid arthritis
Ulcerative colitis
For Remicade
A documented Diagnosis of one of the following:
Active Crohn’s Disease that has remained active despite
treatment with either 6-mercaptopurine, azathioprine, or
corticosteroids
Active non-axial psoriatic arthritis AND a documented
failure of two or more non-biologic disease-modifying antirheumatic drugs (DMARDs) (e.g., anti-malarials,
cyclosporine, gold compounds, methotrexate, or
sulfasalazine)
Active axial psoriatic arthritis and an inadequate response
to 2 or more NSAIDs
Adult Moderate to Severe Active Rheumatoid Arthritis
Ankylosing Spondylitis and Other Spondyloarthropathies
AND a documented inadequate response to two or more
non-steroidal anti-inflammatory drugs (NSAIDS) (e.g.,
celecoxib, diclofenac, ibuprofen, indomethacin, meloxicam,
naproxen, sulindac)
Refractory Behcet's uveitis
Chronic Moderate to Severe Plaque psoriasis in adults
aged 18 years and older AND documented to be a
candidate for systemic therapy or phototherapy when the
following selection criteria are met: 10 % or more body
surface area is affected by plaque psoriasis (or 5 percent
or more of body surface area if psoriasis involves
6 months
OtezlaPRE
documented trial of one
month each of two preferred
alternatives indicated for
active psoriatic arthritis such
as Enbrel, Humira, Remicade,
Simponi, or Stelara
Up to 1
starter
pack in 1
year; Up
to 60
tablets in
30 days
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
SIMPONI
SIMPONI-PRE
Ankylosing spondylitis
Psoriatic arthritis
Rheumatoid arthritis
Ulcerative colitis
Simponi ARIA
Simponi ARIA-PRE
Ankylosing spondylitis
Psoriatic arthritis
Rheumatoid arthritis
Ulcerative colitis
STELARA
STELARA-PRE
Plaque psoriasis
Psoriatic arthritis
A documented Diagnosis of one of the following:
Active ankylosing spondylitis with evidence of
inflammatory disease in members who have had an
inadequate response to NSAIDS (e.g., celecoxib,
diclofenac, ibuprofen, indomethacin, meloxicam,
naproxen, sulindac, or valdecoxib) (unless
contraindicated)
Active non-axial psoriatic arthritis AND a documented
failure of two or more non-biologic disease-modifying antirheumatic drugs (DMARDs) (e.g., anti-malarials,
cyclosporine, gold compounds, methotrexate, or
sulfasalazine)
Active axial psoriatic arthritis and an inadequate response
to 2 or more NSAIDs
Adult Moderate to Severe Active Rheumatoid Arthritis in
combination with methotrexate
Active Ulcerative Colitis AND Member is hospitalized with
fulminant ulcerative colitis (i.e., persons severe ulcerative
colitis who have more than 10 stools per day, continuous
bleeding, abdominal pain, and distension, and acute,
severe toxic symptoms including fever and anoxia) OR
Member has moderate to severe active ulcerative colitis
and meets all of the following criteria: Member is refractory
to or requires continuous immunosuppression with
corticosteroids (e.g., methylprednisolone, prednisone) at
a dose of prednisone 40 to 60 mg/day (or equivalent) for
A documented diagnosis of moderately-to-severely active 18 or greater
rheumatoid arthritis in adult members 18 years of age or
older in combination with methotrexate
6 months
A documented diagnosis of one of the following:
Chronic Moderate to Severe Plaque psoriasis in adults
aged 18 years and older AND documented to be a
candidate for systemic therapy or phototherapy when the
following selection criteria are met: 10 % or more body
surface area is affected by plaque psoriasis (or 5 percent
or more of body surface area if psoriasis involves
sensitive areas (hands, feet, face, or genitals)) or member
has a Psoriasis Area and Severity Index (PASI) score of
10 or more AND
Member has failed to adequately respond to or is
intolerant to a 3-month trial of one of the following
phototherapies (unless contraindicated) Psoralens
(methoxsalen, trioxsalen) with UVA light (PUVA)
UVB with coal tar or dithranol
UVB (standard or narrow-band)
6 months
6 months
Active non-axial psoriatic arthritis AND a documented
failure of two or more non-biologic disease-modifying antirheumatic drugs (DMARDs) (e.g., anti-malarials,
cyclosporine, gold compounds, methotrexate, or
sulfasalazine)
Active axial psoriatic arthritis and an inadequate response
XELJANZ
XELJANZ-PRE
Rheumatoid arthritis
A documented diagnosis of moderately to severely active
rheumatoid arthritis in patients who have had an
inadequate response or intolerance to methotrexate AND
A documented confirmation that Xeljanz will not be used in
combination with other biologic therapy (i.e. Enbrel,
Humira) or potent immunosuppressants (i.e. azathioprine,
cyclosporine) AND
A documented recent Tuberculin skin test (within 6
months) to check for latent Tuberculosis AND
A documented contraindication or intolerance or allergy or
inadequate response to a trial of one month each of two
preferred alternatives indicated for rheumatoid arthritis
such as Enbrel, Humira, Remicade, Simponi, or Simponi
ARIA
6 months
Alprolix
Alprolix-PRE
Bleeding
A documented diagnosis of hemophilia B (endogenous
factor IX level of ≤2 IU per deciliter, or ≤2% of normal
levels) for the following indications: control and prevention
of bleeding episodes; or
perioperative management; or
routine prophylaxis to prevent or reduce the frequency of
bleeding episodes.
1 year
Kcentra
Kcentra-PRE
Reversal of acquired coagulation factor deficiency
1 year
Wilate
Wilate-PRE
Bleeding
Tretten
Tretten-PRE
Bleeding
Corifact
Corifact-PRE
Bleeding
A documented diagnosis of urgent reversal of acquired
coagulation factor deficiency induced by vitamin K
antagonist (e.g., warfarin) therapy in adults with acute
major bleeding.
A documented diagnosis of treatment of spontaneous
and/ or trauma-induced bleeding episodes in individuals
with severe von Willebrand disease (VWD) or individuals
with mild or moderate VWD when there is failure,
contraindication or intolerance to desmopressin.
A documented diagnosis of routine prophylaxis of
bleeding in persons with congenital factor XIII A-subunit
deficiency.
A documented diagnosis of the prevention of bleeding
and for the peri-operative management of surgical
bleeding in persons with congenital factor XIII deficiency.
Feiba NF
Feiba-PRE
Bleeding
1 year
Humate-P
Alphanate
HEMOFIL M
KOATE-DVI
MONOCLATE-P
ADVATE
HELIXATE FS
KOGENATE FS
RECOMBINATE
REFACTO
XYNTHA
BEBULIN VH
PROFILNINE
ALPHANINE SD
BENEFIX
MONONINE
RIXUBIS INJ
Coagulants-PRE
Bleeding
A documented diagnosis of hemophilia A and B with
inhibitors for the control and prevention of bleeding
episodes, perioperative management, and routine
prophylaxis to prevent or reduce the frequency of
bleeding episodes.
A documented diagnosis of one of the following: Prevent
or treat hemorrhagic complications in adults and children
with hemophilia A, hemophilia B or von Willebrand's
disease according to the following criteria limitation:
Standard dose therapy (dose until bleeding stops or up to
14 days after surgery) when both of the following criteria
are met:
2
tablets/da
y
1 year
1 year
1 year
Immune
Tolerance
Induction - 6
months
All others - 1
year
Member has a diagnosis of hemophilia A, hemophilia B, or
von Willebrand's disease (only Humate-P or Alphanate
may be used in von Willebrand’s disease); and
Member is hemorrhaging or physical trauma such as
surgery is anticipated (secondary short-term prophylaxis).
Continuous (long-term) prophylactic therapy when either
of the following criteria is met:
Primary prophylactic therapy: Member has severe
hemophilia A or hemophilia B (less than 1% of normal
factor (less than 0.01 IU/mL)); or
NOVOSEVEN
NOVOSEVEN-PRE
Bleeding
COMBIVENT
COMBIVENT-PRE
Chronic Ostructive Pulmonary Disease (COPD)
NYMALIZE
NYMALIZE-PRE
Subarachnoid hemorrhage
documented diagnosis of prevention of bleeding in
surgical interventions or invasive procedures and for the
control of bleeding events in members with any of the
following indications: Members with hemophilia A or
hemophilia B who have developed inhibitor antibodies to
factor VIII or factor IX; or
Members with acquired hemophilia or congenital FVII
deficiency; or
Members with Glanzmann's thrombasthenia with
antibodies to glycoprotein IIb-IIIa and/or human leukocyte
antigen (HLA), and with past or present refractoriness to
platelet transfusions.
A documented diagnosis of chronic obstructive pulmonary
disease (COPD) AND
A documented trial of one month of Combivent Respimat
(propellant-free inhaler)
1 year
A documented diagnosis of subarachnoid hemorrhage
(SAH) in adults AND
A documented contraindication or intolerance or allergy or
failure of an adequate trial of one week of the preferred
generic alternative, nimodipine ORMember is unable to
tolerate oral capsule or tablet
21 days
1 year
120ml/day
for 21
days
maximum
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
XYREM
XYREM-PRE
Cataplexy and narcolepsy
Narcolepsy, to treat excessive daytime sleepiness
(A or B or C) and D and E
1 year
9 gm/day
(540ml/30
day
supply)
A. Member has a documented diagnosis of narcolepsy
confirmed by sleep lab evaluation OR
B. Member has episodes of cataplexy including
hypnagogic hallucinations and/or sleep paralysis OR
C. Member has excessive daytime sleepiness with
symptoms that limit the ability to perform normal daily
activities
AND
D. Member and physician are enrolled in the Xyrem
Success Program.
AND
LOSEASONIQUE
SEASONIQUE
LOSEASONIQUE-PRE
Contraception
ACTHAR
ACTHAR-PRE
West syndrome (infantile spasms)
CLARINEX
desloratidine
Antihistamines -PRE
Idiopathic urticaria, chronic
Perennial allergic rhinitis
Seasonal allergic rhinitis
E. Quantity limits: According to the manufacturer, Xyrem
can be dosed up to a maximum daily dose at the
interval(s) as indicated in the table below. A quantity of
the drug will be considered medically necessary as
indicated in the table below
A documented diagnosis of pregnancy prevention in
women AND
A documented contraindication or intolerance or allergy or
failure of an adequate trial of one month of one generic
equivalent alternative
A documented diagnosis of West syndrome (infantile
spasms)
A documented** diagnosis of one of the following :
FDA-approved indications: Allergic conjunctivitis
Chronic idiopathic urticaria (hives)
Rhinitis (allergic perennial or seasonal, vasomotor)
1 year
3 months
1 year
Note: levocetirizine,
loratadine, Alavert,
cetirizine, Claritin, Xyzal and
Zyrtec are designated as
Pregnancy Category B;
Allegra, Clarinex,
desloratadine and
fexofenadine are
designated as Pregnancy
Category C
2.5 mg
and 5 mg
=1
tablet/day
Syrup =
10 ml/day
1 year
Note: levocetirizine,
loratadine, Alavert,
cetirizine, Claritin, Xyzal and
Zyrtec are designated as
Pregnancy Category B;
Allegra, Clarinex,
desloratadine and
fexofenadine are
designated as Pregnancy
Category C
1
tablet/day
2.5 mg/5
ml solution
= 10
ml/day
1 year
Note: levocetirizine,
loratadine, Alavert,
cetirizine, Claritin, Xyzal and
Zyrtec are designated as
Pregnancy Category B;
Allegra, Clarinex,
desloratadine and
fexofenadine are
designated as Pregnancy
Category C
2.5mg and
5mg = 1
reditab/
day
1 year
Note: levocetirizine,
loratadine, Alavert,
cetirizine, Claritin, Xyzal and
Zyrtec are designated as
Pregnancy Category B;
Allegra, Clarinex,
desloratadine and
fexofenadine are
designated as Pregnancy
Category C
2.5
mg/120
mg = 2
tablets/da
y5
mg/240
mg = 1
tablet/day
1 year
Note: levocetirizine,
loratadine, Alavert,
cetirizine, Claritin, Xyzal and
Zyrtec are designated as
Pregnancy Category B;
Allegra, Clarinex,
desloratadine and
fexofenadine are
designated as Pregnancy
Category C
4
capsules/
day
Accepted unlabeled indications listed in the
pharmaceutical compendia (United States Pharmacopeia
Drug Information or American Hospital Formulary Service):
allergies
angioedema
asthma
atopic dermatitis(eczema)
dermatographism
mastocytosis
pruritus can be caused for example by (atopic dermatitis
i.e eczema, or contact dermatitis ) urticaria (hives)
transfusion reactions
urticarial, anaphylactic/anaphylactoid reactions
XYZAL
levocetirizine
Antihistamines -PRE
Idiopathic urticaria, chronic
Perennial allergic rhinitis
Seasonal allergic rhinitis
AND
A documented:**contraindication or intolerance or allergy
or failure of two weeks each of TWO of the following
nonprescription (OTC) products (single entity or
combination product); one containing loratadine, one
containing fexofenadine or one containing cetirizine OR
A documented** diagnosis of one of the following :
FDA-approved indications: Allergic conjunctivitis
Chronic idiopathic urticaria (hives)
Rhinitis (allergic perennial or seasonal, vasomotor)
Accepted unlabeled indications listed in the
pharmaceutical compendia (United States Pharmacopeia
Drug Information or American Hospital Formulary Service):
allergies
angioedema
asthma
atopic dermatitis(eczema)
dermatographism
mastocytosis
pruritus can be caused for example by (atopic dermatitis
i.e eczema, or contact dermatitis ) urticaria (hives)
transfusion reactions
urticarial, anaphylactic/anaphylactoid reactions
desloratidine
desloratadine odt tab
Antihistamines -PRE
Idiopathic urticaria, chronic
Perennial allergic rhinitis
Seasonal allergic rhinitis
AND
A documented:**contraindication or intolerance or allergy
or failure of two weeks each of TWO of the following
nonprescription (OTC) products (single entity or
combination product); one containing loratadine, one
containing fexofenadine or one containing cetirizine OR
A documented** diagnosis of one of the following :
FDA-approved indications: Allergic conjunctivitis
Chronic idiopathic urticaria (hives)
Rhinitis (allergic perennial or seasonal, vasomotor)
Accepted unlabeled indications listed in the
pharmaceutical compendia (United States Pharmacopeia
Drug Information or American Hospital Formulary Service):
allergies
angioedema
asthma
atopic dermatitis(eczema)
dermatographism
mastocytosis
pruritus can be caused for example by (atopic dermatitis
i.e eczema, or contact dermatitis ) urticaria (hives)
transfusion reactions
urticarial, anaphylactic/anaphylactoid reactions
CLARINEX-D
Antihistamines -PRE
Idiopathic urticaria, chronic
Perennial allergic rhinitis
Seasonal allergic rhinitis
AND
A documented:**contraindication or intolerance or allergy
or failure of two weeks each of TWO of the following
nonprescription (OTC) products (single entity or
combination product); one containing loratadine, one
containing fexofenadine or one containing cetirizine OR
A documented** diagnosis of one of the following :
FDA-approved indications: Allergic conjunctivitis
Chronic idiopathic urticaria (hives)
Rhinitis (allergic perennial or seasonal, vasomotor)
Accepted unlabeled indications listed in the
pharmaceutical compendia (United States Pharmacopeia
Drug Information or American Hospital Formulary Service):
allergies
angioedema
asthma
atopic dermatitis(eczema)
dermatographism
mastocytosis
pruritus can be caused for example by (atopic dermatitis
i.e eczema, or contact dermatitis ) urticaria (hives)
transfusion reactions
urticarial, anaphylactic/anaphylactoid reactions
SEMPREX-D
Antihistamines -PRE
Idiopathic urticaria, chronic
Perennial allergic rhinitis
Seasonal allergic rhinitis
AND
A documented:**contraindication or intolerance or allergy
or failure of two weeks each of TWO of the following
nonprescription (OTC) products (single entity or
combination product); one containing loratadine, one
containing fexofenadine or one containing cetirizine OR
A documented** diagnosis of one of the following :
FDA-approved indications: Allergic conjunctivitis
Chronic idiopathic urticaria (hives)
Rhinitis (allergic perennial or seasonal, vasomotor)
Accepted unlabeled indications listed in the
pharmaceutical compendia (United States Pharmacopeia
Drug Information or American Hospital Formulary Service):
allergies
angioedema
asthma
atopic dermatitis(eczema)
dermatographism
mastocytosis
pruritus can be caused for example by (atopic dermatitis
i.e eczema, or contact dermatitis ) urticaria (hives)
transfusion reactions
urticarial, anaphylactic/anaphylactoid reactions
AND
A documented:**contraindication or intolerance or allergy
or failure of two weeks each of TWO of the following
nonprescription (OTC) products (single entity or
combination product); one containing loratadine, one
containing fexofenadine or one containing cetirizine OR
LOSEASO A documented adequate trial
NIQUEof one month of one generic
PRE
equivalent alternative
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
promethazine
promethazine-PRE
tab/cap/supp/syrup,
promethazine w/codeine,
phenylephrinepromethazine-codeine,
promethazine-dm,
Prometh VC,
promethegan and
Phenergan
Administration of analgesic; Prophylaxis
Allergic condition
Motion sickness
Nausea and vomiting
Postoperative pain
Sedation
A AND C – For promethazine tab/cap/supp/syrup,
promethazine-dm, Prometh VC, promethegan and
Phenergan
1 year
B AND C – For promethazine w/codeine, phenylephrinepromethazine-codeine
A. Member is less than 2 years of age
OR
B. Member is less than 6 years of age
FDA alert6 Use of
Phenergan/promethazine is
contraindicated in Infants
and Children < 2 years of
age, due to risks for fatal
respiratory depression. In
addition the use of
promethazine and codeine
(with or without
phenylephrine) is
contraindicated in pediatric
patients less than 6 years
of age
AND
SIGNIFOR
SIGNIFOR-PRE
Pituitary dependent hypercortisolism
C. Member's physician provides documentation
(controlled clinical trial) from the peer reviewed medical
literature that supports use in specified indication for this
age group.
A documented diagnosis of Cushing’s disease (i.e.,
pituitary-dependent elevated production of cortisol) in
adults AND a documented all of the following:
Pituitary surgery is not an option or has not been curative
Assessment of anti-diabetic therapy for patients with
poorly controlled diabetes prior to initiating therapy
Established baseline values of the following prior to
initiating therapy: Fasting plasma glucose (FPG)
Hemoglobin A1c (HbA1c)
Liver function tests (i.e., alanine aminotransferase (ALT),
aspartate aminosferase (AST))
Electrocardiogram (EKG) and gallbladder ultrasound
Pituitary function (i.e., TSH/free T4, GH/IGF-1)
6 months
60
ampules/
30 days
2/day
Ongoing patient evaluation to monitor appropriate
treatment response and adverse events, including the
following: Monitoring of blood glucose and/or FPG
assessments will be done every week for the first three
months and as clinically appropriate thereafter
Liver function tests will be done after 1 to 2 weeks on
treatment, then monthly for 3 months, and every 6 months
thereafter
gallbladder ultrasound at 6 to 12 month intervals
KALYDECO
KALYDECO-PRE
Cystic fibrosis
A documented diagnosis of cystic fibrosis in patients aged ≥6
6 years and older who have 1 of the following mutations in
the cystic fibrosis transmembrane conductance regulator
(CFTR) gene: G551D, G1244E, G1349D, G178R, G551S,
S1251N, S1255P, S549N, or S549R
1 year
PULMOZYME
PULMOZYME-PRE
Cystic fibrosis
A documented diagnosis of one of the following: Cystic
fibrosis
Primary ciliary dyskinesia
1 year
AND
A documented concurrent use of at least one standard
therapy of treatment. Standard cystic fibrosis treatments
include: oral, inhaled and/or parenteral antibiotics
(examples: Tobi, Cayston, azithromycin), bronchodilators
(examples: albuterol solution, ProAir HFA, Proventil HFA,
Maxair Autohaler, Ventolin HFA, Xopenex solution/HFA),
enzyme supplements (examples: Creon, Lipram,
Pancrelipase, Digex, Pancreaze, Zenpep), vitamins, oral
or inhaled corticosteroids (examples: Pulmicort,
Symbicort, prednisone) and analgesics.
PROCYSBI
PROCYSBI-PRE
Cystinosis
≥6
A documented diagnosis of nephropathic cystinosis in
adults and children ages 6 years and older AND
Member will not be using Cystagon concomitantly AND
A documented contraindication or intolerance or allergy or
failure of an adequate trial of one month of the preferred
alternative, Cystagon
1 year
SYMLIN
SYMLIN PEN
SYMLIN-PRE
Diabetes
A documented diagnosis of type I or type II diabetes AND
Concurrent use of a rapid or short-acting insulin i.e.,
Humalog or regular insulin
1 year
Avandia
Avandamet
Avandaryl
Avandia-PRE
Diabetes
A documented diagnosis of type 2 diabetes mellitus in
adults, AND
A documented HbA1C lab value greater than 6.5%, AND
Members must be enrolled in the Avandia-Rosiglitazone
Medicines Access Program, AND Member is already
taking Avandia and has been advised by a healthcare
professional of the risks and benefits of Avandia including
the potential increased risk of myocardial infarction, OR
Member is not already taking Avandia and is: Unable to
achieve adequate glycemic control (HbA1C lab value
greater than 6.5%) on other diabetes medications, and
Has been advised of the risks and benefits of Avandia,
including the potential increased risk of myocardial
infarction, and
In consultation with their healthcare provider, has decided
not to take pioglitazone for medical reasons
1 year
PROCYSB
I-PRE
A documented trial of one
month of the preferred
alternative, Cystagon
25 mg =
120
capsules
/30 days.
75 mg =
750
capsules /
30 days.
AND
A documented contraindication or intolerance or allergy or
failure of an adequate trial of one month each of
metformin AND a GLP-1 agonist (i.e., Bydureon), or a
DPP-4 inhibitor (i.e., Januvia), or insulin
KORLYM
KORLYM-PRE
Diabetes
A documented diagnosis of type 2 diabetes mellitus or
glucose intolerance in adults with Cushing’s syndrome
who have failed surgery or not a candidate for surgery
AND
A negative pregnancy test for females of childbearing age
within the last 14 days, unless it is documented that the
member is sterile (e.g. hysterectomy, unable to achieve
pregnancy) or in menopause
1 year
4
tablets/da
y
FABRAZYME
BRAVELLE
chorionic gonadotropin
novarel
pregnyl
Ovidrel
Follistim AQ
Gonal-F/Gonal-F RFF
Menopur
Repronex
FABRAZYME-PRE
BRAVELLE-PRE
Fabry disease
Ovulation induction
Assisted reproductive technology
A documented diagnosis of Fabry disease
A documented diagnosis of any of the following:
Clomiphene plus gonadotropins may be considered
medically necessary in women who do not ovulate using
clomiphene alone
For use in pituitary down-regulation as part of in vitro
fertilization treatment (Note: coverage of gonadotropins
for this indication is limited to plans that cover advanced
reproductive technologies. Please check benefit plan
descriptions for details.)
Pulsatile administration of gonadotropins are considered
medically necessary for women with WHO Group I
ovulation disorders (hypothalamic pituitary failure,
characterized by hypothalamic amenorrhea or
hypogonadotropic hypogonadism)
Women with WHO Group II ovulation disorders such as
polycystic ovary syndrome who do not ovulate with
clomiphene citrate or tamoxifen
1 year
1 year
Female
1 year
Male
1 year
Female
AND
Bravelle
Follistim AQ
Gonal-F
Gonal-F RFF
Menopur
Repronex
Follistim
Ovulation induction
Assisted reproductive technology
Ganirelix AC
Cetrotide
Ganirelix-PRE
Ovulation induction
A documented Contraindication or Intolerance or Allergy
or Failure of an adequate trial of one month each of two
preferred gonadotropins - For Repronex and Follistim AQ
A documented diagnosis of use with human chorionic
gonadotropin (hCG) for the induction of spermatogenesis
in men with primary or secondary hypogonadotropic
hypogonadism in whom the cause of infertility is not due to
primary testicular failure AND
A documented contraindication or intolerance or allergy or
failure of an adequate trial of one month each of 2
preferred gonadotropins (For Follistim AQ and Repronex
only)
A documented diagnosis of prevention of premature LH
surge in women undergoing assisted reproduction
techniques (ART) i.e. allowing the follicles to mature for
planned oocyte collection
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
novarel
pregnyl
novarel-PRE
Cryptorchidism
Hypogonadotropic hypogonadism
DIFLUCAN
DIFLUCAN-PRE
Bone marrow transplant - Candidiasis; Prophylaxis
Candidal vulvovaginitis
Candidiasis
Cryptococcal meningitis
Oropharyngeal candidiasis
Diflucan 150mg not
included
A documented diagnosis of one of the following: male
infertility due to hypogonadotropic hypogonadism (select
cases of hypogonadism secondary to pituitary deficiency);
or
prepubertal cryptorchidism not due to anatomic
obstruction.
1 year
Male
A documented Diagnosis of one of the below indications
and specified criteria AND
A documented contraindication or intolerance or allergy
or failure of an adequate trial of preferred generic
fluconazole (if request is for brand Diflucan)
Blastomycosis
Bone Marrow Transplant (prophylaxis)
Candidiasis (Systemic); Chronic cutaneous candidal
infection
Coccidoidmycosis (valley fever) or Coccidiomeningitis
Chronic Candidal Paronychia
Cryptococcus
Cutaneous dermatophyte infection: NOTE: tinea pedis
(athletes foot), tinea cruris (jock itch), or tinea corporis
(ringworm on the body), does NOT include tinea
versicolor] ANDA documented contraindication or
intolerance or allergy or failure of an adequate trial of one
topical antifungal AND preferred generic oral terbinafine
1 year
For coverage of additional
quantities, a member's
treating physician must
request prior authorization
through the Pharmacy
Management
Precertification Unit. A prior
authorization will be granted
for coverage of additional
quantities of Diflucan,
fluconazole, or Oravig for
those members who meet
ANY of the following criteria:
For member that has a
diagnosis of vulvovaginal
candidiasis (VVC)/Vaginal
Yeast Infection complicated
with any of the following:
antibiotic use or an immune
compromised state such as
HIV/AIDS or diabetes, or
cancer, or chronic
corticosteroid use: or
recurrent (4 or more
episodes per year) or
severe VVC as determined
Fungal Otitis externa ANDA documented Contraindication
or Intolerance or allergy OR Failure of an adequate trial of
one week of one preferred topical alternative
ONMEL
ONMEL-PRE
onychomycosis (Tinea unguium)
Histoplasmosis
HIV or Cancer
Mastitis or a candidal infection of the breast (due to breast
A documented diagnosis of onychomycosis (Tinea
unguium) due to dermatophyte AND
1 year
A documented positive laboratory test such as (potassium
hydroxide-KOH preparation, fungal culture, or nail biopsy)
to confirm the diagnosis of onychomycosis
(NOTE: This positive test should be recent (within the
last 3-6 months) and associated with the current infection)
AND
A documented contraindication or intolerance or allergy or
failure of an adequate trial of 6 weeks of preferred generic
terbinafine OR any of the following: Presence of hepatic
dysfunction or increased risk for liver disease
Fungal culture indicating lack of sensitivity to terbinafine
Non-dermatophyte fungal infection (mixed infection, a
mold or yeast infection) AND
A documented contraindication or intolerance or allergy or
failure of an adequate trial of 6 weeks of the preferred
generic, itraconazole
LAMISIL
terbinafine
LAMISIL-PRE
Cutaneous leishmaniasis
Cutaneous sporotrichosis
Paracoccidioidomycosis
Seborrheic dermatitis
Tinea capitis
Onychomycosis (Tinea unguium)
A documented Diagnosis of one of the below indications
and specified criteria AND
A documented contraindication or intolerance or allergy
or failure of an adequate trial of preferred generic
terbinafine (if request is for brand Lamisil)
Chromoblastomycosis
Cutaneous dermatophyte infection: NOTE: tinea
pedis/manuum(athletes foot/hand), tinea cruris (jock itch),
or tinea corporis (ringworm on the body), does NOT
include tinea versicolor] ANDA documented
contraindication or intolerance or allergy or failure of an
adequate trial of one topical antifungal
1 year
A Documented Diagnosis of
Tinea capitis AND
A documented
contraindication or
intolerance or allergy or
failure of two weeks of
preferred generic
terbinafine OR
Cutaneous leishmaniasis
Cutaneous sporotrichosis
Paracoccidioidomycosis
Seborrheic dermatitis
Tinea capitis
Onychomycosis (Tinea unguium) due to dermatophyte
ANDA documented positive laboratory test such as
(potassium hydroxide-KOH preparation, fungal culture, or
nail biopsy) to confirm the diagnosis of onychomycosis
(NOTE: This positive test should be recent (within the
last 3-6 months) and associated with the current infection)
itraconazole
SPORANOX
ciclodan
ciclopirox
JUBLIA
PENLAC
SPORANOX-PRE
Fungal-PRE
Aspergillosis, Invasive, salvage therapy
Blastomycosis
Candidiasis of the esophagus
Histoplasmosis, Disseminated
Onychomycosis due to dermatophyte
Oropharyngeal candidiasis
Pulmonary histoplasmosis
Onychomycosis due to dermatophyte
A documented Diagnosis of one of the below indications
and specified criteria AND
A documented contraindication or intolerance or allergy
or failure of an adequate trial of preferred generic
itraconazole (if request is for brand Sporanox)
Aspergillosis
Blastomycosis
Treatment of oropharyngeal/esophageal candidiasis in
HIV-infected persons
Chromoblastomycosis
Coccidioidomycosis associated with AIDS, treatment and
prophylaxis
Cryptococcosis
Cryptococcal meningitis - HIV infection
Cutaneous dermatophyte infection: NOTE: tinea
pedis/manuum (athletes foot/hand), tinea cruris (jock itch),
or tinea corporis (ringworm on the body), does NOT
include tinea versicolor] ANDA documented
contraindication or intolerance or allergy or failure of an
adequate trial of one topical antifungal AND preferred
generic oral terbinafine
Febrile neutropenia
Histoplasmosis
Penicillium marneffei infection
Prophylaxis of invasive fungal infections in persons with
A documented diagnosis of onychomycosis confirmed by
either a positive KOH stain (potassium hydroxide), positive
PAS stain (para-aminosalicylic acid), a positive DTM
(dermatophyte test medium) or positive fungal culture
(positive test should be recent (within the last 3 - 6
months) and associated with the current infection)
Member requires a liquid
dosage form
1 year
1 year
AND
A documented contraindication or intolerance or allergy or
failure of an adequate trial of one systemic (oral)
alternative either terbinafine (6 weeks for fingernail
infections; 12 weeks for toenail infections); fluconazole (6
months); griseofulvin (6 months); itraconazole (60 days
(PulsePak) for fingernail infections; 90 days for toenail)
OR
Presence of hepatic dysfunction or increased risk for liver
disease (for example, has a history of alcohol abuse or a
history of hepatitis) OR
Member is female and is pregnant and/or breastfeeding
AND
Member is NOT receiving a systemic (oral) antifungal
agent – terbinafine, fluconazole, griseofulvin, itraconazole
for onychomycosis at the same time
CEREZYME
ELELYSO
VPRIV
ZAVESCA
Gaucher-PRE
Gaucher's disease, Type 1
A documented diagnosis of Type 1 Gaucher disease in
adults members who have any of the symptoms below; or
A documented diagnosis of neuronopathic Type 3
Gaucher disease in children and adults who have any of
the symptoms below and have neurologic findings
consistent with Type 3 Gaucher disease (encephalopathy,
ophthalmoplegia, progressive myoclonic epilepsy,
cerebellar ataxia, spasticity, or dementia) (Cerezyme,
Elelyso, and VPRIV ONLY) Moderate to severe anemia
(hemoglobin less than or equal to 11.5 g/dL (adult
women) or 12.5 g/dL (adult men) or less than or equal to
1.0 g/dL or more below the lower limit of normal for age
and sex); or
Significant hepatomegaly (liver size 1.25 or more times
normal (1,750 cc in adults)) or splenomegaly (spleen size
5 or more times normal (875 cc in adults)); or
Skeletal disease beyond mild osteopenia and Erlenmeyer
flask deformity; or
Symptomatic disease, including abdominal or bone pain,
fatigue, exertional limitation, weakness, or cachexia; or
Thrombocytopenia (platelet count less than or equal to
120,000/mm3); or
A documented diagnosis of Type 1 Gaucher disease in
children and adolescents less than 18 years of age
For Lamisil oral granules
1 year
150 mg
only = 1
dose/30
day
supply
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
KRYSTEXXA
KRYSTEXXA-PRE
Gout
A documented diagnosis of symptomatic gout; AND
At least 3 gout flares in the previous 18 months that were
inadequately controlled by colchicine [Colcrys] and nonsteroidal anti-inflammatory drugs (i.e., ibuprofen,
naproxen, indomethacin), or at least 1 gout tophus or
gouty arthritis; AND
Failure to normalize serum uric acid to less than 6 mg/dL
after 3 months of maximum medically appropriate dose of
xanthine oxidase inhibitors (maximum recommended
dosage of allopurinol [Zyloprim] is 800 mg/day and
febuxostat [Uloric] is 80 mg/day or when xanthine oxidase
inhibitors are contraindicated; AND
Member has undertaken appropriate life style
modifications, i.e. limiting of alcohol consumption and
other medications known to precipitate gout attacks have
been discontinued/changed when possible; AND
Member does not have G6PD deficiency. (Persons at
higher risk for G6PD deficiency (e.g., those of African and
Mediterranean ancestry) should be screened due to the
risk of hemolysis and methemoglobinemia. G6PD
deficiency is a contraindication for Krystexxa therapy.)
1 year
GATTEX
GATTEX-PRE
Short bowel syndrome
A documented diagnosis of short bowel syndrome in
adults AND all of the following:
Member has been dependent on parenteral
nutrition/intravenous support for at least 12 months
Member requires parenteral nutrition at least 3 times per
week
6 months
HELIDAC
HELIDAC-PRE
Helicobacter pylori infection
Peptic ulcer disease
A documented diagnosis of Helicobacter pylori infection
and peptic ulcer disease (gastric or duodenal ulcer
disease)
1 year
HELIDAC- A documented trial of two
weeks of the preferred generic
PRE
alternatives, metronidazole,
tetracycline, and over-thecounter bismuth subsalicylate,
all taken concomitantly with an
H2-blocker or PPI (i.e.,
ranitidine, omeprazole,
lansoprazole)
1 year
PREVPAC- A documented trial of two
PRE
weeks of the preferred generic
alternatives, lansoprazole,
amoxicillin, and clarithromycin,
all taken concomitantly
PREVPAC
PREVPAC-PRE
Helicobacter pylori infection
Peptic ulcer disease
AND
A documented contraindication or intolerance or allergy or
failure of an adequate trial of two weeks of the preferred
generic alternatives, metronidazole, tetracycline, and overthe-counter bismuth subsalicylate, all taken concomitantly
with an H2-blocker or PPI (i.e., ranitidine, omeprazole,
lansoprazole)
A documented diagnosis of Helicobacter pylori infection
and peptic ulcer disease (gastric or duodenal ulcer
disease)
AND
A documented contraindication or intolerance or allergy or
failure of an adequate trial of two weeks of the preferred
generic alternatives, lansoprazole, amoxicillin, and
clarithromycin, all taken concomitantly
ARANESP
PROCRIT
EPOGEN
ESA-PRE
Anemia from myelodysplastic syndrome; or
Anemia of prematurity; or
Special circumstance members who will not or can not
receive whole blood or components as replacement for
traumatic or surgical loss; or
Treatment of anemic members scheduled to undergo
high-risk surgery who are at increased risk of or
intolerant to transfusions; or
Treatment of anemia associated with chronic renal
failure, whether or not on dialysis; or
Treatment of anemia in members receiving
chemotherapy for hepatitis C; or
Treatment of anemia of chronic disease other than
cancer when an underlying chronic disease associated
with anemia has been identified (see appendix); or
Treatment of anemia secondary to myelosuppressive
anticancer chemotherapy in solid tumors, multiple
myeloma, lymphomas and lymphocytic leukemia; or
Treatment of anemia due to zidovudine in HIV-infected
members.
OMONTYS
OMONTYS-PRE
Anemia
PROMACTA
PROMACTA-PRE
Thrombocytopenia
A documented diagnosis of one of the following:
Anemia from myelodysplastic syndrome; or
Anemia of prematurity; or
Special circumstance members who will not or can not
receive whole blood or components as replacement for
traumatic or surgical loss; or
Treatment of anemic members scheduled to undergo highrisk surgery who are at increased risk of or intolerant to
transfusions; or
Treatment of anemia associated with chronic renal failure,
whether or not on dialysis; or
Treatment of anemia in members receiving chemotherapy
for hepatitis C; or
Treatment of anemia of chronic disease other than cancer
when an underlying chronic disease associated with
anemia has been identified (see appendix); or
Treatment of anemia secondary to myelosuppressive
anticancer chemotherapy in solid tumors, multiple
myeloma, lymphomas and lymphocytic leukemia; or
Treatment of anemia due to zidovudine in HIV-infected
members.
A documented diagnosis of anemia due to chronic kidney
disease in adults with dialysis
A documented diagnosis of one of the following:
Thrombocytopenia in patients with chronic immune
(idiopathic) thrombocytopenia (ITP) who have had an
insufficient response to corticosteroids, immunoglobulins,
or splenectomy OR
Thrombocytopenia in patients with chronic hepatitis C to
allow the initiation and maintenance of interferon-based
therapy
4 months
4 months
1 year
AND
Documented measure of serum ALT, AST, and bilirubin
prior to initiation of therapy, every 2 weeks during dose
adjustment phase, and monthly following establishment of
a stable dose AND
Documented current platelet count of less than 75 x 109/L
AND
Documented complete blood count (CBC) with differentials
(including platelet counts) weekly during the dose
adjustment phase of therapy, then monthly following
establishment of a stable dose, then again weekly for at
least 4 weeks following discontinuation of therapy
FIRAZYR
FIRAZYR-PRE
Hereditary angioedema
Member must have a diagnosis of HAE, where diagnosis is ≥18
based on evidence of a low C4 level (C4 less than 14
mg/dL; normal range 14 to 40 mg/dL, or C4 below the
lower limit of normal as defined by the laboratory
performing the test) plus: A low C1 inhibitor (C1INH)
antigenic level (C1INH less than 19 mg/dL normal range
19 to 37 mg/dL, or C1INH antigenic level below the lower
limit of normal as defined by the laboratory performing the
test); or
A normal C1INH antigenic level (C1INH greater than or
equal to 19 mg/dL) and a low C1INH functional level
(functional C1INH less than 50 %,) or
Below the lower limit of normal as defined by the
laboratory performing the test)
1 year
Aetna considers Firazyr
experimental and
investigational for
prophylaxis against
angioedema attacks and
other indications (e.g.,
acute pancreatitis, airways
disease, thermal injury,
drug-induced angioedema,
use in combination with
Berinert or Kalbitor, and
refractory ascites in
persons with liver cirrhosis)
because its effectiveness
for these indications has
not been established.
1 year
Aetna considers Cinryze
medically necessary for
prophylaxis against
angioedema attacks in
adolescents and adults with
hereditary angioedema
(HAE)
AND
Member must be experiencing at least one symptom of the
moderate or severe attack (e.g., airway swelling, severe
abdominal pain, facial swelling, nausea and vomiting,
painful facial distortion); and
CINRYZE
CINRYZE-PRE
Hereditary angioedema
Medications known to cause angioedema (i.e. ACEMember has a history of at least 1 HAE attack per month;
and
Diagnosis of HAE is documented based on evidence of a
low C4 level (C4 < 14 mg/dL; normal range 14 to 40
mg/dL), or C4 below the lower limit of normal as defined
by the laboratory performing the test) plus: A low C1
inhibitor (C1INH) antigenic level (C1INH < 19 mg/dL normal
range 19 to 37 mg/dL, or C1INH antigenic level below the
lower limit of normal as defined by the laboratory
performing the test); or
A normal C1INH antigenic level (C1INH ≥ 19 mg/dL) and a
low C1INH functional level (functional C1INH < 50% or
C1INH functional level below the lower limit of normal as
defined by the laboratory performing the test); or
A known HAE-causing C1INH mutation.
AND
Medications known to cause angioedema (i.e. ACEInhibitors, estrogens, angiotensin II receptor blockers)
have been evaluated and discontinued when appropriate;
and
Member has tried and failed or is intolerant
30
vials/30
days
For coverage of additional
quantities, a member's
treating physician must
request prior authorization
through the Pharmacy
Management
Precertification Unit. Up to
30 additional vials will be
granted for those members
who meet any of the
following criteria:
Member's body weight
exceeds 76 kg
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
BERINERT
BERINERT-PRE
Hereditary angioedema
Member must have a diagnosis of HAE; and where
≥13
diagnosis is documented by documented based on
evidence of a low C4 level (C4 < 14 mg/dL; normal range
14 to 40 mg/dL, or C4 below the lower limit of normal as
defined by the laboratory performing the test) plus:
a) A low C1 inhibitor (C1INH) antigenic level (C1INH < 19
mg/dL normal range 19 to 37 mg/dL, or C1INH antigenic
level below the lower limit of normal as defined by the
laboratory performing the test); or
b) A normal C1INH antigenic level (C1INH ≥ 19 mg/dL) and
a low C1INH functional level (functional C1INH < 50%, or
below the lower limit of normal as defined by the
laboratory performing the test); and
Member must be experiencing at least one symptom of the
moderate or severe attack (e.g., airway swelling, severe
abdominal pain, facial swelling, nausea and vomiting,
painful facial distortion); and
Medications known to cause angioedema (i.e. ACEInhibitors, estrogens, angiotensin II receptor blockers)
have been evaluated and discontinued when appropriate.
1 year
Aetna considers Berinert
experimental and
investigational for
prophylaxis against
angioedema attacks, for
use in combination with
Kalbitor or Firazyr, and for
other indications because
its effectiveness for these
indications has not been
established.
KALBITOR
KALBITOR-PRE
Hereditary angioedema
≥12
Member must have a diagnosis of HAE; and where
diagnosis is documented by documented based on
evidence of a low C4 level (C4 < 14 mg/dL; normal range
14 to 40 mg/dL, or C4 below the lower limit of normal as
defined by the laboratory performing the test) plus: A low
C1 inhibitor (C1INH) antigenic level (C1INH < 19 mg/dL
normal range 19 to 37 mg/dL, or C1INH antigenic level
below the lower limit of normal as defined by the
laboratory performing the test); or
A normal C1INH antigenic level (C1INH ≥ 19 mg/dL) and a
low C1INH functional level (functional C1INH < 50%, or
below the lower limit of normal as defined by the
laboratory performing the test)
1 year
Aetna considers Kalbitor
experimental and
investigational for all other
indications (e.g., reduction
of blood loss during
surgery, hereditary
angioedema with normal
C1INH inhibitor (previously
called type III hereditary
angioedema, and
characterized by normal
C1INH antigenic and
functional levels), use in
combination with Berinert or
Firazyr) because its
effectiveness for these
indications has not been
established.
AND
Member must be experiencing at least one symptom of the
moderate or severe attack (e.g., airway swelling, severe
abdominal pain, facial swelling, nausea and vomiting,
painful facial distortion); and
Medications known to cause angioedema (i.e. ACEInhibitors, estrogens, angiotensin II receptor blockers)
have been evaluated and discontinued when appropriate.
FULYZAQ
FULYZAQ-PRE
HIV infection
A documented diagnosis of treatment of symptomatic
relief of non-infectious diarrhea in adult patients with
HIV/AIDS AND ALL of the following:
Currently stable on anti-retroviral therapy
History of diarrhea for one month or more
Diarrhea is documented to be persistent loose stools
despite regular use of anti-diarrheal medication (ADM)
(i.e., loperamide, diphenoxylate, bismuth subsalicylate) or
one or more watery bowel movements per day without
regular ADM use
Negative GI culture or stool test for ALL of the following:
bacteria, bacteria toxin, ova, parasites, or viruses
No history of other GI diseases associated with diarrhea
(i.e. ulcerative colitis, Crohn’s disease, celiac sprue
(gluten-enteropathy), chronic pancreatitis, malabsorption)
1 year
2/day
MAKENA
MAKENA-PRE
Preterm labor
The documented indication of prevention of preterm birth
(defined as delivery at less than 37 weeks, 0 days
gestation) in women who are pregnant with a singleton
pregnancy and have history of a prior spontaneous
preterm birth of a singleton delivery. Consistent with FDAapproved labeling, Makena should be initiated between 16
weeks, 0 days and 20 weeks, 6 days of gestation and
should continue though 37 weeks, 0 days gestation
6 months
Up to 5
vials per
yea
ELAPRASE
ELAPRASE-PRE
Mucopolysaccharidosis
XENAZINE-PRE
Huntington's disease
A documented diagnosis of Hunter syndrome
(mucopolysaccharidosis II)
A documented diagnosis of chorea associated with
Huntington's disease OR
A documented diagnosis of Tourette's syndrome (TS)
1 year
XENAZINE
ADAGEN
ADAGEN-PRE
Adenosine deaminase deficiency
A documented diagnosis of adenosine deaminase
deficiency (ADA) in patients with severe combined
immunodeficiency disease (SCID) AND
The patient is not a candidate or has failed a bone
marrow transplantation
1 year
BIVIGAM
CARIMUNE
NANOFILTERED
FLEBOGAMMA
GAMASTAN S/D
GAMMAGARD
GAMMAGARD S/D
GAMMAKED
GAMMAPLEX
GAMUNEX
GAMUNEX-C
HIZENTRA
OCTAGAM
PRIVIGEN
VIVAGLOBIN
IVIG-PRE
Acquired red cell aplasia
Aetna considers the use of intravenous immunoglobulin
(IVIG) therapy medically necessary in members with the
conditions specified below:
1 year
ELIDEL
ELIDEL-PRE
atopic dermatitis
PROTOPIC
PROTOPIC-PRE
atopic dermatitis
ARCALYST
ARCALYST-PRE
Cryopyrin-Associated Periodic Syndrome (CAPS)
familial cold auto-inflammatory syndrome (FCAS)
Muckle-Wells Syndrome (MWS)
1. Acquired red cell aplasia
2. Acute disseminated encephalomyelitis (see Appendix)
3. Autoimmune mucocutaneous blistering diseases: IVIG
is considered medically necessary for members with
pemphigus vulgaris, pemphigus foliaceus, bullous
pemphigoid, mucous membrane pemphigoid (a.k.a.,
cicatrical pemphigoid), and epidermolysis bullosa
acquisita if the member has either failed or has
contraindications to conventional therapy, or the member
has rapidly progressive disease in which a clinical
response could not be affected quickly enough using
conventional agents. When indicated for rapidly
progressive disease, accepted guidelines indicate that
IVIG should be given along with conventional treatment(s)
and IVIG should be used only until conventional therapy
could take effect. (See Appendix) Note: IVIG for the
treatment of autoimmune mucocutaneous blistering
disease is considered medically necessary only for shortterm therapy and not as a maintenance therapy
4. B-cell chronic lymphocytic leukemia (CLL): for persons
with hypogammaglobulinemia associated with CLL and
recurrent infections or specific antibody deficiency (see
A documented diagnosis of mild to moderate atopic
dermatitis in patients (eczema) less than 2 years of age
for short-term use (up to 3 months)
(Note: requirement of a trial of topical corticosteroid is not
required)
OR
A documented diagnosis of atopic dermatitis (eczema) in
an adult or child 2 years of age or older, AND one of the
following: A documented contraindication, intolerance or
allergy to one preferred alternative topical corticosteroid
indicated for the patient’s condition, OR
A documented failure of an adequate trial of 2 weeks (14
days) of one preferred alternative topical corticosteroid
indicated for the patient’s condition, OR
Treatment is in an area at high risk for skin atrophy such
as face, eyelids, or genital areas
For Protopic 0.1%
≥16 FOR
A documented diagnosis of atopic dermatitis (eczema) in 0.1%
an adult or an adolescent 16 years of
age or older, AND one of the following: A documented
contraindication, intolerance or allergy to one preferred
alternative topical corticosteroid indicated for the patient’s
condition, OR
A documented failure of an adequate trial of 2 weeks (14
days) of one preferred alternative topical corticosteroid
indicated for the patient’s condition, OR
Treatment is in an area at high risk for skin atrophy such
as face, eyelids, or genital areas.
For Protopic 0.03%
A documented diagnosis of mild to moderate atopic
dermatitis (eczema) in patients less than 2 years of age
for short-term use (up to 3 months)
(Note: requirement of a trial of topical corticosteroid is not
required)
OR
A documented diagnosis of atopic dermatitis (eczema) in
an adult or child 2 years of age or older, AND one of the
following: A documented contraindication, intolerance or
allergy to one preferred alternative topical corticosteroid
indicated for the patient’s condition, OR
A documented failure of an adequate trial of 2 weeks (14
A documented diagnosis of Cryopyrin-Associated Periodic
Syndrome (CAPS), including only subtypes familial cold
auto-inflammatory syndrome (FCAS) and Muckle-Wells
Syndrome (MWS
1 year
3 months if
applied to
face, eyelids,
genital areas;
6 months if
applied to
other areas
of body; 3
months for
patients less
than 2 years
of age
3 months if
applied to
face, eyelids,
genital areas;
6 months if
applied to
other areas
of body; 3
months for
patients less
than 2 years
of age
1 year
II. Aetna considers
subcutaneously
administered
immunoglobulins as an
alternative to intravenous
immunoglobulin therapy
medically necessary for
members who meet the
criteria for IVIG set forth
above.
III. Aetna considers
intramuscularly
administered
immunoglobulins (e.g.,
GamaSTAN S/D) medically
necessary as an alternative
to intravenous
immunoglobulin therapy for
conditions associated with
hypogammaglobulinemia
that meet the criteria for
IVIG set forth above.
Intramuscular formulations
of immune globulin are also
considered medically
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
ILARIS
ILARIS-PRE
Cryopyrin-Associated Periodic Syndrome (CAPS)
familial cold auto-inflammatory syndrome (FCAS)
Muckle-Wells Syndrome (MWS)
Active Systemic Juvenile Idiopathic Arthritis (SJIA)
A documented diagnosis of one of the following: CryopyrinAssociated Periodic Syndrome (CAPS), including only
subtypes familial cold auto-inflammatory syndrome
(FCAS) and Muckle-Wells Syndrome (MWS) OR
Active Systemic Juvenile Idiopathic Arthritis (SJIA) in
patients aged 2 years and older
ELMIRON
UCERIS
ELMIRON-PRE
interstitial cystitis.
A documented diagnosis of interstitial cystitis.
6 months
UCERIS-PRE
ulcerative colitis
A documented diagnosis of active, mild to moderate
ulcerative colitis AND
A documented contraindication or intolerance or allergy or
failure of an adequate trial of one month each of two
preferred 5-ASA therapies (i.e., balsalazide, Canasa,
Delzicol) AND one preferred generic corticosteroid
therapy (i.e., budesonide sr, prednisone, prednisolone)
2 months
LOTRONEX
LOTRONEX-PRE
Irritable bowel syndrome
Diagnosis of severe** irritable bowel syndrome (IBS) with
primary symptom of diarrhea with:
6 months
Female
1 year
Coverage of additional
quantities may be
requested by the member's
treating physician through
the Aetna Pharmacy
Management
Precertification Unit.
Additional quantities of
Myalept will be considered
medically necessary for
members who meet any of
the following criteria:
1 year
3
capsules/
day
1/day
chronic IBS symptoms (generally lasting 6 months or
longer) AND
anatomic or biochemical abnormalities of the
gastrointestinal tract have been excluded AND
failure of response to at least one conventional therapy
agent for at least one month
**Diarrhea-predominant IBS is severe if it includes
diarrhea and one or more of the following:
(1) frequent and severe abdominal pain/discomfort; or
(2) frequent urgency or fecal incontinence; or
(3) disability or restriction of daily activities due to IBS.
MYALEPT
MYALEPT-PRE
Lipodystrophy
A documented diagnosis of complications of leptin
deficiency (serum leptin levels less than the 7th percentile
of normal values reported by the 3rd National Health and
Nutrition Examination survey (less than 7.0 ng/mL in
females and less than 3.0 ng/mL in males)) in persons
with congenital generalized or acquired generalized
lipodystrophy with at least one of the following: Type 2
diabetes mellitus
Hypertriglyceridemia as defined by fasting triglyceride
concentrations greater than 300 mg/ dL
Hyperinsulinemia as defined by fasting serum insulin
greater than 20 uU/
Up to 15
vials in 30
days
For Myalept
Member weighs >40 kg and
is on maximal dose
Member weighs >40 kg and
is titrating to the maximal
dose
Member is an infant and
Myalept will be reconstituted
with preservative-free water
for injection
LUPANETA
ARALEN
chloroquine
LUPANETA-PRE
ARALEN-PRE
Endometriosis
Malaria
Members who meet above
criteria may be eligible to
A documented diagnosis of endometriosis
A documented diagnosis of one of the following:
Maximum
Time of
Approval for
Malaria: 30
days
Maximum
Time of
Approval for
all other
indications:
One year
malaria
rheumatoid arthritis
systemic and discoid lupus erythematosus
scleroderma
pemphigus
lichen planus
polymyositis
sarcoidosis
DARAPRIM
DARAPRIM-PRE
Malaria
Toxoplasmosis
A documented diagnosis of one of the following:
-malaria
-toxoplasmosis
Differin gel/cream/lotion
0.1%
Differin-PRE
acne vulgaris
A documented diagnosis of acne vulgaris
COARTEM
MALARONE
mefloquine
atovaquone/proguanil
COARTEM-PRE
Malaria
A documented diagnosis of malaria
PLAQUENIL
hydroxychloroquine
PLAQUENIL-PRE
QUALAQUIN
quinine sulfate
COARTEM-PRE
>35
Maximum
Time of
Approval for
Malaria: 30
days
Maximum
Time of
Approval for
all other
indications:
One year
1 year
DifferinPRE
A documented trial of one
month of the preferred generic
equivalent alternative,
adapalene cream or gel 0.1%
Maximum
Time of
Approval for
Malaria: 30
days
Maximum
Time of
Approval for
all other
indications:
One year
Malaria
Rheumatoid arthritis
Systemic lupus erythematosus
A documented diagnosis of one of the following: malaria
rheumatoid arthritis
systemic lupus erythematosus
Malaria
A documented diagnosis of malaria
Maximum
Time of
Approval for
Malaria: 30
days
Maximum
Time of
Approval for
all other
indications:
One year
Maximum
Time of
Approval for
Malaria: 30
days
Maximum
Time of
Approval for
all other
indications:
One year
For coverage of additional
quantities, a member's
treating physician must
request prior authorization
through the Pharmacy
Management
Precertification Unit.
Additional quantities of this
drug will be considered
medically necessary for
those members who meet
ANY of the following criteria:
Diagnosis of uncomplicated
Plasmodium falciparum
malaria necessitating one
additional treatment- may
approve an additional 42
capsules one time
42
capsules/y
ear
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
SIVEXTRO
SIVEXTRO-PRE
Infection of skin AND/OR subcutaneous tissue
30 Days
Up to 6
tablets in
30 days
Hepatic
encephalopat
hy: One year
Traveler's
Diarrhea: 1
Week
200 mg =
9
tablets/30
day
supply,
550 mg =
2
tablets/da
y
A documented diagnosis of acute bacterial skin and skin
structure infections (ABSSSI), and
Culture and susceptibility information or, in the absence of
such data, local epidemiology and susceptibility patterns
indicate that the current infection is caused by one of the
following Gram-positive microorganisms: Staph. aureus
(including methicillin-resistant [MRSA] and methicillinsusceptible [MSSA] isolates), or
Strep. pyogenes, or
Strep. agalactiae, or
Strep. anginosus Group (including Strep. anginosus,
Strep. intermedius, and Strep. constellatus), or
E. faecalis
XIFAXAN
XIFAXAN-PRE
A documented diagnosis of traveler's diarrhea caused
by noninvasive strains of Escherichia coli (non-bloody
diarrhea without fever)
OR
A documented diagnosis of hepatic encephalopathy
Small intestinal bacterial
overgrowth (SIBO)
A documented:
Contraindication to one preferred alternative agent
indicated for the member's condition OR
Intolerance to one preferred alternative agent indicated
for the member's condition OR
Allergy to one preferred alternative agent indicated for the
member's condition OR
Failure of an adequate trial of two weeks of one preferred
alternative agent indicated for the member's condition
DDAVP (all forms)
desmopressin
minirin
STIMATE
DDAVP-PRE
≤17
Diagnosis of central diabetes insipidus
(neurohypophyseal diabetes insipidus) including
polydipsia and polyuria
OR
Diagnosis of hemophilia A or mild to moderate von
Willebrand's disease (vWd)
1 year
DDAVPPRE
Under some plans, including
plans that use an open or
closed formulary, DDAVP
nasal/injection/tablets are
subject to step-therapy.
Aetna considers DDAVP
nasal/injection/tablets to be
medically necessary for those
members who meet the
following step-therapy
criterion:
A documented trial of one
month of the generic
alternative agent
desmopressin -the alternative
on the Preferred Drug List.
ALDURAZYME
ALDURAZYME-PRE
urler and Hurler-Scheie forms of mucopolysaccharidosis
I (MPS I)
NAGLAZYME
NAGLAZYME-PRE
Mucopolysaccharidosis VI (MPS VI)
AMPYRA
AMPYRA-PRE
Multiple sclerosis
A documented diagnosis of Hurler and Hurler-Scheie
forms of mucopolysaccharidosis I (MPS I) and for
members diagnosed with the Scheie form who have
moderate to severe symptoms
A documented diagnosis of mucopolysaccharidosis VI
(MPS VI)
A documented diagnosis of multiple sclerosis AND ALL of
the following: Normal creatinine clearance (> 50 ml/min)
No past medical history of seizures
One of the following criteria:
Has completed two 25-foot walk test with no more than 5
minutes break between the two rest with an average time
of 45 seconds (walking speed of 0.55 ft/s) or faster, prior
to treatment with Ampyra, or
Has achieved a 20% increase in walking speed from
baseline* after starting treatment with Ampyra
1 year
1 year
18 or greater
6 months
For renewal at 6 weeks and every 6 months thereafter
Member has continued therapeutic response defined as
at least 20%
increase in walking speed from baseline*
*Baseline walking speed (ft/s) is the average walking
speed before member
takes Ampyra, obtained from two trials of 25-foot walk with
no more than 5
minutes break between the two tests; it is calculated by
dividing 25 by the
average time (in seconds) of the two tests)
For Aubagio
AUBAGIO
AUBAGIO-PRE
Multiple sclerosis
A documented diagnosis of relapsing remitting multiple
sclerosis AND documentation of ALL of the following:
Discontinuation of other therapies used for treating
multiple sclerosis (Note: This does NOT require having to
discontinue Ampyra)
Recent (within 6 months) complete blood count (CBC)
Recent (within 6 months) liver transaminase and bilirubin
levels
Recent Tuberculin skin test (within 6 months) to check for
latent Tuberculosis
Blood pressure monitoring at initiation and during
treatment
If Female, confirmation of negative pregnancy test at
initiation of therapy and confirmation that reliable
contraception will be used during treatment with Aubagio
A documented contraindication or intolerance or allergy or
failure of an adequate trial* of both preferred alternatives,
Copaxone 20 or 40 mg and Rebif
1 year
AVONEX
AVONEX-PRE
Multiple sclerosis
A documented diagnosis of relapsing remitting multiple
sclerosis AND documentation of all of the following:
Discontinuation of other therapies used for treating
multiple sclerosis (Note: This does NOT require having to
discontinue Ampyra)
A documented contraindication or intolerance or allergy or
failure of an adequate trial* of both preferred alternatives,
Copaxone 20 or 40 mg and Rebif
1 year
* For purposes of this
policy, failure of an
adequate trial of therapy for
multiple sclerosis is defined
as follows:
The member has increasing
relapses (defined as two or
more relapses in a year, or
one severe relapse
associated with either poor
recovery or MRI lesion
progression); OR
The member has lesion
progression by MRI
(increased number or
volume of gadoliniumenhancing lesions, T2
hyperintense lesions or T1
hypointense lesions); OR
The member has worsening
disability (sustained
worsening of Expanded
Disability Status Scale
(EDSS) score or
neurological examination
findings)
* For purposes of this
policy, failure of an
adequate trial of therapy for
multiple sclerosis is defined
as follows:
The member has increasing
relapses (defined as two or
more relapses in a year, or
one severe relapse
associated with either poor
recovery or MRI lesion
progression); OR
The member has lesion
progression by MRI
(increased number or
volume of gadoliniumenhancing lesions, T2
hyperintense lesions or T1
hypointense lesions); OR
The member has worsening
disability (sustained
worsening of Expanded
Disability Status Scale
(EDSS) score or
neurological examination
findings)
* For purposes of this
policy, failure of an
adequate trial of therapy for
multiple sclerosis is defined
as follows:
The member has increasing
relapses (defined as two or
more relapses in a year, or
one severe relapse
associated with either poor
recovery or MRI lesion
progression); OR
The member has lesion
progression by MRI
(increased number or
volume of gadoliniumenhancing lesions, T2
hyperintense lesions or T1
hypointense lesions); OR
The member has worsening
disability (sustained
worsening of Expanded
Disability Status Scale
(EDSS) score or
neurological examination
findings)
2/day
1/day
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
BETASERON
EXTAVIA
BETASERON-PRE
Multiple sclerosis
A documented diagnosis of relapsing remitting multiple
sclerosis AND documentation of all of the following:
Discontinuation of other therapies used for treating
multiple sclerosis (Note: This does NOT require having to
discontinue Ampyra)
A documented contraindication or intolerance or allergy or
failure of an adequate trial* of both preferred alternatives,
Copaxone 20 or 40 mg and Rebif
1 year
COPAXONE
COPAXONE-PRE
Multiple sclerosis
A documented diagnosis of one of the following AND
discontinuation of other therapies used for treating
multiple sclerosis (Note: This does NOT require having to
discontinue Ampyra) Clinically isolated syndrome (CIS)
suggestive of multiple sclerosis(MS) (i.e. persons who
have experienced a first clinical episode and have
magnetic resonance imaging (MRI) features consistent
with MS))
Relapsing, remitting multiple sclerosis (Note: Does not
include diagnosis of chronic progressive multiple
sclerosis(MS))
1 year
GILENYA
GILENYA-PRE
Multiple sclerosis
1 year
REBIF
REBIF-PRE
Multiple sclerosis
For new starts or restarts after 6 months or more of
treatment interruption:
A documented diagnosis of relapsing, remitting multiple
sclerosis AND documentation of ALL of the following:
Discontinuation of other therapies used for treating
multiple sclerosis (Note: This does NOT require having to
discontinue Ampyra)
Recent (within 6 months) complete blood count (CBC)
Recent (within 6 months) liver transaminase and bilirubin
levels
A documented EKG (i.e. electrocardiogram that measures
rate and regularity of heartbeats) prior to the first dose
AND a documented EKG at the end of the observation
period AND documented to have NONE of the following:
Recent (within the last 6 months) occurrence of
myocardial infarction (i.e. heart attack), unstable angina,
stroke, transient ischemic attack (i.e. mini stroke),
decompensated heart failure requiring hospitalization, or
Class III/IV heart failure*
History or presence of Mobitz Type II 2nd degree or 3rd
degree AV block or sick sinus syndrome syndrome (these
are specific types of heart rhythm problems), unless
patient has a pacemaker
Baseline QTc interval ≥500 ms (as measured on most
recent EKG)
Treatment with Class Ia or Class III anti-arrhythmic drugs**
A documented diagnosis of relapsing remitting multiple
sclerosis AND discontinuation of other therapies used for
treating multiple sclerosis (Note: This does NOT require
having to discontinue Ampyra)
TECFIDERA
TECFIDERA-PRE
Multiple sclerosis
A documented diagnosis of relapsing remitting multiple
sclerosis AND documentation of all of the following:
Discontinuation of other therapies used for treating
multiple sclerosis while on therapy with Tecfidera (Note:
This does NOT require having to discontinue Ampyra)
Recent (within 6 months) complete blood count (CBC)
A documented contraindication or intolerance or allergy or
failure of an adequate trial* of both preferred alternatives,
Copaxone 20 or 40 mg and Rebif
1 year
TYSABRI
TYSABRI-PRE
Crohn's disease
Multiple sclerosis
A documented diagnosis of one of the following
Relapsing, remitting multiple sclerosis (Note: Does not
include diagnosis of treatment of chronic progressive
multiple sclerosis (MS) AND documentation of ALL of the
following: A Documented performance of JCV Antibody
ELISA testing
(NOTE: Presence of anti-JCV antibodies has been
identified as a risk factor for progressive multifocal
leukoencephalopathy (PML), a fatal brain infection.
Identifying risk factors along with this test can help reduce
adverse events. Specific timing of administration of test
(before, during/ therapy--thereafter) or test results
(positive or negative) will not result in a coverage denial.)
Discontinuation of other therapies used for treating
multiple sclerosis (Note: This does NOT require having to
discontinue Ampyra)
A documented contraindication or intolerance or allergy or
failure of an adequate trial* of both preferred alternatives,
Copaxone 20 or 40 mg and Rebif
1 year
Crohn’s disease AND A documented contraindication or
intolerance or allergy or failure of an adequate trial of one
month of one preferred alternative Cimzia or Humira or
Remicade
1 year
* For purposes of this
policy, failure of an
adequate trial of therapy for
multiple sclerosis is defined
as follows:
The member has increasing
relapses (defined as two or
more relapses in a year, or
one severe relapse
associated with either poor
recovery or MRI lesion
progression); OR
The member has lesion
progression by MRI
(increased number or
volume of gadoliniumenhancing lesions, T2
hyperintense lesions or T1
hypointense lesions); OR
The member has worsening
disability (sustained
worsening of Expanded
Disability Status Scale
(EDSS) score or
neurological examination
findings)
* For purposes of this
policy, failure of an
adequate trial of therapy for
multiple sclerosis is defined
as follows:
The member has increasing
relapses (defined as two or
more relapses in a year, or
one severe relapse
associated with either poor
recovery or MRI lesion
progression); OR
The member has lesion
progression by MRI
(increased number or
volume of gadoliniumenhancing lesions, T2
hyperintense lesions or T1
hypointense lesions); OR
The member has worsening
disability (sustained
worsening of Expanded
Disability Status Scale
(EDSS) score or
neurological examination
findings)
* For purposes of this
policy, failure of an
adequate trial of therapy for
multiple sclerosis is defined
as follows:
The member has increasing
relapses (defined as two or
more relapses in a year, or
one severe relapse
associated with either poor
recovery or MRI lesion
progression); OR
The member has lesion
progression by MRI
(increased number or
volume of gadoliniumenhancing lesions, T2
hyperintense lesions or T1
hypointense lesions); OR
The member has worsening
disability (sustained
worsening of Expanded
Disability Status Scale
(EDSS) score or
neurological examination
findings)
* For purposes of this
policy, failure of an
adequate trial of therapy for
multiple sclerosis is defined
as follows:
The member has increasing
relapses (defined as two or
more relapses in a year, or
one severe relapse
associated with either poor
recovery or MRI lesion
progression); OR
The member has lesion
progression by MRI
(increased number or
volume of gadoliniumenhancing lesions, T2
hyperintense lesions or T1
hypointense lesions); OR
The member has worsening
disability (sustained
worsening of Expanded
Disability Status Scale
(EDSS) score or
neurological examination
findings)
* For purposes of this
policy, failure of an
adequate trial of therapy for
multiple sclerosis is defined
as follows:
The member has increasing
relapses (defined as two or
more relapses in a year, or
one severe relapse
associated with either poor
recovery or MRI lesion
progression); OR
The member has lesion
progression by MRI
(increased number or
volume of gadoliniumenhancing lesions, T2
hyperintense lesions or T1
hypointense lesions); OR
The member has worsening
disability (sustained
worsening of Expanded
Disability Status Scale
(EDSS) score or
neurological examination
findings)
* For purposes of this
policy, failure of an
adequate trial of therapy for
multiple sclerosis is defined
as follows:
The member has increasing
relapses (defined as two or
more relapses in a year, or
one severe relapse
associated with either poor
recovery or MRI lesion
progression); OR
The member has lesion
progression by MRI
(increased number or
volume of gadoliniumenhancing lesions, T2
hyperintense lesions or T1
hypointense lesions); OR
The member has worsening
disability (sustained
worsening of Expanded
Disability Status Scale
(EDSS) score or
neurological examination
findings)
1/day
120mg =
14
capsules/
28 day;
240mg = 2
capsules/
day
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
BOTOX
DYSPORT
MYOBLOC
XEOMIN
BOTOX-PRE
Strabismus
Blepharospasm
Headache; Prophylaxis
Bladder muscle dysfunction
1. OnabotulinumtoxinA (Botox Brand of Botulinum Toxin
Type A): Aetna considers onabotulinumtoxinA (Botox)
medically necessary for any of the following conditions:
1 year (6
times within
year only)
A. Strabismus (including gaze palsies accompanying
diseases, such as neuromyelitis optica and Schilder's
disease), for deviations less than 50 prism diopters.
Note: Strabismus repair is considered cosmetic in adults
with uncorrected congenital strabismus and no binocular
fusion.
B. Blepharospasm, characterized by intermittent or
sustained closure of the eyelids caused by involuntary
contractions of the orbicularis oculi muscle.
C. Post-facial (7th cranial) nerve palsy synkinesis
(hemifacial spasms), characterized by sudden, unilateral,
synchronous contractions of muscles innervated by the
facial nerve.
D. Laryngeal spasm.
ACTIMMUNE
ACTIMMUNE-PRE
Chronic granulomatous
E. Cervical dystonia (spasmodic torticollis) of moderate or
6 months
A documented diagnosis of one of the following:
Chronic granulomatous disease, to reduce the frequency
and severity of infections; or
Chronic recalcitrant atopic dermatitis; or
Mycosis fungoides and Sezary syndrome; or
Severe, malignant osteopetrosis, to delay time to disease
progression
Currently, the only FDAapproved indications for
interferon gamma
(Actimmune) is for
treatment of chronic
granulomatous disease,
and for delaying time to
disease progression in
patients with severe,
malignant osteopetrosis.
Interferon gamma has also
been shown to be effective
for the treatment of atopic
dermatitis
Aetna considers interferon gamma experimental and
investigational for the following:
treatment of brain tumors,
idiopathic pulmonary fibrosis,
malignant neoplasm of peritoneum,
pulmonary tuberculosis,
Waldenstrom's macroglobulinemia
and all other indications because its effectiveness for
indications other than the ones listed above has not been
established .
AFINITOR
AFINITOR-PRE
Renal cell carcinoma
Subependymal giant cell astrocytoma
Progressive neuroendocrine tumors
Renal angiomyolipoma and tuberous sclerosis complex
(TSC)
ARIMIDEX
FEMARA
ARIMIDEX-PRE
Breast cancer
anastrozole
AROMASIN
letrozole
exemestane
ARIMIDEX-PRE
Breast cancer
BOSULIF
BOSULIF-PRE
All FDA and NCCN 1, 2a and 2b approved indications
COMETRIQ
COMETRIQ-PRE
Medullary thyroid carcinoma
A documented diagnosis of one of the following:
Advanced renal cell carcinoma AND a documented
resistance or intolerance to prior therapy with sunitinib
(Sutent) or pazopanib (Votrient)
Subependymal giant cell astrocytoma (SEGA) associated
with tuberous sclerosis (TSC) that can not be treated with
surgery
Progressive neuroendocrine tumors located in the
pancreas (PNET) that cannot be removed by surgery or
that have spread to other parts of the body (metastatic)
Waldenström’s macroglobulinemia/lymphoplasmacytic
lymphoma, as a single agent for salvage therapy for
disease that does not respond to primary therapy or for
progressive or relapsed disease
Renal angiomyolipoma and tuberous sclerosis complex
(TSC) not requiring immediate surgery
Advanced hormone receptor-positive, HER2-negative
breast cancer (advanced HR+BC) in combination with
exemestane (Aromasin) after failure of treatment with
letrozole (Femara) or anastrozole (Arimidex)
Documented diagnosis of one of the following:
Breast cancer AND post-menopausal
OR
Infertility *
*(Note: Coverage is limited to plans with infertility
coverage; please check benefit plan descriptions)
Documented diagnosis of one of the following:
Breast cancer AND post-menopausal
OR
Infertility *
*(Note: Coverage is limited to plans with infertility
coverage; please check benefit plan descriptions)
1. Patients diagnosed with Philadelphia chromosome positive
chronic myeloid leukemia (Ph+ CML) in chronic phase, accelerated
phase, or blast phase;
AND
2. Patients who are intolerant or resistant to prior imatinib
(Gleevec®) therapy.
1 year
female
For Breast
Cancer: One
year
For
Infertility: 3
months
CAPRELSA-PRE
Medullary thyroid carcinoma
A documented diagnosis of one of the following:
Symptomatic or progressive medullary thyroid cancer in
patients with unresectable (i.e. cannot be treated with
surgery), locally advanced, or metastatic disease
FIRMAGON
FIRMAGON-PRE
Prostate cancer
ERIVEDGE
ERIVEDGE-PRE
Basal cell carcinoma of skin
A documented diagnosis of advanced prostate cancer in
male members
A documented diagnosis of one of the following: Locally
advanced basal cell carcinoma that has recurred following
surgery or who are not candidates for surgery, and who
are not candidates for radiation
Metastatic basal cell carcinoma
GILOTRIF
GILOTRIF-PRE
Non-small cell lung cancer
GLEEVEC
GLEEVEC-PRE
Chronic Myelogenous Leukemia (CML)
Philadelphia chromosome positive chronic myeloid
leukemia
HERCEPTIN
HERCEPTIN-PRE
Breast cancer
Gastric cancer
A documented diagnosis of metastatic, non-small cell lung
cancer (NSCLC) in patients whose tumors have epidermal
growth factor receptor (EGFR) exon 19 deletions or exon
21 (L858R) substitution mutations, as detected by an FDAapproved test
Gleevec
A documented diagnosis of one of the following:
Chronic Myelogenous Leukemia (CML) documented as
any one of the following:
Newly diagnosed adult patients with Philadelphia
chromosome positive chronic myeloid leukemia (Ph+ CML)
in chronic phase
Primary therapy for newly diagnosed CML confirmed by
Ph+ or BCR-ABL+gene
Pediatric patients with Ph+ CML in chronic phase who are
newly diagnosed or whose disease has recurred after
stem cell transplant or who are resistant to interferonalpha therapy
Philadelphia chromosome positive (Ph+ CML) in blast
crisis, accelerated phase, or in chronic phase after failure
of interferon-alpha therapy
Follow-up therapy for CML patients with molecular or
cytogenetic relapse, or patients not in cytogenetic
remission, after hematopoietic stem cell transplant (HSCT)
Patient is stable on the medication
Acute lymphoblastic leukemia (Ph+ ALL) documented as
any one of the following: Newly diagnosed Ph+ ALL in
combination with chemotherapy
Adult patients with relapsed or refractory Philadelphia
chromosome positive acute lymphoblastic leukemia (Ph+
Aetna considers trastuzumab (Herceptin, Genentech, Inc.)
medically necessary for use in members with breast
cancer, advanced esophageal adenocarcinomas, gastric
adenocarcinomas, gastroesophageal junction
adenocarcinomas, or non-small cell lung
adenocarcinomas that over-express the HER2 (human
epidermal growth factor receptor 2) protein (i.e., level 3+
on an immunohistochemical assay) or where HER2 gene
amplification is detected using FIS, a HER2
gene/chromosome 17 ratio greater than 2, or HER2 gene
copy number greater than 6 signals/nucleus.
FEMARA- A documented trial of one
PRE
month of a preferred generic
alternative
For Breast
Cancer: One
year
For
Infertility: 3
months
1 YEAR
30 day
supply (Up
to 84
tablets)
1 year
All
strengths
= 30 day
supply
All
strengths
= 30 day
supply
A documented diagnosis of progressive, metastatic
medullary thyroid cancer
CAPRELSA
All
strengths
= 30 day
supply
1 year
1 year
1 year
All
strengths
= 30 day
supply
1 year
All
strengths
= 30 day
supply
1 year
All
strengths
= 30 day
supply
6 months
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
TASIGNA
TASIGNA-PRE
Accelerated phase chronic myeloid leukemia
Chronic phase chronic myeloid leukemia
o A documented diagnosis of one of the following:
 Newly diagnosed Philadelphia chromosome positive
chronic myelogenous leukemia (Ph+CML) in chronic
phase AND resistance or intolerance to imatinib (Gleevec)
 Chronic phase (CP) or accelerated phase (AP)
Philadelphia chromosome positive chronic myelogenous
leukemia (Ph+CML) AND resistance or intolerance to
imatinib (Gleevec)
 Philadelphia chromosome-positive acute lymphoblastic
leukemia (Ph+ ALL) in patients who achieve complete
response to induction chemotherapy following HSCT AND
resistance or intolerance to imatinib (Gleevec)
 Relapsed/refractory Philadelphia chromosome-positive
acute lymphoblastic leukemia (Ph+ ALL) in patients with
F317L/V/I/C, T315A. or V299L mutations AND resistance
or intolerance to imatinib (Gleevec)
 Gastrointestinal Stromal Tumor (GIST), for treatment of
progressive disease after failure of imatinib (Gleevec)
1 year
All
strengths
= 30 day
supply
ICLUSIG
ICLUSIG-PRE
Chronic myeloid leukemia
Philadelphia chromosome-positive acute lymphoblastic
leukemia
A documented diagnosis of one of the following: Chronic
phase, accelerated phase, or blast phase chronic myeloid
leukemia (CML) AND Documented confirmation of the
presence of the T315i mutation OR
No other tyrosine kinase inhibitor (TKI) therapy is
indicated (i.e., imatinib (Gleevec), nilotinib (Tasigna))
1 year
All
strengths
= 30 day
supply
1 year
All
strengths
= 30 day
supply
All
strengths
= 30 day
supply
All
strengths
= 30 day
supply
Philadelphia chromosome positive acute lymphoblastic
leukemia (Ph+ALL) AND Documented confirmation of the
presence of the T315i mutation OR
No other tyrosine kinase inhibitor (TKI) therapy is
indicated (i.e., imatinib (Gleevec), dasatinib (Sprycel))
AND
Patient will be monitored for evidence of thromboembolism
and vascular occlusion
Patient will be monitored for evidence of heart failure
Patient will be monitored for hepatic function
A documented diagnosis of one of the following: Mantle
cell lymphoma (MCL) in patients who have received at
least one prior therapy
Chronic lymphocytic leukemia (CLL) in patients who have
received at least one prior therapy
Chronic lymphocytic leukemia (CLL) in patients with a 17p
deletion
Waldenström’s macroglobulinemia, for disease that does
not respond to primary therapy or for progressive or
relapsed disease
IMBRUVICA
IMBRUVICA-PRE
Chronic lymphoid leukemia
Mantle cell lymphoma
INLYTA
INLYTA-PRE
Renal cell carcinoma
A documented diagnosis of advanced renal cell carcinoma
AND a documented resistance or intolerance to prior
therapy with sunitinib (Sutent) or pazopanib (Votrient)
1 year
JAKAFI
JAKAFI-PRE
Myelofibrosis
6 months
JEVTANA
JEVTANA-PRE
Hormone refractory prostate cancer
A documented diagnosis of myelofibrosis that can include
any of the following: either primary myelofibrosis, or postpolycythemia vera myelofibrosis or post-essential
thrombocythemiayelofibrosis
OR
A. Diagnosis of polycythemia vera, AND
B. Failure of or intolerance to hydroxyurea
A. Documented diagnosis of hormone refractory
metastatic prostate cancer AND documented failure with
docetaxel containing regimens
KADCYLA
KADCYLA-PRE
Metastatic breast cancer
MEKINIST
MEKINIST-PRE
Malignant melanoma
1 year
AND
B. Concomitant use of prednisone
Aetna considers ado-trastuzumab emtansine (Kadcyla)
medically necessary for the treatment of members with
HER2-positive recurrent or metastatic breast cancer who
were previously treated with trastuzumab.
A documented diagnosis of one of the following: As a
single agent in unresectable or metastatic melanoma in
adult patients with BRAF V600E or V600K mutations as
detected by an FDA approved test AND Member has not
received prior BRAF inhibitor therapy (i.e., vemurafenib
(Zelboraf), dabrafenib (Tafinlar))
6 months
1 year
All
strengths
= 30 day
supply
In combination with dabrafenib (Tafinlar) in unresectable
or metastatic melanoma in adult patients with BRAF
V600E or V600K mutations as detected by an FDA
approved test
NEXAVAR
NEXAVAR-PRE
Liver carcinoma
Malignant tumor of thyroid gland
Renal cell carcinoma
A documented diagnosis of one of the following:
Unresectable (i.e. cannot be treated with surgery),
hepatocellular carcinoma (HCC)
Advanced renal cell carcinoma (RCC) AND a documented
resistance or intolerance to prior therapy with sunitinib
(Sutent) or pazopanib (Votrient)
Progressive or symptomatic metastatic thyroid carcinoma
in patients with nonradioiodineresponsive tumors at sites
other than central nervous system, with any of the
following histologic types: follicular, Hürthle cell, or
papillary
Disseminated symptomatic medullary thyroid carcinoma
Progressive gastrointestinal stromal tumor (GIST) when
patient is no longer receiving benefit from imatinib or
sunitinib
Angiosarcoma as a single agent, in the following soft
tissue OR sarcoma (STS) subtypes: STS of extremity,
retroperitoneal/intra-abdominal STS
Locally recurrent or metastatic, progressive, differentiated
thyroid carcinoma (DTC) refractory to radioactive iodine
treatment
1 year
All
strengths
= 30 day
supply
OFORTA
OFORTA-PRE
B-cell chronic lymphocytic leukemia
1 year
All
strengths
= 30 day
supply
PERJETA
PERJETA-PRE
Breast cancer
A documented diagnosis of B-cell chronic lymphocytic
leukemia (CLL) whose disease has not responded to or
has progressed during or after treatment with at least one
standard alkylating agent-containing regimen
Aetna considers pertuzumab (Perjeta) medically
necessary when used in combination with trastuzumab for
recurrent or metastatic HER2-positive breast cancer and
for neoadjuvant treatment of HER2-positive breast cancer.
POMALYST
POMALYST-PRE
Multiple myeloma
6 months
Because of the embryofetal risk, POMALYST is
available only through a
restricted program under a
Risk Evaluation and
Mitigation Strategy (REMS)
called “POMALYST REMS.”
Prescribers and
pharmacists must be
certified with the program;
patients must sign an
agreement form and comply
with the requirements
PURIXAN
PURIXAN-PRE
Acute lymphoid leukemia
A documented diagnosis of multiple myeloma and
documentation of ALL of the following:
- Two prior therapies that include lenalidomide (Revlimid)
and bortezomib (Velcade)
before initiating therapy with Pomalyst
- Disease progression on or within 60 days of completion
of the last therapy
- If Female-of reproductive potential, documentation of all
of the following:
--Two negative pregnancy tests obtained prior to initiating
therapy with Pomalyst
-- Monthly negative pregnancy tests during therapy
-- Patient has been counseled about the use of reliable
contraception and must use 2 forms of contraception
before, during, and 1 month after initiation of therapy with
Pomalyst
- Patient assessment to determine if prophylactic aspirin
or anti-thrombotic treatment (warfarin, clopidogrel) will
need to be taken to reduce the risk of VTE (embolism,
stroke).
- Confirmation of enrollment in the restricted distribution
program called POMALYST REMS (refer to special notes
below)
A documented diagnosis acute lymphoblastic leukemia
1 year
For coverage of additional
quantities, a member's
treating physician must
request prior authorization
through the Aetna
Pharmacy Management
Precertification Unit.
Additional quantities will be
considered medically
necessary for those
members who meet the
following criteria:
Documentation that the
(ALL) AND
A documented contraindication, intolerance, allergy, or
failure of an adequate trial of one month of the preferred
generic alternative, mercaptopurine
6 months
All
strengths
= 30 day
supply
PURIXAN- A documented trial of one
All
PRE
month of the preferred generic strengths
alternative, mercaptopurine
= 30 day
supply
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
REVLIMID
REVLIMID-PRE
Mantle cell lymphoma
Multiple myeloma
Myelodysplastic syndrome
RITUXAN
RITUXAN-PRE
Lymphoid leukemia
Microscopic polyarteritis nodosa
Non-Hodgkin's lymphoma
Corticosteroid-refractory autoimmune blistering diseases
Wegener's granulomatosis
SPRYCEL
SPRYCEL-PRE
Acute lymphoid leukemia
Accelerated phase chronic myeloid leukemia
Blastic phase chronic myeloid leukemia
Chronic phase chronic myeloid leukemia
STIVARGA
STIVARGA-PRE
Metastatic colorectal cancer
Gastrointestinal stromal tumor
SUTENT
SUTENT-PRE
SYLATRON
A documented diagnosis of one of the following:
Myelodysplastic syndrome (MDS) documented as any one
of the following: Transfusion-dependent anemia due to
Low- or Intermediate (INT)-1-risk myelodysplastic
syndrome (MDS) associated with a deletion 5q
cytogenetic abnormality with or without additional
cytogenetic abnormalities
Low or INT-1 risk MDS with deletion 5q cytogenetic
abnormality with symptomatic anemia and clinically
significant cytopenias
Low or INT-1 risk MDS without deletion 5q cytogenetic
abnormality with symptomatic anemia and serum
erythropoietin levels > 500 mU/mL and a low probability of
response to immunosuppressive therapy
Low or INT-1 risk MDS without deletion 5q cytogenetic
abnormality with symptomatic anemia and no response to
initial treatment with epoetin alfa or darbepoetin alfa
Multiple myeloma documented as any one of the following:
Will be taken in combination with dexamethasone in
patients who have received at least one prior therapy
Multiple myeloma (including symptomatic smoldering
myeloma and progressive solitary plasmacytoma) in
combination with dexamethasone as primary therapy
Will be taken as monotherapy for disease relapse or for
progressive or refractory disease
A documented Diagnosis of one of the following:
- Acute lymphoid leukemia (induction/consolidation
therapy for Philadelphia chromosone-negative ALL for
patients aged greater than or equal to 40 years)
- Anti-neutrophil cytoplasmic antibody-associated (ANCAassociated) vasculitides (Wegener granulomatosis, ChurgStrauss syndrome, microscopic polyangiitis, and pauciimmune glomerulonephritis) in persons with an inadequate
response to cyclophosphamide
- Antibody mediated rejection in heart transplant
recipients, prevention of recurrence
- CD20-positive chronic lymphocytic leukemia
- Chronic graft versus host disease (last resort treatment)
- Corticosteroid-refractory autoimmune blistering diseases
(pemphigus vulgaris, pemphigus foliaceus, bullous
pemphigoid, cicatricial pemphigoid, epidermolysis bullosa
acquisita and paraneoplastic pemphigus)
- Cryoglobulinemia refractory to corticosteroids and other
immunosuppressive agents
- Multi-centric Castleman's disease (angiofollicular lymph
node hyperplasia)
- Non-Hodgkin's lymphoma
- Opsoclonus-myoclonus-ataxia associated with
neuroblastoma, that is refractory to steroids,
chemotherapy and intravenous immunoglobulins
- Post-transplant lymphoproliferative disorder
• A documented diagnosis of one of the following:
- Newly diagnosed Philadelphia chromosome-positive
chronic myeloid leukemia AND resistance or intolerance to
prior therapy with imatinib (Gleevec)
- Chronic, accelerated, or myeloid or lymphoid blast phase
Philadelphia chromosome-positive chronic myeloid
leukemia (CML) AND resistance or intolerance to prior
therapy with imatinib (Gleevec)
- Philadelphia chromosome-positive acute lymphoblastic
leukemia (Ph+ ALL) AND resistance or intolerance to prior
therapy with imatinib mesylate (Gleevec)
1 year
6 months
1 year
All
strengths
= 30 day
supply
A documented diagnosis of one of the following:
o Metastatic colorectal cancer AND documentation of prior
therapy with ALL of the following:
- (fluoropyrimidine-, oxaliplatin-, and irinotecan)-based
chemotherapy (i.e. FOLFIRI/FOLFOX/CapOx, others)
- bevacizumab (Avastin)
- panitumumab (Vectibix) OR cetuximab (Erbitux) ( FOR
KRAS mutation-negative patients only)
• Locally advanced, unresectable or metastatic
gastrointestinal stromal tumor (GIST) AND documentation
of prior therapy with imatinib mesylate (Gleevec) AND
sunitinib (Sutent)
6 months
All
strengths
= 30 day
supply
Advanced Renal Cell Carcinoma
Gastrointestinal Stromal Tumor
• A documented diagnosis of one of the following:
o Advanced Renal Cell Carcinoma
o Gastrointestinal Stromal Tumor (GIST) AND a
documented disease progression while on therapy with
imatinib mesylate/Gleevec OR documented intolerance to
imatinib mesylate /Gleevec
o Progressive neuroendocrine tumors located in the
pancreas (pNET) that cannot be removed by surgery or
that have spread to other parts of the body (metastatic)
1 year
All
strengths
= 30 day
supply
SYLATRON-PRE
Malignant melanoma
A documented diagnosis of melanoma with microscopic or
gross nodal involvement within 84 days of surgery
including complete lymphadenectomy
1 year
TARCEVA
TARCEVA-PRE
Carcinoma of pancreas
◾Non-small cell lung cancer
1 year
TAFINLAR
TAFINLAR-PRE
Malignant melanoma
TEMODAR
TEMODAR-PRE
Anaplastic astrocytoma of brain
Glioblastoma multiforme of brain
A documented diagnosis of one of the following:
 Non-small cell lung cancer (NSCLC) AND any one of the
following:
 Locally advanced or metastatic NSCLC after failure of
at least one prior chemotherapy regimen
 Locally advanced or metastatic non-small cell lung
cancer whose disease has not progressed after four
cycles of platinum-based first line chemotherapy
 Non-small cell lung cancer in members with known
active EGFR mutation or gene amplification
 Advanced, unresectable, or metastatic pancreatic
cancer in combination with gemcitabine
A documented diagnosis of one of the following:
 As a single agent in unresectable or metastatic
melanoma in adult patients with BRAF V600E mutation as
detected by an FDA approved test
 In combination with trametinib (Mekinist) in unresectable
or metastatic melanoma in adult patients with BRAF
V600E or BRAF V600K mutations as detected by an FDA
approved test
AND
o Documentation that Tafinlar will not be used in patients
with wild-type BRAF melanoma due to the potential risk of
tumor promotion in these patients
A documented diagnosis of one of the following:
 Newly diagnosed glioblastoma multiforme (GBM), taken
concomitantly with radiotherapy and then as maintenance
treatment
 Refractory anaplastic astrocytoma (i.e. patients who
have experienced disease progression on a drug regimen
containing nitrosourea and procarbazine)
 Ewing's Sarcoma Family of Tumors – for progressive,
relapsed ormetastatic disease
 Adult Low-Grade Infiltrative Supratentorial
Astrocytoma/Oligodendroglioma (excluding pilocytic
astrocytoma) –adjuvant chemotherapy, or for recurrent or
progressive disease
 Adult Medulloblastoma and Supratentorial Primitive
Neuroectodermal Tumors (PNET) – progression or
recurrence (salvage therapy)
 Anaplastic Gliomas – adjuvant treatment, and treatment
of recurrent disease or salvage therapy
 Glioblastoma – treatment following resection, or for
recurrent disease or salvage therapy
 Central Nervous System Cancers - Limited (1-3)
Metastatic Lesions – for brain metastases in disseminated
or recurrent disease
 Central Nervous System Cancers - Multiple (>3)
Metastatic Lesions – for brain metastases in recurrent
stable systemic disease
All
strengths
= 30 day
supply
All
strengths
= 30 day
supply
1 year
1 year
All
strengths
= 30 day
supply
For coverage of additional
quantities, a member's
treating physician must
request prior authorization
through the Aetna
Pharmacy Management
Precertification Unit.
Additional quantities will be
considered medically
necessary for those
members who meet the
following criteria:
Member is being treated in
the concomitant phase for
newly diagnosed
glioblastoma multiforme (in
combination with
radiotherapy) for 42 days
(with a maximum of 49
days)
All
strengths
= 30 day
supply
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
TYKERB
TYKERB-PRE
Breast cancer
A documented diagnosis of one of the following:
 Breast cancer, Advanced or metastatic, HER2
overexpression in combination with capecitabine after
prior therapies
 Breast cancer -Inflammatory, relapsed or refractory
 Metastatic breast cancer, HER2 overexpression, firstline
 Metastatic breast cancer, HER2 overexpression,
refractory, monotherapy
 Breast cancer, Advanced, hormone positive and HER2positive in combination with letrozole (Femara)
 Breast cancer in combination with trastuzumab (without
cytotoxic therapy) or capecitabine for trastuzumabexposed HER2 positive recurrent metastatic disease
 Hormone receptor positive metastatic breast cancer
that overexpresses the HER2 receptor in postmenopausal
women for whom hormonal therapy is indicated
 Breast cancer in combination with aromatase inhibitor
for the treatment if recurrent or stage IV estrogen receptorpositive, HER2-positive disease in postmenopausal
women who have received no prior endocrine therapy
within one year
VALCHLOR
VALCHLOR-PRE
Stage IA and IB mycosis fungiodes-type cutaneous Tcell lymphoma
VOTRIENT
VOTRIENT-PRE
Renal cell carcinoma
Soft tissue sarcoma
A documented diagnosis of stage IA and IB mycosis
fungiodes-type cutaneous T-cell lymphoma in patients
who have received prior skin-directed therapy
A documented diagnosis of one of the following:
o Advanced renal cell carcinoma with clear cell hisotology
o Advanced soft tissue sarcoma after failure of one prior
chemotherapy regimen
o Clinically progressive or symptomatic metastatic thyroid
carcinoma - follicular carcinoma, Hürthle cell carcinoma, or
papillary carcinoma in patients with nonradioiodineresponsive tumors at sites other than central nervous
system
o Medically inoperable uterine sarcoma limited to the
uterus
XALKORI
XALKORI-PRE
Non-small cell lung cancer
XELODA
XELODA-PRE
Colon cancer
Metastatic breast cancer
Metastatic colorectal cancer
XTANDI
XTANDI-PRE
Metastatic prostate cancer
YERVOY
YERVOY-PRE
Malignant melanoma
ZELBORAF
ZELBORAF-PRE
Malignant melanoma
ZOLINZA
ZOLINZA-PRE
ZYTIGA
1 year
All
strengths
= 30 day
supply
1 year
1 year
All
strengths
= 30 day
supply
A documented diagnosis of locally advanced or metastatic
non-small cell lung cancer (NSCLC) that is anaplastic
lymphoma kinase (ALK) positive as detected by an FDA
approved test
o A documented diagnosis of one of the following:
 Breast cancer
• HER (-) Recurrent, metastatic alone or in combination
with docetaxel
• HER (+) Recurrent, metastatic in combination with
trastuzumab or lapatinib
 CNS lesions (1-3 and > 3), alone or in combination with
lapatinib
 Colon cancer
• Adjuvant chemotherapy in advanced or metastatic
disease, alone or in combination with oxaliplatin
• Neoadjuvant or adjuvant chemotherapy in advanced or
metastatic disease, in combination with oxaliplatin
• Neoadjuvant chemotherapy in advanced or metastatic
disease, in combination with oxaliplatin and bevacizumab
• Advanced or metastatic disease, in combination with
bevacizumab
 Esophageal cancer, locally advanced or metastatic
disease alone or in combination with other
chemotherapeutic agents
 Gastric cancer, alone or in combination with other
chemotherapeutic agents
 Head and neck cancer, advanced, recurrent, or
persistent disease
 Intrahepatic or extrahepatic cholangiocarcinoma,
resectable, unresectable, or metastatic disease, alone or
• A documented diagnosis of metastatic castrationresistant prostate cancer in patients who have previously
received docetaxel AND
• A documented resistance or intolerance to prior therapy
with (abiraterone) Zytiga OR
o A medical contraindication to corticosteroids
1 year
All
strengths
= 30 day
supply
A documented trial of one
All
month of the preferred generic strengths
equivalent alternative,
= 30 day
capecitabine
supply
A documented diagnosis of the treatment of the following
malignant melanomas:
o Unresectable stage III in-transit metastases
o Local, satellitosis, and/or in-transit unresectable
recurrence
o Incompletely resected nodal recurrence
o Limited recurrence or metastatic disease
o Disseminated recurrence or metastatic disease in
persons with good performance status (Eastern
Cooperative Oncology Group [ECOG] performance status
0 to 2)
o Disseminated recurrence with brain metastases in
persons with good performance status (ECOG
performance status 0 to 2)
o Reinduction in persons who experienced no significant
systemic toxicity during prior medically necessary
ipilimumab therapy and who relapse after initial clinical
response or progress after stable disease greater than
three months.
A documented diagnosis of unresectable or metastatic
melanoma with BRAFV600E mutation as detected by an
FDA approved test.
One year (4
times within
one year)
Primary cutaneous T-cell lymphoma
A documented diagnosis of one of the following:
 Cutaneous manifestations in patients with T-cell
lymphoma (CTCL) who have progressive, persistent or
recurrent disease on or following two systemic therapies
(e.g. oral tretinoin AND oral bexarotene (Targretin)
 Primary systemic biologic therapy for mycosis fungoides
(MF)/Sezary syndrome documented as any one of the
following:
 Early–stage MF (stage IA, IB-IIA) with blood involvement
or with folliculotropic/large cell transformation
 Advanced-stage MF (stage IIB, stage III) or Sezary
syndrome
 Adjuvant systemic biologic therapy for MF/Sezary
syndrome
 After total skin electron beam therapy in patients with
stage IIB MF
 After chemotherapy in patients with stage IV disease
 Systemic biologic therapy for refractory or progressive
early-stage or stage IIB disease with patch/plaque lesions
1 year
ZYTIGA-PRE
Metastatic prostate cancer
A documented diagnosis of late-stage (metastatic)
castration-resistant prostate cancer and documentation of
ALL of the following:
Will be taking Zytiga in combination with prednisone
Will NOT be used in combination with Xtandi
1 year
All
strengths
= 30 day
supply
ZYKADIA
ZYKADIA-PRE
metastatic non-small cell lung cancer
A documented diagnosis of anaplastic lymphoma kinase
(ALK)-positive metastatic non-small cell lung cancer
(NSCLC) AND
Documented disease progressed on, or intolerance to,
crizotinib (Xalkori)
1 year
All
strengths
= 30 day
supply
EVZIO
EVZIO-PRE
Overdose of opiate
6 months
RELISTOR
RELISTOR-PRE
Opioid-induced constipation
Aetna considers Evzio medically necessary for the
emergency treatment of known or suspected opioid
overdose, as manifested by respiratory and/ or central
nervous system depression
A documented diagnosis of opioid-induced constipation,
AND
A documented diagnosis of an advanced illness (i.e.,
incurable cancer, end-stage COPD/emphysema,
cardiovascular disease/heart failure, Alzheimer's
disease/dementia, HIV/AIDS), AND
Member is receiving palliative care, AND
Concomitant use of opioid therapy (i.e., codeine, fentanyl,
hydrocodone, hydromorphone, meperidine, methadone,
morphine, oxycodone, oxymorphone, propoxyphene or
tramadol), AND
Trial and failure of two (2) laxatives (i.e., docusate sodium,
Miralax, bisacodyl, lactulose, senna)
CYSTARAN
CYSTARAN -PRE
◾Cystinosis
A document diagnosis of treatment of corneal cystine
crystal accumulation in patients with cystinosis
1 year
XELODAPRE
1 year
XTANDIPRE
1 year
1 year
1 year
A documented diagnosis of
metastatic castration-resistant
prostate cancer in patients
who have previously received
docetaxel AND
A documented resistance or
intolerance to prior therapy
with (abiraterone) Zytiga OR
A medical contraindication to
corticosteroids
All
strengths
= 30 day
supply
All
strengths
= 30 day
supply
All
strengths
= 30 day
supply
For coverage of additional
quantities, a member's
treating physician must
request prior authorization
through the Pharmacy
Management
Precertification Unit.
Additional quantities of
Relistor will be considered
medically necessary for
those members who meet
ANY of the following criteria:
Member requires dosing of
one vial/syringe every other
day (maximum quantity of
15 vials or 2 kits per 30
days).
Inj = 10
syringes
per month
Kit = 1 kit
(7
syringes)
per month
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
EUFLEXXA
GEL-ONE
HYALGAN
MONOVISC
ORTHOVISC
SUPARTZ
SYNVISC
SYNVISC ONE
Osteoarthritis-PRE
AREDIA
pamidronate
Osteoarthritis
Bone metastasis
Hypercalcemia of malignancy
Paget's disease
BONIVA (inj only)
ibandronate (inj only)
BONIVA-PRE
Postmenopausal osteoporosis
FORTEO
FORTEO-PRE
Osteoporosis
Postmenopausal osteoporosis
MIACALCIN (inj only)
MIACALCIN -PRE
Hypercalcemia
Paget's disease
Postmenopausal osteoporosis
PROLIA
PROLIA-PRE
Bone metastasis
Osteoporosis
Postmenopausal osteoporosis
For Members Starting Therapy:
o A documented diagnosis of symptomatic osteoarthritis of
the knee and member meets ALL of the following:
o Conservative therapy (including physical therapy,
pharmacotherapy (e.g., non-steroidal anti-inflammatory
drugs (NSAIDs), acetaminophen (up to 1 g 4 times/day)
and/or topical capsaicin cream) has been attempted in
each joint to be treated with viscosupplements and has
not resulted in functional improvement after at least 3
months or the member is unable to tolerate conservative
therapy because of adverse side effects; AND
o The clinical diagnosis is supported by radiologic
evidence of osteoarthritis of the knee such as joint space
narrowing, subchondral sclerosis, osteophytes and subchondral cysts, or, if radiographs are not available, the
member has documented symptomatic osteoarthritis of
the knee according to American College of Rheumatology
(ACR) clinical and laboratory criteria, which requires knee
pain and at least 5 of the following:
 Bony enlargement
 Bony tenderness
 Crepitus (noisy, grating sound) on active motion
 Erythrocyte sedimentation rate (ESR) less than 40
mm/hr
 Less than 30 minutes of morning stiffness
 No palpable warmth of synovium
A documented diagnosis of one of the following: Chronic
nonbacterial osteomyelitis
Hypercalcemia of malignancy
Low bone mass or osteoporotic fractures following organ
transplantation
Osteolytic bone metastases or bone pain from cancer
Refractory immobilization hypercalcemia
Osteogenesis imperfecta, severe cases presenting with
bone pain and repeated fractures
Paget's disease (osteitis deformans), symptomatic and
characterized by abnormal and accelerated bone
metabolism in one or more bones, where oral
bisphosphonates have been ineffective. (Signs and
symptoms may include bone pain, deformity, and/or
fractures; increased concentrations of serum alkaline
phosphatase and/or urinary hydroxyproline; neurologic
disorders associated with skull lesions and spinal
deformities; and elevated cardiac output and other
vascular disorders associated with increased vascularity
of bones)
Osteopenia in quadriplegic cerebral palsy
Complex regional pain syndrome refractory to other
treatments
A documented diagnosis of one of the following:
Treatment of bone metastases or bone pain presumed
due to bone metastases from breast cancer
Treatment of hypercalcemia of malignancy
Treatment of osteoporosis in post-menopausal women
who are unable to tolerate either 2 oral bisphosphonates
(e.g., alendronate (Fosamax), risedronate (Actonel)) or 1
oral bisphosphonate plus 1 selective estrogen receptor
modulator (SERM) (e.g., raloxifene (Evista)), or for whom
oral bisphosphonate therapy is contraindicated (e.g., due
to inability to swallow, or inability to remain in an upright
position after oral bisphosphonate administration for the
required length of time)
Three
months
Aetna considers daily injection of teriparatide (Forteo)
medically necessary for women with post-menopausal
osteoporosis^ AND documentation of the following:
o High risk for fractures (e.g., those who have had an
osteoporotic fracture, or have certain risk factors for
fracture***)
AND
o Failed* or unable to tolerate two oral bisphosphonates
(e.g., alendronate (Fosamax), risedronate (Actonel)), or
one oral bisphosphonate plus one selective estrogen
receptor modulator (SERM) (e.g., raloxifene (Evista) OR
o Oral bisphosphonate therapy is contraindicated (e.g.,
due to inability to swallow, or inability to remain in an
upright position after oral bisphosphonate administration
for the required length of time).
Aetna considers daily injection of teriparatide (Forteo)
medically necessary for the treatment of men with primary
or hypogonadal osteoporosis^ AND documentation of the
following:
o High risk for fractures (e.g., those who have had an
osteoporotic fracture, or have certain risk factors for
fracture***), AND
o Failed* or are unable to tolerate two oral
bisphosphonates (e.g., alendronate [Fosamax],
risedronate [Actonel]), OR
o Oral bisphosphonate therapy is contraindicated (e.g.,
documented diagnosis of one of the following:
Hypercalcemia
Individuals who present with an osteoporotic spinal
compression fracture on imaging with correlating clinical
signs and symptoms suggesting an acute injury (0 to 5
days after identifiable event or onset of symptoms) and
who are neurologically intact. (Note: Calcitonin treatment
is considered medically necessary for 4 weeks for this
indication).
Paget’s disease of bone (osteitis deformans)
Treatment of Osteoporosis in postmenopausal women
AND
documentation of any of the following: Unable to tolerate
two oral bisphosphonates (e.g., alendronate (Fosamax),
risedronate (Actonel), or one oral bisphosphonate plus
one selective estrogen receptor modulator (SERM) (e.g.,
raloxifene (Evista)
Oral bisphosphonate therapy is contraindicated (e.g., due
to inability to swallow, or inability to remain in an upright
position after oral bisphosphonate administration
for the required length of time).
1 year
A documented diagnosis of one of the following:
Treatment of women with post-menopausal osteoporosis
who are at high-risk for fractures (e.g., those who have
had an osteoporotic fracture, or have multiple risk factors
for fracture (including parental history of hip fracture and
alcohol intake of 4 or more units per day), and AND
documentation of any of the following:
Unable to tolerate two oral bisphosphonates (e.g.,
alendronate (Fosamax), risedronate (Actonel)), or one
oral bisphosphonate plus one selective estrogen receptor
modulator (SERM) (e.g., raloxifene (Evista)
Oral bisphosphonate therapy is contraindicated (e.g., due
to inability to swallow, or inability to remain in an upright
position after oral bisphosphonate administration for the
required length of time).
Prevention of osteoporosis in persons receiving
aromatase inhibitors (e.g., anastrozole (Arimidex),
letrozole (Femara), exemestane (Aromasin) AND
documentation of any of the following: Unable to tolerate
two oral bisphosphonates (e.g., alendronate (Fosamax),
1 year
1 year
1 year
1 year
Notes: Since the effects of
long-term treatment with
Forteo are not known at this
time, therapy for more than
2 years duration is
considered experimental
and investigational.
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
RECLAST
RECLAST-PRE
Bone metastasis
Hypercalcemia of malignancy
Osteoporosis
Paget's disease
Postmenopausal osteoporosis
XGEVA
XGEVA-PRE
Prevention of skeletal-related events in patients with
bone metastases from solid tumors
Giant cell tumor of the bone
ZOMETA
ZOMETA-PRE
Bone metastasis
Hypercalcemia of malignancy
Osteoporosis
Paget's disease
Postmenopausal osteoporosis
zoledronic acid
ABSTRAL
ZOMETA-PRE
PAIN-PRE
Bone metastasis
Hypercalcemia of malignancy
Osteoporosis
Paget's disease
Postmenopausal osteoporosis
Breakthrough cancer pain
General anesthesia
A documented diagnosis of one of the following: Bone
metastases or bone pain presumed due to bone
metastases from breast cancer, lung cancer,
neuroendocrine tumors, prostate cancer*, thyroid cancer,
and other solid tumor types;
Hypercalcemia of malignancy;
Multiple myeloma, including smoldering multiple myeloma
and solitary plasmacytomas;
Osteogenesis imperfecta in persons who have failed or
are intolerant of pamidronate;
Paget disease of bone;
Prevention of osteoporosis in post-menopausal women
with osteopenia AND documentation of any of the
following: Unable to tolerate two oral bisphosphonates
(e.g., alendronate (Fosamax), risedronate (Actonel)), or
one oral bisphosphonate plus one selective estrogen
receptor modulator (SERM) (e.g., raloxifene (Evista)
Oral bisphosphonate therapy is contraindicated (e.g., due
to inability to swallow, or inability to remain in an upright
position after oral bisphosphonate administration for the
required length of time).
Prevention of osteoporosis in persons receiving
aromatase inhibitors (e.g., anastrozole (Arimidex),
letrozole (Femara), exemestane (Aromasin) AND
documentation of any of the following: Unable to tolerate
A documented diagnosis of one of the following:
Prevention of skeletal-related events in patients with bone
metastases from solid tumors (e.g., breast cancer, kidney
cancer, ovarian cancer, thyroid cancer, non-small cell
lung cancer, and prostate cancer; not an all inclusive list)
Giant cell tumor of the bone
A documented diagnosis of one of the following: Bone
metastases or bone pain presumed due to bone
metastases from breast cancer, lung cancer,
neuroendocrine tumors, prostate cancer*, thyroid cancer,
and other solid tumor types;
Hypercalcemia of malignancy;
Multiple myeloma, including smoldering multiple myeloma
and solitary plasmacytomas;
Osteogenesis imperfecta in persons who have failed or
are intolerant of pamidronate;
Paget disease of bone;
Prevention of osteoporosis in post-menopausal women
with osteopenia AND documentation of any of the
following: Unable to tolerate two oral bisphosphonates
(e.g., alendronate (Fosamax), risedronate (Actonel)), or
one oral bisphosphonate plus one selective estrogen
receptor modulator (SERM) (e.g., raloxifene (Evista)
Oral bisphosphonate therapy is contraindicated (e.g., due
to inability to swallow, or inability to remain in an upright
position after oral bisphosphonate administration for the
required length of time).
Prevention of osteoporosis in persons receiving
aromatase inhibitors (e.g., anastrozole (Arimidex),
letrozole (Femara), exemestane (Aromasin) AND
documentation of any of the following: Unable to tolerate
A documented diagnosis of one of the following: Bone
metastases or bone pain presumed due to bone
metastases from breast cancer, lung cancer,
neuroendocrine tumors, prostate cancer*, thyroid cancer,
and other solid tumor types;
Hypercalcemia of malignancy;
Multiple myeloma, including smoldering multiple myeloma
and solitary plasmacytomas;
Osteogenesis imperfecta in persons who have failed or
are intolerant of pamidronate;
Paget disease of bone;
Prevention of osteoporosis in post-menopausal women
with osteopenia AND documentation of any of the
following: Unable to tolerate two oral bisphosphonates
(e.g., alendronate (Fosamax), risedronate (Actonel)), or
one oral bisphosphonate plus one selective estrogen
receptor modulator (SERM) (e.g., raloxifene (Evista)
Oral bisphosphonate therapy is contraindicated (e.g., due
to inability to swallow, or inability to remain in an upright
position after oral bisphosphonate administration for the
required length of time).
Prevention of osteoporosis in persons receiving
aromatase inhibitors (e.g., anastrozole (Arimidex),
letrozole (Femara), exemestane (Aromasin) AND
documentation of any of the following: Unable to tolerate
A documented diagnosis of cancer AND concomitant use
of long acting opioid therapy** OR
Member's resident state or contract state is California and
the member is terminally ill
1 year
PAIN-PRE
Breakthrough cancer pain
General anesthesia
A documented diagnosis of cancer AND concomitant use
of long acting opioid therapy* OR
Member's resident state or contract state is California and
the member is terminally ill
RECLASTPRE
A documented trial of one
dose of the preferred generic
equivalent alternative,
zoledronic acid
5mg = 1
bottle/ 1
year
Note: Consistent with
Zometa’s Food and Drug
Administration (FDA)approved labeling,
zoledronic acid is
considered medically
necessary for bone
metastases from prostate
cancer if cancer has
progressed after treatment
with at least 1 hormonal
therapy.
ZOMETA- A documented trial of one
PRE
dose of the preferred generic
equivalent alternative,
zoledronic acid
4mg = 1
bottle/ 3
weeks
1 year
1 year
1 year
1 year
AND
A documented contraindication or intolerance or allergy or
failure of an adequate trial of one week each of the
preferred generic alternative, fentanyl transmucosal
lozenge AND two other short acting opioids (i.e.,
morphine, hydrocodone, oxycodone, hydromorphone)
FENTORA
Note: Consistent with
Zometa’s Food and Drug
Administration (FDA)approved labeling,
zoledronic acid is
considered medically
necessary for bone
metastases from prostate
cancer if cancer has
progressed after treatment
with at least 1 hormonal
therapy.
1 year
5mg = 1
bottle/ 1
year or
4mg = 1
bottle/ 3
weeks
A Documented diagnosis of
cancer and prescription is
written by an oncologist or
pain specialist OR
Member is enrolled in a
hospice program or meets
hospice criteria OR
Member's resident state or
contract state is California
and the member is
terminally ill OR
Patient has signed opioid
agreement in support of
clinical guidelines by the
American Pain Society and
the American Academy of
Pain Medicine
(Note: ALL additional
quantities above what is
allowed in the chart above
require that a Patient have
a signed opioid agreement
in support of clinical
guidelines by the American
Pain Society and the
American Academy of Pain
A Documented diagnosis of
cancer and prescription is
written by an oncologist or
pain specialist OR
Member is enrolled in a
hospice program or meets
hospice criteria OR
Member's resident state or
contract state is California
and the member is
terminally ill OR
Patient has signed opioid
agreement in support of
clinical guidelines by the
American Pain Society and
the American Academy of
Pain Medicine
(Note: ALL additional
quantities above what is
allowed in the chart above
require that a Patient have
a signed opioid agreement
in support of clinical
guidelines by the American
Pain Society and the
American Academy of Pain
ABSTRAL- A documented trial of one
PRE
week each of the preferred
generic alternative, fentanyl
transmucosal lozenge AND
two other short acting opioids
(i.e., morphine, hydrocodone,
oxycodone, hydromorphone)e
15
tablets/30
day
supply
ABSTRAL- A documented trial of one
PRE
week each of the preferred
generic alternative, fentanyl
transmucosal lozenge AND
two other short acting opioids
(i.e., morphine, hydrocodone,
oxycodone, hydromorphone)e
15
lollipops/3
0 day
supply
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
CELEBREX
fentanyl lozenge
CELEBREX-PRE
PAIN-PRE
Breakthrough cancer pain
General anesthesia
Breakthrough cancer pain
General anesthesia
Should not be given to
patients who have
experienced asthma,
urticaria, or allergic-type
reactions after taking
aspirin or other NSAIDs.
Severe, rarely fatal,
anaphylactic-like reactions
to NSAIDs and aspirin have
been reported in such
patients.
Should not be given to
patients who have
experienced allergic-type
reactions to sulfonamides.
Age greater than 60 OR
Diagnosis of Juvenile Rheumatoid Arthritis [JRA] OR
Concomitant use of warfarin (Coumadin®) or other
anticoagulant/antiplatelet therapy OR
Concomitant use of chronic oral (systemic) corticosteroid
therapy (>60 days) OR
Documented history of ulcer disease** or GI bleed; OR
Documented use of an H2 receptor antagonist
(cimetidine/Tagamet®, famotidine/Pepcid®,
nizatidine/Axid®, ranitidine/ Zantac®) or a proton pump
inhibitor (AcipHex®, Nexium®, omeprazole/Prilosec®,
Prevacid®, Protonix®), or misoprostol (Cytotec®) due to
one of the following: History of significant GI disease** OR
NSAID GI adverse effects, necessitating discontinuation of
NSAID therapy
A documented diagnosis of cancer AND concomitant use
of long acting opioid therapy** OR
Member's resident state or contract state is California and
the member is terminally ill
1 Year for
chronic
diagnosis
1 Month for
acute pain
1 week
LAZANDA
LAZANDA-PRE
Breakthrough cancer pain
General anesthesia
A documented diagnosis of cancer AND concomitant use
of long acting opioid therapy* OR
Member's resident state or contract state is California and
the member is terminally ill
1 year
ONSOLIS
PAIN-PRE
Breakthrough cancer pain
General anesthesia
A documented diagnosis of cancer AND concomitant use
of long acting opioid therapy** OR
Member's resident state or contract state is California and
the member is terminally ill
1 year
AND
A documented contraindication or intolerance or allergy or
failure of an adequate trial of one week each of the
preferred generic alternative, fentanyl transmucosal
lozenge AND two other short acting opioids (i.e.,
morphine, hydrocodone, oxycodone, hydromorphone)
SUBSYS -PRE
Breakthrough cancer pain
General anesthesia
A documented diagnosis of cancer AND concomitant use
of long acting opioid therapy* OR
Member's resident state or contract state is California and
the member is terminally ill
ACTIQ
PAIN-PRE
Breakthrough cancer pain
General anesthesia
A documented diagnosis of cancer AND concomitant use
of long acting opioid therapy** OR
Member's resident state or contract state is California and
the member is terminally ill
AND
A documented contraindication or intolerance or allergy or
failure of an adequate trial of one week each of the
preferred generic alternative, fentanyl transmucosal
lozenge AND two other short acting opioids (i.e.,
morphine, hydrocodone, oxycodone, hydromorphone)
Documented diagnosis of
rheumatoid arthritis (RA) or
Juvenile Rheumatoid
Arthritis [JRA] (approvable
dose is 200 mg twice daily
or 60 capsules (200mg) per
30 days) OR
Failure of 200mg total daily
dose (approvable dose is
200 mg twice daily or 60
capsules (200mg) per 30
days) OR,
AND
A documented contraindication or intolerance or allergy or
failure of an adequate trial of one week each of the
preferred generic alternative, fentanyl transmucosal
lozenge AND two other short acting opioids (i.e.,
morphine, hydrocodone, oxycodone, hydromorphone)
SUBSYS SPRAY
50 mg and
100 mg =
60
capsules/
30 day
supply
200 mg =
30
capsules/
30 day
supply
400 mg =
60
capsules/
30 day
supply
For Celebrex 100 mg and
200 mg
1 year
Documented diagnosis of
acute pain (approvable
dose is 200 mg twice daily
or 60 capsules (200 mg)
per
30 days; 30diagnosis
day limit) of
A
Documented
cancer and prescription is
written by an oncologist or
pain specialist OR
Member is enrolled in a
hospice program or meets
hospice criteria OR
Member's resident state or
contract state is California
and the member is
terminally ill OR
Patient has signed opioid
agreement in support of
clinical guidelines by the
American Pain Society and
the American Academy of
Pain Medicine
(Note: ALL additional
quantities above what is
allowed in the chart above
require that a Patient have
a signed opioid agreement
in support of clinical
guidelines by the American
Pain Society and the
American Academy of Pain
A Documented diagnosis of
cancer and prescription is
written by an oncologist or
pain specialist OR
Member is enrolled in a
hospice program or meets
hospice criteria OR
Member's resident state or
contract state is California
and the member is
terminally ill OR
Patient has signed opioid
agreement in support of
clinical guidelines by the
American Pain Society and
the American Academy of
Pain Medicine
(Note: ALL additional
quantities above what is
allowed in the chart above
require that a Patient have
a signed opioid agreement
in support of clinical
guidelines by the American
Pain Society and the
American Academy of Pain
A Documented diagnosis of
cancer and prescription is
written by an oncologist or
pain specialist OR
Member is enrolled in a
hospice program or meets
hospice criteria OR
Member's resident state or
contract state is California
and the member is
terminally ill OR
Patient has signed opioid
agreement in support of
clinical guidelines by the
American Pain Society and
the American Academy of
Pain Medicine
(Note: ALL additional
quantities above what is
allowed in the chart above
require that a Patient have
a signed opioid agreement
in support of clinical
guidelines by the American
Pain Society and the
American Academy of Pain
A Documented diagnosis of
cancer and prescription is
written by an oncologist or
pain specialist OR
Member is enrolled in a
hospice program or meets
hospice criteria OR
Member's resident state or
contract state is California
and the member is
terminally ill OR
Patient has signed opioid
agreement in support of
clinical guidelines by the
American Pain Society and
the American Academy of
Pain Medicine
(Note: ALL additional
quantities above what is
allowed in the chart above
require that a Patient have
a signed opioid agreement
in support of clinical
guidelines by the American
Pain Society and the
American Academy of Pain
A Documented diagnosis of
cancer and prescription is
written by an oncologist or
pain specialist OR
Member is enrolled in a
hospice program or meets
hospice criteria OR
Member's resident state or
contract state is California
and the member is
terminally ill OR
Patient has signed opioid
agreement in support of
clinical guidelines by the
American Pain Society and
the American Academy of
Pain Medicine
(Note: ALL additional
quantities above what is
allowed in the chart above
require that a Patient have
a signed opioid agreement
in support of clinical
guidelines by the American
Pain Society and the
American Academy of Pain
15 buccal
tablets/30
day
supply
LAZANDA- A documented trial of one
PRE
week of the preferred generic
alternative, fentanyl
transmucosal lozenge
4 bottles
per 30
day
supply
ABSTRAL- A documented trial of one
15 tabs/30
PRE
week each of the preferred
day
generic alternative, fentanyl
supply
transmucosal lozenge AND
two other short acting opioids
(i.e., morphine, hydrocodone,
oxycodone, hydromorphone)e
LAZANDA- A documented trial of one
PRE
week of the preferred generic
alternative, fentanyl
transmucosal lozenge
15
units/30
day
supply
ABSTRAL- A documented trial of one
PRE
week each of the preferred
generic alternative, fentanyl
transmucosal lozenge AND
two other short acting opioids
(i.e., morphine, hydrocodone,
oxycodone, hydromorphone)e
15
lollipops/3
0 day
supply
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
XARTEMIS XR
XARTEMIS-PRE
acute pain
A documented diagnosis of acute pain severe enough to
require opioid treatment and for which alternative
treatment options are inadequate AND
A documented contraindication or intolerance or allergy or
failure of an adequate trial of two days each of two
preferred generic short-acting opioid alternatives, i.e.,
morphine, hydrocodone, oxycodone, hydromorphone
1 year
ZORVOLEX
ZORVOLEX-PRE
mild to moderate acute pain in adults
A documented diagnosis of mild to moderate acute pain in
adults, AND
1 year
For coverage of additional XARTEMI
S-PRE
quantities, member's
treating physician must
request prior authorization
through the Aetna
Pharmacy Management
Precertification Unit.
Additional quantities of the
above medications will be
considered medically
necessary for those
members who meet the
following criterion:
A Documented diagnosis of
cancer and prescription is
written by an oncologist or
pain specialist OR
Member is enrolled in a
hospice program or meets
hospice criteria OR
Member's resident state or
contract state is California
and the member is
terminally ill OR
Patient has signed opioid
agreement in support of
ZORVOLE
X-PRE
A documented trial of two days 4
each of two preferred generic tablets/da
short-acting opioid
y
alternatives, i.e., morphine,
hydrocodone, oxycodone,
hydromorphone
A documented trial of two
weeks of the preferred generic
alternative, dicolfenac
A documented contraindication or allergy or intolerance or
failure of an adequate trial of two weeks of the preferred
generic alternative, dicolfenac
ZOHYDRO ER
KADIAN-PRE
moderate to severe pain when a continuous, around-theclock opioid analgesic is needed for an extended period
of time
A documented diagnosis of moderate to severe pain when
a continuous, around-the-clock opioid analgesic is
needed for an extended period of time, AND
A documented progression through the World Health
Organization analgesic ladder*, AND
A documented contraindication or intolerance or allergy or
failure of an adequate trial of one month each of the
following preferred generic alternatives: morphine sr cap
24hr (Kadian CR), AND
morphine sr tab 12hr (MS Contin), AND
oxymorphone er (Opana ER)
1 year
SOLIRIS
SOLIRIS-PRE
Hemolytic uremic syndrome
Paroxysmal nocturnal hemoglobinuria
A documented diagnosis of paroxysmal nocturnal
hemoglobinuria (PNH), with flow cytometric confirmation of
at least 10% PNH type III red cells or greater than 50% of
glycosylphosphatidylinositol-anchored proteins (GPI-AP)deficient polymorphonuclear cells (PMNs); ANDMember
has been vaccinated against meningococcal infection (at
least 2 weeks prior to eculizumab treatment, if not
previously vaccinated); AND
Member does not meet diagnostic criteria for severe
aplastic anemia (see special notes); AND
Member meets either of the following criteria: Member is
transfusion-dependent (i.e., has at least 1 transfusion in
the 24 months prior to initiation of eculizumab due to
documented hemoglobin less than 7 g/dL in persons
without anemic symptoms or less than 9 g/dL in persons
with symptoms from anemia) and has platelet counts of at
least 30,000/microliter prior to initiation of eculizumab
treatment; or
Member has a documented history of major adverse
vascular events from thromboembolism (see special
notes).
1 year
LUMIZYME
LUMIZYME-PRE
A documented diagnosis of individuals aged 8 years and
older with late-onset (non-infantile) Pompe disease who
do not have evidence of cardiac hypertrophy
MYOZYME
MYOZYME-PRE
NUEDEXTA
NUEDEXTA-PRE
A documented diagnosis of infantile-onset Pompe
disease
Pseudobulbar affect
ADCIRCA
PHA-PRE
Pulmonary hypertensive arterial disease
A documented diagnosis of the treatment of atypical
hemolytic uremic syndrome without serious unresolved
A Documented diagnosis of LA
cancer and prescription is OPIOIDSwritten by an oncologist or PRE
pain specialist OR
Member is enrolled in a
hospice program or meets
hospice criteria OR
Member's resident state or
contract state is California
and the member is
terminally ill OR
Patient has signed opioid
agreement in support of
clinical guidelines by the
American Pain Society and
the American Academy of
Pain Medicine
(Note: ALL additional
quantities above what is
allowed in the chart above
require that a Patient have
a signed opioid agreement
in support of clinical
guidelines by the American
Pain Society and the
American Academy of Pain
2
Trial of 1 month each of
capsules/
morphine sulfate cr tablets
(MS Contin) and oxymorphone day
extended release (Opana ER)
1 year
1 year
A documented diagnosis of pseudobulbar affect
1 year
A documented diagnosis of pulmonary hypertension with
World Health Organization (WHO) Class II to IV symptoms*
(Adcirca, Letairis, Tracleer, Opsumit, Revatio inj, Revatio
tab, and sildenafil ONLY) or WHO Class III to IV symptoms*
(epoprostenol, Flolan, Remodulin, Tyvaso, Veletri,
Ventavis ONLY) and a mean pulmonary artery pressure
greater than 25 mm Hg at rest or greater than 30 mm Hg
with exertion, documented by right-heart catheterization or
echocardiography; AND
1 year
2
capsules/
day
2
tablets/da
y
Member has primary pulmonary hypertension, or has
pulmonary hypertension secondary to any of the following
conditions: Group 1 pulmonary hypertension: Anorectic
agents (diet drugs); or
Congenital heart disease with shunting; or
Connective tissue diseases; or
HIV infection; or
Portopulmonary hypertension; or
Familial pulmonary hypertension.
Chronic thromboembolic pulmonary hypertension not
adequately responsive to anticoagulants or surgical
thromboendarterectomy; or
Congenital diaphragmatic hernia; or
Sarcoidosis.
sildenafil
REVATIO
PHA-PRE
Pulmonary hypertensive arterial disease
A documented diagnosis of pulmonary hypertension with
World Health Organization (WHO) Class II to IV symptoms*
(Adcirca, Letairis, Tracleer, Opsumit, Revatio inj, Revatio
tab, and sildenafil ONLY) or WHO Class III to IV symptoms*
(epoprostenol, Flolan, Remodulin, Tyvaso, Veletri,
Ventavis ONLY) and a mean pulmonary artery pressure
greater than 25 mm Hg at rest or greater than 30 mm Hg
with exertion, documented by right-heart catheterization or
echocardiography; AND
Member has primary pulmonary hypertension, or has
pulmonary hypertension secondary to any of the following
conditions: Group 1 pulmonary hypertension: Anorectic
agents (diet drugs); or
Congenital heart disease with shunting; or
Connective tissue diseases; or
HIV infection; or
Portopulmonary hypertension; or
Familial pulmonary hypertension.
Chronic thromboembolic pulmonary hypertension not
adequately responsive to anticoagulants or surgical
thromboendarterectomy; or
Congenital diaphragmatic hernia; or
Sarcoidosis.
1 year
3
tablets/da
y
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
ADEMPAS
ADEMPAS-PRE
Pulmonary hypertensive arterial disease
A documented diagnosis of pulmonary hypertension with
World Health Organization (WHO) Class II to IV symptoms*
and a mean pulmonary artery pressure greater than 25
mm Hg at rest or greater than 30 mm Hg with exertion,
documented by right-heart catheterization or
echocardiography; AND
Member has primary pulmonary hypertension, or has
pulmonary hypertension secondary to any of the following
conditions: Group 1 pulmonary hypertension: Anorectic
agents (diet drugs); or
Congenital heart disease with shunting; or
Connective tissue diseases; or
HIV infection; or
Portopulmonary hypertension; or
Familial pulmonary hypertension.
1 year
3
tablets/day
1 year
1
tablet/day
Congenital diaphragmatic hernia; or
Sarcoidosis; AND
Member is NOT concurrently using organic nitrates (i.e.,
isosorbide mononitrate, isosorbide dinitrate, nitroglycerin)
OR PDE inhibitors (i.e., sildenafil, Adcirca, dipyridamole,
or theophylline); AND
Member is not pregnant; AND
OPSUMIT
PHA-PRE
Pulmonary hypertensive arterial disease
Member has a documented contraindication or intolerance
A documented diagnosis of pulmonary hypertension with
World Health Organization (WHO) Class II to IV symptoms*
(Adcirca, Letairis, Tracleer, Opsumit, Revatio inj, Revatio
tab, and sildenafil ONLY) or WHO Class III to IV symptoms*
(epoprostenol, Flolan, Remodulin, Tyvaso, Veletri,
Ventavis ONLY) and a mean pulmonary artery pressure
greater than 25 mm Hg at rest or greater than 30 mm Hg
with exertion, documented by right-heart catheterization or
echocardiography; AND
Member has primary pulmonary hypertension, or has
pulmonary hypertension secondary to any of the following
conditions: Group 1 pulmonary hypertension: Anorectic
agents (diet drugs); or
Congenital heart disease with shunting; or
Connective tissue diseases; or
HIV infection; or
Portopulmonary hypertension; or
Familial pulmonary hypertension.
Chronic thromboembolic pulmonary hypertension not
adequately responsive to anticoagulants or surgical
thromboendarterectomy; or
Congenital diaphragmatic hernia; or
Sarcoidosis.
epoprostenol
FLOLAN
TRACLEER
TYVASO
VELETRI
VENTAVIS
PHA-PRE
Pulmonary hypertensive arterial disease
LETAIRIS
REMODULIN
A documented diagnosis of pulmonary hypertension with
World Health Organization (WHO) Class II to IV symptoms*
(Adcirca, Letairis, Tracleer, Opsumit, Revatio inj, Revatio
tab, and sildenafil ONLY) or WHO Class III to IV symptoms*
(epoprostenol, Flolan, Remodulin, Tyvaso, Veletri,
Ventavis ONLY) and a mean pulmonary artery pressure
greater than 25 mm Hg at rest or greater than 30 mm Hg
with exertion, documented by right-heart catheterization or
echocardiography; AND
1 year
Member has primary pulmonary hypertension, or has
pulmonary hypertension secondary to any of the following
conditions: Group 1 pulmonary hypertension: Anorectic
agents (diet drugs); or
Congenital heart disease with shunting; or
Connective tissue diseases; or
HIV infection; or
Portopulmonary hypertension; or
Familial pulmonary hypertension.
Chronic thromboembolic pulmonary hypertension not
adequately responsive to anticoagulants or surgical
thromboendarterectomy; or
Congenital diaphragmatic hernia; or
Sarcoidosis.
ORENITRAM
ORENITRAM-PRE
Pulmonary hypertensive arterial disease
A documented diagnosis of pulmonary hypertension with
World Health Organization (WHO) Class II to IV symptoms*
and a mean pulmonary artery pressure greater than 25
mm Hg at rest or greater than 30 mm Hg with exertion,
documented by right-heart catheterization or
echocardiography; AND
1 year
Member has primary pulmonary hypertension, or has
pulmonary hypertension secondary to any of the following
conditions: Group 1 pulmonary hypertension: Anorectic
agents (diet drugs); or
Congenital heart disease with shunting; or
Connective tissue diseases; or
HIV infection; or
Portopulmonary hypertension; or
Familial pulmonary hypertension.
Chronic thromboembolic pulmonary hypertension not
adequately responsive to anticoagulants or surgical
thromboendarterectomy; or
Congenital diaphragmatic hernia; or
Sarcoidosis.
SYNAGIS
SYNAGIS-PRE
Respiratory syncytial virus infection
AND
1.Early Preterm Infants:
1.In the first year of life, palivizumab prophylaxis is
considered medically necessary for infants born before 29
weeks, 0 days’ gestation.
2.Palivizumab prophylaxis is considered not medically
necessary for otherwise healthy infants born at or after 29
weeks, 0 days’ gestation.
2.Chronic Lung Disease (CDL) of Prematurity:
INTERMEZZO
INTERMEZZO-PRE
Insomnia
1.In the first year of life, palivizumab prophylaxis is
considered medically necessary for preterm infants with
chronic lung disease (CLD) of prematurity (formerly known
as broncho-pulmonary dysplasia or BPD), defined as birth
at <32 weeks, 0 days’ gestation and a requirement for
greater than 21% oxygen for at least 28 days after birth.
2.Palivizumab prophylaxis is considered medically
necessary in the second year of life for children with CLD
who required at least 28 days of supplemental oxygen
after birth and who continue to require medical
intervention (supplemental oxygen, chronic corticosteroid,
or diuretic therapy) during the 6-month period before the
start of the second RSV season.
3.Palivizumab prophylaxis is considered not medically
For Intermezzo 1.75 mg - (for males or females)
A documented diagnosis of treatment of insomnia when
middle-of-the-night awakening is followed by difficulty
returning to sleep
See dosing in Dosing of Palivizumab:
other criteria 1.Up to a maximum of 5
monthly doses of
palivizumab (15 mg/kg per
dose) are considered
medically necessary during
the RSV season for infants
who qualify for prophylaxis
in the first year of life. For
infants born during the RSV
season, fewer than 5
monthly doses are
considered medically
necessary. (For example,
infants born in January
would receive their last
dose in March.)
2.Palivizumab prophylaxis
for sporadic RSV infections
outside of RSV season is
considered not medically
necessary.
3.A postoperative dose of
palivizumab (15 mg/kg) is
considered medically
necessary after cardiac
1 year
SedativePRE
A documented trial of 7 days 1
(one week) of the preferred
tablet/day
generic alternative zolpidem or
zolpidem er.
For Intermezzo 3.5mg – (for males only)
A documented diagnosis of treatment of insomnia when
middle of the night awakening is followed by difficulty
returning to sleep AND ALL of the following: Member is
male
Member is less than or equal to 65 years of old
It is documented they will NOT taking Intermezzo
concomitantly with other CNS depressants (e.g.
benzodiazepines, opioids, tricyclic antidepressants,
alcohol)
HETLIOZ
HETLIOZ-PRE
Non-24 hour sleep-wake cycle
A documented diagnosis of non-24 sleep-wake disorder
AND
Member is documented to be totally blind and has no light
perception AND
Member has a history of at least 3 months of difficulty
initiating sleep, difficulty awakening in the morning, or
excessive daytime sleepiness AND
Member has no other concomitant sleep disorder, i.e.,
sleep apnea, insomnia
1 year
1
tablet/day
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
DALIRESP
DALIRESP-PRE
COPD
BENLYSTA
BENLYSTA-PRE
Systemic lupus erythematosus
ACIPHEX
ESOMEPRAZOLE
PREVACID
PREVACID SOLUTAB
PRILOSEC
PROTONIX
ZEGERID
PPI-PRE
Gastroesophageal reflux disease
Duodenal ulcer disease
Gastric hypersecretion
A documented diagnosis of severe (Stage III) or very
severe (Stage IV) chronic obstructive pulmonary disease
(COPD) associated with chronic bronchitis and a history of
exacerbations AND
A documented contraindication or intolerance or allergy or
failure of an adequate trial of one week of one preferred
alternative bronchodilator, albuterol/ ipratropium,
ipratropium inhalation solution, or Combivent Respimat
AND Spiriva AND
A documented contraindication or intolerance or allergy or
failure of an adequate trial of one month of the preferred
alternative bronchodilator, Symbicort
A documented diagnosis of active Systemic Lupus
Erythematosus (SLE) in adults aged 18 or older based on
ACR criteria*; and
Positive autoantibody test (e.g., anti-nuclear antibody
[ANA] greater than or equal to 1:80 and/or anti-doublestranded DNA [anti-dsDNA] greater than or equal to 30
IU/ml); and
At least one of the following 3 baseline measurement
scores**: SELENA-SLEDAI score, British Isles Lupus
Assessment Group (BILAG) scores or Physician’s Global
Assessment (PGA) score; and
An insufficient response to two (2) standard of care drug
classes: Glucocorticoids (e.g., prednisone,
methylprednisolone, dexamethasone)
Antimalarials (e.g., hydroxychloroquine)
Immunosuppressives (e.g., azathioprine, methotrexate,
mycophenolate, cyclosporine, cyclophosphamide,
chlorambucil, nitrogen mustard)
Aetna does NOT consider
prescription PPIs to be
medically necessary for
members with the following
indications:
1. Uncomplicated heartburn
of greater than 1-month
duration, with a frequency
of at least 2 heartburn
episodes per week when all
of the following criteria are
met:
a. The heartburn can be
controlled by use of OTC
medications AND
b. There is no diagnosis of
more complicated acid
reflux disease, such as
erosive esophagitis AND
c. There are no symptoms
of a more complicated GI
condition.*
AND
Member does not have active nephritis or severe active
lupus nephritis (proteinuria greater than 6 g/24 hour or
equivalent using spot urine protein to creatinine ratio, or
serum creatinine greater than 2.5 mg/dL); and
A. Documented diagnosis listed below (no requirement for
nonprescription Prilosec OTC)
Indication
Ulcers
Gastrojejunal ulcer - active; maintenance
Healing of NSAID-associated gastric ulcer
Maintenance of healed duodenal ulcers
Stress ulcer/surgical prophylaxis
Treatment of benign gastric ulcer
Treatment of duodenal ulcers
Other GI Conditions
Gastric residual reduction
Gastrointestinal bleed
GERD - moderate to severe with symptoms
GERD- with atypical symptoms or complications (ex
dysphagia, hoarseness, asthma exacerbations, noncardiac chest pain, esophageal stricture)
Healing erosive esophagitis
Helicobacter pylori eradication to reduce risk of duodenal
ulcer recurrence (Additional documentation of two
concurrent antibiotics that will be used in the treatment
regimen combined with the requested PPI as part of the
therapy are required.
Examples of antibiotics include: amoxicillin or
Member has a documented diagnosis of hyponatremia
AND
Therapy is being initiated or re-initiated in a hospital within
the past month where serum sodium can be monitored
closely AND
Member has no underlying liver disease, including
cirrhosis AND
Member will not concurrently take any strong CYP 3A
inhibitor medications, such as the following: clarithromycin
indinavir
itraconazole
ketoconazole
nefazodone
nelfinavir
ritonavir
saquinavir
telithromycin
1 year
DALIRESP- A documented trial of one
PRE
week of one preferred
alternative bronchodilator,
albuterol/ ipratropium,
ipratropium inhalation solution,
or Combivent Respimat AND
Spiriva AND a documented
trial of one month of the
preferred alternative
bronchodilator, Symbicort
Initial
authorization
is for one
year.
Additional
therapy will
be authorized
at 6 month
intervals if
there is
documentatio
n of
continued
improvement
in disease
activity
indicating a
therapeutic
response/
stability of
the disease.
1 year
30 days
SAMSCA
SAMSCA-PRE
Hyponatremia, Hypervolemic or euvolemic
INFERGEN
INFERGEN-PRE
hepatitis C
A documented diagnosis of one of the following:
Chronic hepatitis C, initial treatment
Chronic hepatitis C, retreatment in patients who have
failed to respond to a complete therapeutic course of
pegylated interferon (Pegasys, Peg-Intron) Treatment
failure is defined as less than a 2 log decline in viral load
after undergoing at least 12 weeks of previous pegylated
interferon plus ribavirin therapy with greater than 80%
adherence, or a detectable viral load at end-of-treatment
after completing at least 24 weeks of therapy
Up to 48 weeks of treatment with consensus interferon is
considered medically necessary for retreatment;
continued treatment with consensus interferon is
considered not medically necessary for persons with a
poor response to re-treatment at week 12 (defined as less
than 2 log10 reduction in viral load from baseline) or
persons who have detectable virus at week 24
AND
Member does not meet clinical criteria for Harvoni
OR
Member has contraindication or intolerance to Harvoni
1 year
INTRON-A
INTRON-PRE
AIDS-associated Kaposi's sarcoma
Carcinoid syndrome
Chronic myelogenous leukemia
Condylomata acuminata (genital warts) (intralesional
only)
Cutaneous T-cell lymphoma (including mycosis
fungoides)
Desmoid tumors (fibromatosis), for unresctable disease
or gross residual disease following surgery
Essential thrombocythemia
Giant cell tumor of bone
Hairy cell leukemia
Hepatitis C (non-A, non-B hepatitis)
A documented diagnosis of one of the following:
AIDS-associated Kaposi's sarcoma
Carcinoid syndrome
Chronic myelogenous leukemia
Condylomata acuminata (genital warts) (intralesional only)
Cutaneous T-cell lymphoma (including mycosis fungoides)
Desmoid tumors (fibromatosis), for unresctable disease or
gross residual disease following surgery
Essential thrombocythemia
Giant cell tumor of bone
Hairy cell leukemia
Hepatitis C (non-A, non-B hepatitis). Up to a maximum of
24 weeks of interferon alpha is considered medically
necessary for persons with HCV genotypes 2, 3, and 7
through 10
Up to a maximum of 48 weeks of interferon alpha is
considered medically necessary for persons with HCV
genotypes 1 and 4 through 6
Continued treatment with interferon alpha is considered
not medically necessary for persons with HCV genotypes
1 and 4 through 6 who have failed to attain an early
virologic response after 12 weeks of treatment (where
early virologic response is indicated by achievement of at
least a 100-fold (2 log10) decrease in serum HCV from
pretreatment baseline)
A course of standard interferon alpha in persons with
1 year
For coverage of additional PPI-PRE
quantities, a member's
treating physician must
request prior authorization
through the Pharmacy
Management
Precertification Unit.
Additional quantities of
proton pump inhibitors may
be considered medically
necessary for those
members who meet ANY of
the following criteria:
Member has a diagnosis of
a pathological
hypersecretory condition
[e.g., Zollinger-Ellison
Syndrome, multiple
endocrine neoplasia type 1
(MEN-1)] OR
Member is being treated for
Barrett’s esophagus OR
Member is being treated for
eradication of H. pylori
(triple therapy only; 30-day
duration) OR
Under some plans,
including plans that use an
open or closed
formulary, Harvoni,
Infergen, Intron-A, Olysio,
Pegasys, Peg-Intron/
Redipen/pak, Sovaldi, and
Victrelis are subject to
precertification. If
precertification
requirements apply Aetna
considers these
medications to be
medically necessary for
those members who meet
all of the following
precertification criteria.
There are several brands of
medications for the
treatment of Chronic
Hepatitis C on the market.
For those patients meeting
clinical criteria for
Harvoni as outlined below,
the use of Harvoni will be
required unless the
Under some plans,
including plans that use an
open or closed
formulary, Harvoni,
Infergen, Intron-A, Olysio,
Pegasys, Peg-Intron/
Redipen/pak, Sovaldi, and
Victrelis are subject to
precertification. If
precertification
requirements apply Aetna
considers these
medications to be
medically necessary for
those members who meet
all of the following
precertification criteria.
There are several brands of
medications for the
treatment of Chronic
Hepatitis C on the market.
For those patients meeting
clinical criteria for
Harvoni as outlined below,
the use of Harvoni will be
required unless the
A documented trial of one
month each of two preferred
PPIs: Dexilant OR Nexium OR
generic lansoprazole/ODT –
alternatives on the Preferred
Drug List.
1 tablet,
capsule or
packet/da
y
Prilosec
powder - 2
packets/d
ay
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
OLYSIO
OLYSIO-PRE
hepatitis C
For initial authorization (6 week maximum), provider must
submit medical records documenting the diagnosis of
chronic hepatitis C with genotype and subtype, if
applicable (i.e., genotype 1a, genotype 1b; diagnoses
further defined below) AND submit medical records
documenting any one of the following related to staging of
liver disease:
1.Metavir scores
2.Fibroscan score
3.FibroSURE score
4.APRI score
5.Radiological imaging consistent with cirrhosis (i.e.,
evidence of portal hypertension)
6.Physical findings or clinical evidence consistent with
cirrhosis as attested by the prescribing physician
AND meet the criteria specified below:
Member does not have decompensated liver disease
Member is not co-infected with hepatitis B or HIV
Member has a documented diagnosis of one of the
following, with documented viral load taken within 6
months of beginning therapy:
Chronic Hepatitis C Virus (HCV) infection, genotype 1,
AND all of the following:
PEGASYS
PEG-INTRON
PEGASYS-PRE
HARVONI
hepatitis C
hepatitis b
hepatitis C
SOVALDI
SOVALDI-PRE
hepatitis C
VICTRELIS
VICTRELIS-PRE
hepatitis C
ACANYA
BENZACLIN
BENZAMYCIN
DUAC
RIAX AER
BENZEFOAM ULTRA
ARICEPT (5 mg, 10 mg
and 23 mg)
ARICEPT ODT (5 mg
and 10mg)
RANEXA
DEPAKOTE
DEPAKOTE ER
DEPAKOTE SPRINKLE
KEPPRA
KEPPRA XR
TOPAMAX
Concurrent therapy with peginterferon alfa (PEG) and
A documented diagnosis of one of the following:
Chronic hepatitis C, as monotherapy or in combination
with ribavirin, boceprevir (Victrelis), or simeprevir (Olysio),
in patients who are interferon naïve or who have relapsed
or failed to respond to prior non-pegylated interferon
therapy
Continued treatment with pegylated interferon alpha is
considered not medically necessary for persons with HCV
genotypes 1 and 4 through 6 who have failed to attain an
early virologic response after 12 weeks of therapy (early
virologic response is indicated by achievement of at least
a 100-fold (2 log10) decrease in serum HCV RNA from
pretreatment baseline)
Up to 48 weeks of treatment with pegylated interferons is
considered medically necessary for persons infected with
HCV genotype 1 and genotypes 4 through 6 who have
attained an early virologic response by 12 weeks of
therapy
Up to 72 weeks of treatment with pegylated interferons is
considered medically necessary for persons with
HCVgenotype 1 infection who have delayed virus
clearance (HCV
RNA test becomes negative between weeks 12 and 24)
Up to 24 weeks of treatment with pegylated interferons is
considered medically necessary for persons with other
HCV genotypes (i.e., genotypes 2 and 3, and genotypes 7
For initial authorization, provider must submit medical
records documenting
the diagnosis of chronic hepatitis C with genotype and
subtype, if applicable
(i.e., genotype 1a, genotype 1b; diagnoses further
defined
below) AND submit medical records documenting any one
of the following
related to staging of liver disease:
1. Metavir scores
2. Fibroscan score
3. FibroSURE score
4. APRI score
5. Radiological imaging consistent with cirrhosis (i.e.,
evidence of portal
hypertension)
6. Physical findings or clinical evidence consistent with
cirrhosis as
attested by the prescribing physician
AND meet the criteria specified below:
Member does not have decompensated liver disease,
AND
Member is not co-infected with hepatitis B or HIV-1, AND
A documented viral load taken within 6 months of
beginning therapy,
AND
For initial authorization (6 week maximum), provider must
submit medical
records documenting the diagnosis of chronic hepatitis C
with genotype and
subtype, if applicable (i.e., genotype 1a, genotype 1b;
diagnoses further
defined below) AND submit medical records documenting
any one of the
following related to staging of liver disease:
1. Metavir scores
2. Fibroscan score
3. FibroSURE score
4. APRI score
5. Radiological imaging consistent with cirrhosis (i.e.,
evidence of portal
hypertension)
6. Physical findings or clinical evidence consistent with
cirrhosis as
attested by the prescribing physician
AND meet the criteria specified below
Member is not co-infected with hepatitis B
Member has a documented diagnosis of one of the
following, with
documented viral load taken within 6 months of beginning
therapy:
Chronic Hepatitis C Virus (HCV) infection, genotype 1,
Initiating Therapy: (Max time of approval 10 weeks)
Patient will NOT be taking
concurrently with any of the A documented diagnosis of hepatitis C Genotype 1 AND
concurrent therapy with ribavirin AND Intron-A, Peg-Intron
following:
or Pegasys AND documentation of
Adcirca or Revatio when
used for pulmonary arterial ALL of the specified criteria listed below
Patient has or will receive 4 weeks of PEG-IFN and
hypertension (PAH)
ribavirin prior to starting Victrelis
alfuzosin
Patient has NOT previously failed nor is currently on
carbamazepine
therapy with at reatment regimen that includes a protease
drospirenone (oral
inhibitor (e.g. Victrelis)
contraceptive)
HCV RNA levels will be assessed at weeks 4, 8, 12, and
ergot derivatives (ie,
24 of treatment
dihydroergotamine,
ergonovine,ergotamine,met For Renewal at <10 weeks (Max time of approval 10
weeks)
hylergonovine)
A documented diagnosis of hepatitis C Genotype 1 AND
lovastatin
concurrent therapy with ribavirin AND Intron-A, Peg-Intron
midazolam, oral
or Pegasys AND documented ALL of the following:
phenobarbital
Patient has NOT previously failed with a treatment
phenytoin
regimen that includes a protease inhibitor (e.g. Victrelis)
pimozide
Patient is currently receiving and has not received
rifampin
Victrelis in combination with ribavirin and Intron-A or Pegsimvastatin
Intron or Pegasys for ≥8 weeks after initial 4 weeks of lead
St. John’s wort
triazolam
in therapy with interferon and ribavirin therapy.
CV RNA levels will be assessed at weeks 12, and 24 of
treatment.
For Renewal assessment at treatment week 12 (Max time
Initial
Under some plans,
authorization - including plans that use an
6 weeks,
open or closed
reauthorizatio formulary, Harvoni,
n at 6 weeks Infergen, Intron-A, Olysio,
Pegasys, Peg-Intron/
Redipen/pak, Sovaldi, and
Victrelis are subject to
precertification. If
precertification
requirements apply Aetna
considers these
medications to be
medically necessary for
those members who meet
all of the following
precertification criteria.
There are several brands of
medications for the
treatment of Chronic
Hepatitis C on the market.
For those patients meeting
clinical criteria for
Harvoni as outlined below,
the use of Harvoni will be
required unless the
1 year
Under some plans,
including plans that use an
open or closed
formulary, Harvoni,
Infergen, Intron-A, Olysio,
Pegasys, Peg-Intron/
Redipen/pak, Sovaldi, and
Victrelis are subject to
precertification. If
precertification
requirements apply Aetna
considers these
medications to be
medically necessary for
those members who meet
all of the following
precertification criteria.
There are several brands of
medications for the
treatment of Chronic
Hepatitis C on the market.
For those patients meeting
clinical criteria for
Harvoni as outlined below,
the use of Harvoni will be
required unless the
Under some plans,
For initial
authorization, including plans that use an
open or closed
6 week
maximum for formulary, Harvoni,
Infergen, Intron-A, Olysio,
12 or 24
Pegasys, Peg-Intron/
week
Redipen/pak, Sovaldi, and
regimen, 8
Victrelis are subject to
week
maximum for precertification. If
precertification
8 week
requirements apply Aetna
regimen (in
considers these
order to be
medications to be
eligible for
the maximum medically necessary for
those members who meet
number of
all of the following
tablets,
member must precertification criteria.
meet both
There are several brands of
medications for the
initial and
reauthorizatio treatment of Chronic
Hepatitis C on the market.
n
For those patients meeting
criteria):
clinical criteria for
Harvoni as outlined below,
the use of Harvoni will be
required unless the
Initial
Under some plans,
authorization - including plans that use an
6 weeks,
open or closed
reauthorizatio formulary, Harvoni,
n at 6 weeks Infergen, Intron-A, Olysio,
Pegasys, Peg-Intron/
Redipen/pak, Sovaldi, and
Victrelis are subject to
precertification. If
precertification
requirements apply Aetna
considers these
medications to be
medically necessary for
those members who meet
all of the following
precertification criteria.
There are several brands of
medications for the
treatment of Chronic
Hepatitis C on the market.
For those patients meeting
clinical criteria for
Harvoni as outlined below,
the use of Harvoni will be
required unless the
Under some plans,
Initial
authorization including plans that use an
open or closed
10 weeks,
formulary, Harvoni,
additonal
Infergen, Intron-A, Olysio,
approval
available if
Pegasys, Peg-Intron/
criteria is
Redipen/pak, Sovaldi, and
Victrelis are subject to
met. See
precertification. If
additional
criteria
precertification
requirements apply Aetna
considers these
medications to be
medically necessary for
those members who meet
all of the following
precertification criteria.
There are several brands of
medications for the
treatment of Chronic
Hepatitis C on the market.
For those patients meeting
clinical criteria for
Harvoni as outlined below,
the use of Harvoni will be
required unless the
1
capsule/d
ay
1
capsule/d
ay
12
capsules/
day
ACANYAPRE
A documented trial of one
month of the preferred generic
alternative, benzoyl
peroxide/clindamycin
phosphate gel OR benzoyl
peroxide/erythromycin gel
BENZEFO A documented trial of one
AM-PRE month of the preferred generic
alternative, benzoyl peroxide
foam
ARICEPT- A documented one month trial
PRE
of the preferred generic
donepezil or donepezil ODT
RANEXAPRE
A documented trial of one
month of one agent from one
of the following classes:
calcium channel blockers
(Norvasc, amlopidine, or
diltiazem), OR beta –blockers
(BUT NOT sotalol AF, sotalol,
sorine, Betapace, or Betapace
AF) OR a nitrate
DEPAKOT A documented trial of one
E-PRE
month of the drug's preferred
generic equivalent
500 mg =
3
tablets/da
y
1000 mg =
2
tablets/da
y
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
LAMICTAL XR
QUDEXY XR
TROKENDI XR
KARBINAL ER
NIACOR
MIRAPEX
MIRAPEX ER
REQUIP XL
LAMICTALPRE
QUDEXY- A documented
contraindication or intolerance
PRE
or allergy or failure of an
adequate trial of one month of
the preferred generic
alternative, topiramate
25 mg; 50
QUDEXY- A documented trial of one
month of the preferred generic mg; 100
PRE
alternative, topiramate
mg- 1/day
200 mg 2/day
KARBINAL- A documented trial of one
PRE
week each of a non-sedating
OTC antihistamine (i.e.,
Claritin, Zyrtec) AND the
preferred generic alternative,
carbinoxamine
NIACOR- A documented trial of niacin er
PRE
MIRAPEX- A documented trial of one
PRE
month of the preferred
alternative generic
pramipexole
REQUIP- A documented trial of one
month of the preferred generic
PRE
equivalent ropinirole ER
Combivir
VIRAMUNE
ZERIT
ZIAGEN
CALCITRENE
SORILUX
A documented trial of one
month of the medication's
preferred generic equivalent
alternative
CALCITR adequate trial of one month of
ENE-PRE the preferred alternatives,
Tazorac or calcipotriene OR
Member is pregnant -- a trial
of calcipotriene only
VALTREX
VALTREX- A documented trial of one
PRE
week of the preferred generic
equivalent alternative,
valacyclovir
NEXICLON- A documented trial of one
PRE
month of the preferred generic
alternative, clonidine
LOTREL- A documented trial of one
PRE
month of the preferred generic
equivalent
amlodipine/benazepril
MAXAIR- A documented trial of one
PRE
week of one of the following
preferred alternatives, Proair
HFA or Proventil HFA
NORVASC- A documented trial of one
PRE
month of the preferred generic
equivalent, amlodipine
NEXICLON XR
LOTREL
MAXAIR AUTOHALER
NORVASC
NYMALIZE
CADUET
ANTARA
FENOGLIDE
FIBRICOR
LIPOFEN
LOFIBRA
TRIGLIDE
TRICOR
TRILIPIX
CombivirPRE
NYMALIZE- A documented trial of one
PRE
week of the preferred generic
alternative, nimodipine
CADUET- A documented trial of one
PRE
month of preferred generic
alternative,
amlodipine/atorvastatin
ANTARA- A documented trial of one
PRE
month of the following
preferred generic alternative,
any preferred fenofibrate
product
LOPID
LOPIDPRE
QUARTETTE
QUARTET A documented trial of one
TE-PRE
month of one preferred
generic extended-cycle 91day contraceptive alternative,
i.e. Amethia, Daysee, Jolessa
CLOBEX lotion/shampoo
CLOBEXPRE
CLODERM
CLODER
M-PRE
CUTIVATE
CUTIVATE- A documented trial of two
PRE
weeks of one preferred
alternative generic betamethasone benzoate,
betamethasone dipropionate,
betamethasone valerate,
desonide lotion, desonide,
desoximetasone, fluocinolone
acetonide, fluticasone,
fluocinonide, hydrocortisone
butyrate, hydrocortisone
valerate, prednicarbate, OR
triamcinolone acetonide
LOCOID
LOCOID LIPOCREAM
LOCOIDPRE
DESONATE
VERDESO
DESONAT A documented trial of two
E-PRE
weeks of one preferred
generic desonide alternative,
any dosage form
LUXIQA documented trial of two
PRE
weeks of a preferred generic
betamethasone alternative
OLUXA documented trial of two
PRE
weeks of a preferred generic
clobetasol alternative
LUXIQ
OLUX
OLUX-E
VANOS
1/day
A documented trial of one
month each of the following
preferred generic alternatives,
gemfibrozil AND any preferred
fenofibrate product
A documented trial of two
weeks of the preferred generic
equivalent alternative,
clobetasol lotion OR
clobetasol shampoo
A documented trial of two
weeks of one preferred
alternative generic, any
dosage form - fluocinolone
acetonide, hydrocortisone
valerate, mometasone furoate,
OR triamcinolone acetonide
A documented trial of two
weeks of one preferred
alternative generic betamethasone benzoate,
betamethasone dipropionate,
betamethasone valerate,
desonide lotion, desonide,
desoximetasone, fluocinolone
acetonide, fluticasone,
fluocinonide, hydrocortisone
butyrate, hydrocortisone
valerate, prednicarbate, OR
triamcinolone acetonide
FORFIVO XL
nefazodone
FORFIVO- A documented trial of one
PRE
month of one of budeprion
SR/XL, bupropion/SR/XL,
citalopram, escitalopram,
fluoxetine, fluvoxamine,
paroxetine/sr, mirtazapine,
selfemra, sertraline,
venlafaxine, venlafaxine er
tablet, venlafaxine sr capgeneric alternatives on the
REMERON
REMERON SOLUTAB
REMERO
N-PRE
GLYCATE
25 mg; 50
mg; 100
mg- 1/day
150 mg;
200 mg 2/day
A documented trial of one
month of the preferred generic
equivalent alternative,
mirtazapine or mirtazapine
ODT
GLYCATE- A documented trial of one
PRE
month of the preferred generic
alternative, glycopyrrolate
1/day
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
SIRTURO
SIRTURO-PRE
pulmonary multi-drug resistant tuberculosis
A documented diagnosis of pulmonary multi-drug resistant
tuberculosis (MDR-TB) in adults AND all of the following:
Member has failed or is failing an adequate treatment
regimen* consisting of at least 4 drugs, administered
under directly observed therapy (DOT) (or serum
medication levels have been documented) or an adequate
treatment regimen consisting of at least 4 drugs cannot
otherwise be provided
(Note: Treatment failure is defined as continuous or
recurrently positive sputum cultures during the course of
appropriate antituberculous therapy)
Drug susceptibility testing for first and second-line agents
will be performed and therapy will be initiated in
combination with at least 3 other drugs which have shown
susceptibility
Treatment will be administered under directly observed
therapy (DOT)
An electrocardiogram (ECG) will be obtained before
initiation of treatment, and at least 2, 12, and 24 weeks
after starting treatment
24 weeks
SIRTURO- A documented trial of at least
According to the
PRE
three months of the preferred
manufacturer, 400 mg of
treatment regimen consisting
Sirturo should be taken
of at least 2 of the following:
daily for 2 weeks, then 200
ethambutol
mg of Sirturo should be
taken three times weekly for
pyrazinamide
22 weeks. A quantity of this
Trecator (ethionamide)
drug will be considered
cycloserine
medically necessary as
Paser (aminosalicylic acid)
indicated in the table below
amoxicillin/ clavulanate
if member fulfills above
imipenem/ cilastatin
criteria:
clarithromycin
Zyvox
68 tablets
in 30 days
And 1 of the following:
Avelox (moxifloxacin)
levofloxacin
ofloxacin
And 1 of the following:
RAYOS
RAYOSPRE
ENTOCO
RT-PRE
ENTOCORT EC
amikacin
Trial of prednisone
A documented trial of one
3/day
month of preferred generic
budesonide SR
Trial of raloxifene
hydrochloride
A documented trial of one
month each of any of the
preferred topical generic
alternatives, metronidazole
and sulfacetamide sodium with
sulfur
VELPHOR A documented trial of one
O-PRE
month of one of the preferred
alternatives, calcium acetate,
Fosrenol, Phoslyra, or
Renvela
RENAGEL- A documented trial of one
PRE
month of the preferred
alternative, Renvela
PHOSLO- A documented trial of one
month of the preferred generic
PRE
equivalent, calcium acetate
EVISTA
EVISTAPRE
MIRVASOPRE
MIRVASO
VELPHORO
RENAGEL
PHOSLO
PLAVIX
PLAVIXPRE
VIOKACE
PERTZYE
ULTRESA
VIOKACE- A documented trial of two
PRE
weeks of two preferred
alternative agents: CREON,
ULTRASE, ULTRASE MT,
ZENPEP
VIMOVO- A documented trial of two
PRE
weeks of one preferred
generic nonsteroidal antiinflammatory agent
EXALGO- A documented trial of two days 2/day
PRE
of the preferred generic
alternative, morphine sr cap
24hr
VOLTAREN GEL
VIMOVO
PENNSAID
EXALGO
DUEXIS
For coverage of additional
quantities, member's
treating physician must
request prior authorization
through the Aetna
Pharmacy Management
Precertification Unit.
Additional quantities of the
above medications will be
considered medically
necessary for those
members who meet the
following criterion:
A Documented diagnosis of
cancer and prescription is
written by an oncologist or
pain specialist OR
Member is enrolled in a
hospice program or meets
hospice criteria OR
Member's resident state or
contract state is California
and the member is
terminally ill OR
Patient has signed opioid
agreement in support of
A documented trial of one
month of the preferred generic
equivalent, clopidogrel
A documented trial of two
weeks of one preferred
generic nonsteroidal antiinflammatory agent
BINOSTO- A documented trial of one
PRE
month each of two preferred
alternatives, alendronate AND
Actonel or Actonel with
calcium or Atelvia
BONIVA- A documented trial of one
PRE
month each of two preferred
alternatives, ibandronate AND
Actonel OR Actonel with
Calcium OR Atelvia
PATANOL- A documented trial of one
PRE
week of Pataday
SILENORPRE
A documented trial of 7 days
(one week) each of preferred
generic doxepin AND zolpidem
or zolpidem er
3/day
AMBIEN CR
EDLUAR
ROZEREM
AMBIENPRE
1
tablet/day
SONATA
AMBIENPRE
A documented trial of 7 days
(one week) of the preferred
generic alternative zolpidem or
zolpidem er.
A documented trial of 7 days
(one week) of the preferred
generic alternative zolpidem or
zolpidem er.
ZOLPIMIST
AMBIENPRE
1 bottle/30
day
supply
AMBIEN
AMBIENPRE
A documented trial of 7 days
(one week) of the preferred
generic alternative zolpidem or
zolpidem er.
A documented trial of 7 days
(one week) of the preferred
generic alternative zolpidem or
zolpidem er.
AMRIX
AMRIXPRE
BINOSTO
FOSAMAX PLUS D
BONIVA tablet
PATANOL
SILENOR-PRE
ACTOS
ACTOPLUS MET /XR
DUETACT
Diabetic test strips (all
but those made by
Abbott Diabetes Care or
Lifescan)
PRANDIN
DUEXISPRE
A documented trial of one
week each of two preferred
alternatives (one of which
should be cyclobenzaprine or
cyclobenzaprine er)
ACTOSA documented trial of one
PRE
month of pioglitazone
ACTOPLU A documented trial of one
S-PRE
month of
pioglitazone/metformin
DUETACT- A documented trial of one
PRE
month of
pioglitazone/glimeperide
DTS-PRE Any two preferred blood
glucose test strips:
FREESTYLE, FREESTYLE
INSULINX, FREESTYLE LITE,
ONE TOUCH FAST TAKE,
ONE TOUCH ULTRA, ONE
TOUCH VERIO IQ, PRECISION
QID, PRECISION SOF-TACT
or PRECISION XTRA
PRANDIN- A documented trial of one
PRE
month of the preferred generic
equivalent alternative,
repaglinide
4 tablets
in 28 days
1/day
1/day
5 mg = 4
capsules/
day
10 mg = 2
capsules/
day
5 mg = 2
tablets/da
y
10 mg = 1
tablet/day
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
NOVOLIN 70/30
RELION 70/30
NOVOLIN-PRE
diabetes
Only for Fully-Insured Plans:
A documented diagnosis of type I or type II diabetes AND
A documented contraindication or intolerance or allergy or
failure of an adequate trial of one month of the preferred
alternative Humalog product
INS1-PRE A documented trial of one
month of HUMULIN 70/30
NOVOLIN N
RELION N
NOVOLIN-PRE
diabetes
Only for Fully-Insured Plans:
A documented diagnosis of type I or type II diabetes AND
A documented contraindication or intolerance or allergy or
failure of an adequate trial of one month of the preferred
alternative Humalog product
INS2-PRE A documented trial of one
month of HUMULIN N
diabetes
Only for Fully-Insured Plans:
A documented diagnosis of type I or type II diabetes AND
A documented contraindication or intolerance or allergy or
failure of an adequate trial of one month of the preferred
alternative, Levemir
LANTUSPRE
LANTUS
A documented trial of one
month of the preferred
alternative, Levemir
NOVOLIN R
RELION R
NOVOLIN-PRE
diabetes
Only for Fully-Insured Plans:
A documented diagnosis of type I or type II diabetes AND
A documented contraindication or intolerance or allergy or
failure of an adequate trial of one month of the preferred
alternative Humulin product
INS3-PRE A documented trial of one
month of HUMULIN R
APIDRA
NOVOLOG
NOVOLONG MIX 70/30
APIDRA-PRE
diabetes
Only for Fully-Insured Plans:
A documented diagnosis of type I or type II diabetes AND
A documented contraindication or intolerance or allergy or
failure of an adequate trial of one month of the preferred
alternative Humalog product
APIDRAPRE
(Only for
FullyInsured
Plans)
A documented trial of one
month of the preferred
alternative Humalog product
LYSTEDA
1/day
LYSTEDA- A documented trial of one
month of the generic preferred
PRE
alternative, tranex acid
ULORIC
ULORICPRE
MIGRANAL
A documented trial of one
month of the preferred generic
alternative, allopurinol
For coverage of additional MIGRANA A documented trial of the
quantities, a member's
L-PRE
preferred generic equivalent,
treating physician must
dihydroergotamine nasal
request prior authorization
spray AND three of the
through the Pharmacy
following preferred generic
Management
alternatives for the treatment
Precertification Unit.
of 2 migraine episodes
Additional quantities of
naratriptan
these anti-migraine agents
rizatriptan/ mlt
will be considered medically
sumatriptan
necessary for those
zolmitriptan/ odt
members who meet ANY of
the following criteria:
1box per
30days
Documented diagnosis of
migraine AND member is
receiving prophylactic
migraine therapy OR
Documented diagnosis of
migraine AND member is
being treated by a
headache clinic, neurologist
or specialist OR
SINGULAIR
GENOTROPIN
HUMATROPE
NORDITROPIN
NUTROPIN
NUTROPIN AQ
SAIZEN
TEV-TROPIN
GENOTROPIN-PRE
Growth Hormone Deficiency
1.
Growth Hormone Deficiency in Children and Adolescents:
1 year
Dosage:
SINGULAI A documented one month trial 1/day
R-PRE
of the preferred generic
equivalent, montelukast
GENOTR A documented trial of
OPIN-PRE OMNITROPE
According to available
guidelines, for the first 2 to
3 months dosage
adjustments should be
made after monthly
assessments of serum
levels of IGF-1, and in
response to the presence
of adverse effects, until a
maintenance dose is
achieved. As a condition of
continued authorization,
Aetna requires at least
annual reassessment of
serum levels of IGF-1 in
adults and appropriate
dosage adjustments, as GH
requirements in adults may
decrease with age.
Aetna considers GH replacement medically necessary for
children and adolescents with the following indications:
1.
Idiopathic growth hormone deficiency (GHD):
Aetna considers GH replacement medically necessary for
children and adolescents with GH deficiency, i.e.,
insufficient GH secretion and growth failure who meet all
of the following criteria:
1.
Member has failed to respond to at least 2 standard GH
stimulation tests†, defined as a serum GH level (peak
level) of less than 10 nanograms per milliliter (ng/ml) (20
mU/liter), after stimulation with insulin, levodopa, arginine,
propranolol, clonidine, or glucagon.* (However, 1
abnormal GH test is sufficient for children with defined
CNS pathology, history of irradiation, multiple pituitary
hormone deficiency (MPHD) or a genetic defect affecting
the GH axis); and
Continued Authorization:
INCRELEX
OMNITROPE
SEROSTIM
ZORBTIVE
GENOTROPIN-PRE
Growth Hormone Deficiency
2.
For children who have insufficient GH secretion (fail to
respond to stimulation tests), appropriate imaging
1.
Growth Hormone Deficiency in Children and Adolescents:
Aetna considers GH replacement medically necessary for
children and adolescents with the following indications:
1.
Idiopathic growth hormone deficiency (GHD):
Aetna considers GH replacement medically necessary for
children and adolescents with GH deficiency, i.e.,
insufficient GH secretion and growth failure who meet all
of the following criteria:
1.
Member has failed to respond to at least 2 standard GH
stimulation tests†, defined as a serum GH level (peak
level) of less than 10 nanograms per milliliter (ng/ml) (20
mU/liter), after stimulation with insulin, levodopa, arginine,
propranolol, clonidine, or glucagon.* (However, 1
abnormal GH test is sufficient for children with defined
CNS pathology, history of irradiation, multiple pituitary
hormone deficiency (MPHD) or a genetic defect affecting
the GH axis); and
1 year
The continued medical
necessity of GH therapy is
Dosage:
According to available
guidelines, for the first 2 to
3 months dosage
adjustments should be
made after monthly
assessments of serum
levels of IGF-1, and in
response to the presence
of adverse effects, until a
maintenance dose is
achieved. As a condition of
continued authorization,
Aetna requires at least
annual reassessment of
serum levels of IGF-1 in
adults and appropriate
dosage adjustments, as GH
requirements in adults may
decrease with age.
Continued Authorization:
NORTHERA
NORTHERA-PRE
Orthostatic hypotension
2.
For children who have insufficient GH secretion (fail to
respond to stimulation tests), appropriate imaging
A documented diagnosis of symptomatic neurogenic
orthostatic hypotension (NOH) (i.e., dizziness, lightheadedness, faintness) caused by primary autonomic
failure (i.e., Parkinson's disease, multiple system atrophy,
or pure autonomic failure), dopamine beta-hydroxylase
deficiency, or non-diabetic autonomic neuropathy
The continued medical
necessity of GH therapy is
For coverage of additional NORTHER A documented trial of one
quantities, a member's
A-PRE
month of the preferred generic
treating physician must
alternatives, midodrine or
request prior authorization
fludrocortisone
through the Pharmacy
Management
Precertification Unit. A prior
authorization will be granted
for coverage of additional
quantities of this medication
for those members who
meet the following criteria:
For Northera (100, 200 mg)
Prescriber is titrating dose
(may allow 180 caps in 30
days for 3 months
AURYXIA (FERRIC
CITRA TAB 210MG)
FERRICPRE
A documented trial of one
month of one of the preferred
alternatives, calcium acetate,
sevelamer, Fosrenol, or
Phoslyra.
100,200m
g - 3/day.
300mg 6/day
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
CERDELGA
CERDELGA-PRE
Type 1 Gaucher disease
A documented diagnosis of Type 1 Gaucher disease who
meet both of the following criteria:
1.Member has any of the following signs and symptoms:
a.Moderate to severe anemia (hemoglobin less than or
equal to 11.5 g/dL (adult women) or 12.5 g/dL (adult men)
or less than or equal to 1.0 g/dL or more below the lower
limit of normal for age and sex); or
b.Significant hepatomegaly (liver size 1.25 or more times
normal (1,750 cc in adults)) or splenomegaly (spleen size
5 or more times normal (875 cc in adults)); or
c.Skeletal disease beyond mild osteopenia and
Erlenmeyer flask deformity; or
d.Symptomatic disease, including abdominal or bone pain,
fatigue, exertional limitation, weakness, or cachexia; or
e.Thrombocytopenia (platelet count less than or equal to
120,000/mm3); and
1 year
2/day
2.For eliglustat (Cerdelga) only, member is a CYP2D6
extensive metabolizer (EM), intermediate metabolizer (IM),
or poor metabolizer (PM) (According to the FDA approved
labeling, CYP2D6 ultra-rapid metabolizers (UMs) may not
achieve adequate concentrations of Cerdelga to achieve
a therapeutic effect.)
Known hypersensitivity to
colchicine.
A documented diagnosis of symptomatic gout; AND
The patient has had at least two acute gout attacks in one
year, presence of tophi, or radiographic joint damage,
AND
Planned initiation of urate-lowering pharmacotherapy such
as allopurinol or Uloric (Uloric requires trial/failure or
contraindication to allopurinol)
AND
Member has undertaken appropriate life style
modifications, i.e. limiting of alcohol consumption and
other medications known to precipitate gout attacks have
been discontinued/changed when possible.
History of hypersensitivity to A documented diagnosis of relapsing remitting multiple
natural or recombinant
sclerosis AND documentation of all of the following:
interferon beta or
Discontinuation of other therapies used for treating
peginterferon, or any other multiple sclerosis (Note: This does NOT require having to
component of the
discontinue Ampyra)
A documented contraindication or intolerance or allergy or
formulation.
failure of an adequate trial* of both preferred alternatives,
Copaxone 20 or 40 mg and Rebif
6 months
MITIGARE- Trial of 1 month of Colcrys
PRE
2/day
6 months
PLEGRID A documented trial of both
Y-PRE
preferred alternatives,
Copaxone 20 or 40 mg and
Rebif.
2/28 days;
no QL on
starter kit
MITIGARE
MITIGARE-PRE
Prophylaxis of gout flares in adults
PLEGRIDY INJ
PLEGRIDY-PRE
Treatment of patients with relapsing forms of multiple
sclerosis
AKYNZEO
AKYNZEO-PRE
Prophylaxis of chemotherapy-induced nausea and
vomiting
A documented diagnosis of nausea and vomiting
associated with cancer chemotherapy
1 year
CONTRAVE
Antiobesity -PRE
Obesity
A documented Body Mass Index (BMI) > 30 kg/ m2 OR
A documented BMI > 27 kg/ m2 with one or more of the
following obesity related risk factors considered serious
enough to warrant pharmacotherapy: Hypertension
(systolic blood pressure > 140 mm Hg or diastolic blood
pressure > 90 mm Hg on more than one occasion):
Dyslipidemia LDL cholesterol >/= 160 mg/ dL
HDL cholesterol < 35 mg/ dL
Triglycerides >/= 400 mg/ dL
Type 2 diabetes mellitus
Coronary heart disease
Obstructive sleep apnea
1 year
TRIUMEQ
TRIUMEQ-PRE
HIV infection
A documented diagnosis of human immunodeficiency
virus (HIV).
AND
A documented trial of one month of the medication's
preferred alternatives abacavir, lamivudine, and
dolutegravir.
1 year
For coverage of additional AKYNZEO- A documented trial of 1
quantities, a member's
PRE
generic 5-HT3 receptor
treating physician must
antagonist (granisetron or
request prior authorization
ondansetron) AND Emend.
through the Pharmacy
Management
Precertification Unit.
Additional quantities of
Akynzeo will be considered
medically necessary for
those members who have a
documented chemotherapy
regimen that requires more
than two cycles of
antiemetic per 30 days
TRIUMEQ- A documented trial of one
PRE
month of concomitant use of
the preferred alternatives,
abacavir, lamivudine, and
dolutegravir.
2 tab / 30
days
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria
2015 Aetna Commercial Formulary for Self-Insured Plans_Prior Authorization and Step-Therapy Coverage Criteria