Pharmacy Clinical Policy Bulletins Aetna Medicare Prescription Drug Plan
Subject: Cephalosporins
Status
Drug
PR-B/D
PR
PR-QL
PR-AL
ST
M EX‡
TOC§
C
cefaclor, er
C
cefadroxil
C
cefdinir
C
cefepime inj
C
cefotetan/dextrose inj
C
cefpodoxime proxetil
C
cefprozil
C
ceftazidime inj
C
cefuroxime axetil
C
cephalexin
C
ceftriaxone inj
C
Maxipime inj®(cefepime)
NC
Ceclor CD®;Ceclor ®(cefaclor, er)
X
NC
Cedax®(ceftibutin)
X
NC
Ceftin®(cefuroxime)
X
NC
Cefzil®(Cefzil)
X
NC
Duricef®(cefadroxil)
X
NC
Fortaz®(ceftazidime inj)
X
NC
Keflex®(cephalexin)
X
NC
Lorabid®(loracarbef)
X
NC
Omnicef®(cefdinir)
X
NC
Panixine™(cephalexin disperse tab)
X
NC
Raniclor™(cefaclor chew tab)
X
NC
Rocephin®(ceftriaxone inj)
X
NC
Spectracef®(cefditoren pivoxil)
X
NC
Suprax®(cefixime)
X
NC
Vantin®(cefpodoxime)
X
Policy:
Medical Exception Criteria
Cedax, Ceclor, Ceclor CD, Ceftin, Cefzil, Duricef, Fortaz, Keflex, Lorabid, Omnicef, Panixine, Raniclor, Rocephin, Spectracef, Suprax and Vantin 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 Cedax, Ceclor, Ceclor CD, Ceftin, Cefzil, Duricef, Fortaz, Keflex, Lorabid, Omnicef, Panixine, Raniclor, Rocephin, Spectracef, Suprax and Vantin to be medically necessary for those members who meet any of the following criteria:
For Cedax, Ceclor, Ceclor CD, Ceftin, Cefzil, Duricef, Fortaz, Keflex, Lorabid, Omnicef, Panixine, Raniclor, Spectracef, Suprax and Vantin
A. A documented:
Contraindication to two covered alternatives indicated for the member's condition (see table below), one of which was a covered cephalosporin OR,
Intolerance to two covered alternatives indicated for the member's condition (see table below), one of which was a covered cephalosporin OR,
Allergy to two covered alternatives indicated for the member's condition (see table below), one of which was a covered cephalosporin OR,
Documented lack of bacterial sensitivity to two covered alternatives indicated for the member's condition (see table below), one of which was a covered cephalosporin OR,
Failure of an adequate trial of 3 days each of two covered alternatives indicated for the member's condition (see table below), one of which was a covered cephalosporin.
For Rocephin inj
A documented:
Contraindication to the covered generic equivalent OR,
Intolerance to the covered generic equivalent OR,
Allergy to the covered generic equivalent OR
Failure of an adequate trial of 3 days of the covered generic equivalent.
The above policy is based on the following references:
(online through Stat!Ref). Thomson MICROMEDEX, Greenwood Village, Colorado; 2004.
McEvoy GK, editor. AmericanHospitalFormulary Service First Professional Edition (Stat Ref online). Bethesda, Maryland 2004..
Medical Economics, Inc., PDR Electronic Library. Thomson Medical Economics, Montvale, NJ; 2003.
Olin BR, editor. Drugs Facts and Comparisons (electronic online version). St. Louis: J.B. Lippincott Company, 2004.
Medispan Drug Information. 2004.
Product Information Insert. Spectracef TM tablets, Purdue Pharmaceuticals, Stamford, CT August 2003.
Product Information Insert. Cedax capsules,suspensio; BioVail Pharmaceuticals Inc. Morrisville , NC March 2002.
Product Information Insert. Duricef® tablets, suspension; Bristol-Myers Squibb, Princeton, NJ February 2000.
Product Information Insert. Ceftin® tablets, suspension; Glaxo SmithKline, Research Triangle Park, NC September 2003.
Product Information Insert. Cefzil® tablets, suspension; Bristol-Myers Squibb, Princeton, NJ June 2002.
Product Information Insert. Lorabid® capsules, suspension; Eli Lilly and Co., Indianapolis, IN May 2002.
Product Information Insert. Vantin® tablets, suspension; Pharmacia and Upjohn Company, Kalamazoo, Michigan August 2003.
Product Information Insert. Suprax® tablets, suspension; Lederle Pharmacetuical, Pearl River, NY 10965.
Product Information Insert. Omnicef® capsules, suspension; Abbott Laboratories, North Chicago, IL October 2001.
Centers for Disease Control and Prevention. “2002 Guidelines for Treatment of Sexually Transmitted Diseases”. MMWR 2002; 51(RR06); 1-170
Sandford, Jay P., Gilbert, David N., Moellering, R.C. Sande, M.A.: Sandford Guide: Guide to Antimicrobial Therapy, 34st edition, Copyright 2004, Antimicrobial Therapy Inc. Hyde Park, Vt
Guay, David. Formulary Forum: Cefdinir: An Extended-Spectrum Oral Cephalosporin. The Annals of Pharmacotherapy 2000; 34: 1469-77.
Fick DM, Cooper JW, Wade WE, et al. Updating the Beers criteria for potentially inappropriate medication use in older adults.Arch Intern Med. 2003;163:2716-24.
Zahn C, Sangl J, Bierman AS, et al. Potentially inappropriate medication use in the community-dwelling elderly.JAMA. 2001;286:2823-29
Property of Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
*C = Covered, copay amount depends on benefits plan
NC = Not Covered Part D drug
PR-B/D = Precertification review criteria to determine coverage as Part B or Part D
PR = Precertification
QL = Quantity Limits
AL = Age Limits
ST = Step-Therapy
‡M EX = Medical Exception
§TOC = Transition of Coverage
*The lists above are subject to change. Not all programs - for example step-therapy, precertification, and quantity limits - are available in all service areas.