Under some plans, including plans that use an open or closed formulary, Alupent is subject to precertification.  If precertification requirements apply Aetna considers Alupent to be medically necessary for those members who meet the following precertification criteria:

A. Member, while using Alupent, will be monitored for cardiac adverse effects, such as excessive cardiac stimulation and tachycardia

Alupent, Atrovent HFA, Brethine, Proventil, Serevent Diskus, Ventolin, Ventolin HFA and Xopenex HFA 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 benefits  plans that use a closed formulary, unless a medical exception is granted.  Aetna considers Alupent, Atrovent HFA, Brethine, Proventil, Serevent Diskus, Ventolin, Ventolin HFA and Xopenex HFA to be medically necessary for those members who meet ANY of the following criteria:
 
For Atrovent HFA and Brethine

A. Member has a documented:

• Contraindication to one preferred alternative OR,
• Allergy to one preferred alternative OR,
• Intolerance to one preferred alternative OR,
• Failure of an adequate trial of one week of one preferred alternative for the member's condition.
   

For Alupent inhaler

A.    Member, while using Alupent, will be monitored for cardiac adverse effects, such as excessive cardiac stimulation and tachycardia

AND

B.  Member has a documented:

• Contraindication to two inhaled covered alternatives indicated for the member's condition OR
• Allergy to two inhaled covered alternatives indicated for the member's condition OR
• Intolerance to two inhaled covered alternatives indicated for the member's condition OR
• Failure of an adequate trial of one week each of two inhaled covered alternatives indiacted for the member's condition.
   

For Proventil and Ventolin 

A.    Member has a documented:

• Contraindication to two inhaled covered alternatives indicated for the member's condition OR
• Allergy to two inhaled covered alternatives indicated for the member's condition OR
• Intolerance to two inhaled covered alternatives indicated for the member's condition OR
• Failure of an adequate trial of one week each of two inhaled covered alternatives indicated for the member's condition.
   

For Ventolin HFA and Xopenex HFA
           
A.     Member has a documented:

• Contraindication to one covered alternative albuterol CFC-free inhaler OR
• Allergy to one covered alternative albuterol CFC-free inhaler OR
• Intolerance to one covered alternative albuterol CFC-free inhaler OR
• Failure of an adequate trial of one week of one covered alternative albuterol CFC-free inhaler.

For Serevent Diskus
 
A.     A documented:

• Contraindication to one inhaled corticosteroid (Aerobid, Aerobid M, Asmanex, Azmacort, Flovent, Pulmicort Flexhaler/Turbuhaler, QVAR, etc) indicated for the member's condition OR,
• Intolerance to one inhaled corticosteroid (Aerobid, Aerobid M, Asmanex, Azmacort, Flovent, Pulmicort Flexhaler/Turbuhaler, QVAR, etc) indicated for the member's condition OR,
• Allergy to one inhaled corticosteroid (Aerobid, Aerobid M, Asmanex, Azmacort, Flovent, Pulmicort Flexhaler/Turbuhaler, QVAR, etc)  indicated for the member's condition OR,
• Failure of an adequate trial of one month of one inhaled corticosteroid (Aerobid, Aerobid M, Asmanex, Azmacort, Flovent, Pulmicort Flexhaler/Turbuhaler, QVAR, etc) indicated for the member's condition OR,
• If member has diagnosis of COPD (Chronic obstructive pulmonary disease), Serevent may be approved if member has a contraindication, intolerance, allergy or failure of an adequate trial of one week of the covered alternative Foradil.