Under some plans, including plans that use an open or closed formulary, Adalat CC, amlodipine, Cardene, Cardene SR, Dynacirc, Dynacirc CR, felodipine, isradipine, nicardipine, nifedical XL, nifedipine, nifedipine CR/ER, nimodipine, Nimotop, Norvasc, Plendil, Procardia, Procardia XL and Sular are subject to precertification. If precertification requirements apply Aetna considers Adalat CC, amlodipine, Cardene, Cardene SR, Dynacirc, Dynacirc CR, felodipine, isradipine, nicardipine, nifedical XL, nifedipine, nifedipine CR/ER, nimodipine, Nimotop, Norvasc, Plendil, Procardia, Procardia XL and Sular to be medically necessary for those members who meet any of the following precertification criteria:

Adalat CC, amlodipine, Cardene, Cardene SR, Dynacirc, Dynacirc CR, felodipine, isradipine, nicardipine, nifedical XL, nifedipine, nifedipine CR/ER, nimodipine, Nimotop, Norvasc, Plendil, Procardia, Procardia XL and Sular

A.  Quantity limits: According to the manufacturer, the calcium channel blockers (dihydropyridines) can be dosed up to a maximum daily dose at the interval(s) as indicated in the table below.  A quantity of each drug will be considered medically necessary as indicated in the table below:

For coverage of additional quantities, a member's treating physician must request prior authorization through the Aetna Pharmacy Management Precertification Unit.  Additional quantities of calcium channel blockers (dihydropyridines) will be considered medically necessary for those members who meet the following criteria:

• Member requires a dose including half tablets OR
• Member's dose is being titrated by physician (3-month limit) OR
• Member has had intolerance to drug administered as a single daily dose OR 
• Member has failed the maximum labeled dose AND has a therapeutic response to a higher dose OR
• Member's physician provides documentation (controlled clinical trial) from the peer-reviewed medical literature for use of a higher dose.

For nifedipine and Procardia

A. Age Limits --  For members greater than or equal to 65 years of age.

• Member has tried and failed alternative drugs that are appropriate in the elderly to the treat the condition OR
• Member has been stabilized on the drug for an extended period and discontinuation or change in the drug might result in physical and/or mental impairment OR
• Member is in a critical or terminal state and disruption of therapy at this point would be inappropriate AND
• Member is being monitored  AND
• Member has no known history of emergency department visits and/or hospital admissions from use of the drug in the member.
  

Under some plans, including plans that use an open or closed formulary, Adalat CC, Cardene, Procardia and Procardia XL are subject to step-therapy.  Aetna considers Adalat CC, Cardene, Procardia, and Procardia XL to be medically necessary for those members who meet the following step-therapy criterion:

A documented trial of one month of one of the following covered generic alternatives: amlodipine, felodipine, isradipine, nicardipine, nifedical XL or nifedipine cr/er.

If it is medically necessary for a member to be treated initially with a medication subject to step-therapy, the member's treating physician may contact the Aetna Pharmacy Management Precertification Unit to request coverage as a medical exception at 1-800-414-2386. (See criteria under section III below.)

Adalat CC, Cardene, Procardia and Procardia XL are currently listed on the Aetna Step-Therapy List.* If it is medically necessary for a member to be treated initially with one of these medications subject to step-therapy, Aetna considers these drugs to be medically necessary for those members who meet the criteria below:

A. Member has a documented:

• Contraindication to one of the following covered generic alternatives: amlodipine, felodipine, isradipine, nicardipine, nifedical XL or nifedipine cr/er OR,
• Intolerance to one of the following covered generic alternatives: amlodipine, felodipine, isradipine, nicardipine, nifedical XL or nifedipine cr/er OR,
• Allergy to one of the following covered generic alternatives: amlodipine, felodipine, isradipine, nicardipine, nifedical XL or nifedipine cr/er OR,
• Failure of an adequate trial of one month of one of the following covered generic alternatives: amlodipine, felodipine, isradipine, nicardipine, nifedical XL or nifedipine cr/er
    

Cardene SR, Dynacirc, Dynacirc CR, Plendil and Sular are currently Not Covered Part D drugs under the Aetna Medicare Prescription Drug Plan.*  Therefore, they are excluded from coverage for members enrolled in prescription drug benefit plans that use a closed formulary, unless a medical exception is granted.  Aetna considers these drugs to be medically necessary for those members who meet the criteria below:

A.   Member has a documented:

• Contraindication to one covered alternative dihydropyridine calcium channel blocker OR,
• Intolerance to one covered alternative dihydropyridine calcium channel blocker OR,
• Allergy to one covered alternative dihydropyridine calcium channel blocker OR, 
• Failure of an adequate trial of one month of one covered alternative dihydropyridine calcium channel blocker.