Under some plans, including plans that use an open or closed formulary, Balacet, butorphanol nasal spray, Combunox, Darvocet-N, Darvon-N, Demerol, meperidine, Opana,    oxycodone/ibuprofen, pentazocine/acetaminophen, pentazocine/naloxone, propoxyphene HCL, propoxyphene/aspirin/caffeine, propoxyphene napsylate/acetaminophen, Talacen, Talwin NX and Trycet are subject to precertification.   If precertification requirements apply Aetna considers Balacet, butorphanol nasal spray, Combunox, Darvocet-N-100, Darvon-N, Demerol, meperidine, Opana, oxycodone/ibuprofen, pentazocine/acetaminophen, pentazocine/naloxone, propoxyphene HCL, propoxyphene/aspirin/caffeine, propoxyphene napsylate/acetaminophen, Talacen, Talwin NX and Trycet to be medically necessary for those members who meet the following precertification criterion:

A.  Quantity limits:

For Butorphanol nasal spray

 A.  Quantity limits: 2 vials/30 day supply increments

For coverage of additional quantities, a member's treating physician must request prior authorization through the Aetna Pharmacy Management Precertification Unit.  Additional quantities of butorphanol nasal spray will be considered medically necessary for those members who meet the following criterion:

• Member's physician provides documentation (controlled clinical trial) from the peer-reviewed medical literature for use of a higher dose.

For Combunox and oxycodone/ibuprofen

A.   Quantity limits:   5 mg/400 mg - 120 tablets per 30 days

For coverage of additional tablets, member's treating physician must request prior authorization through the Aetna Pharmacy Management Precertification Unit.  Additional quantities of Combunox will be considered medically necessary for those members who meet the following criterion:

• Member's physician provides documentation (controlled clinical trial) from the peer-reviewed medical literature for use of a higher dose

For Opana*

A.    Quantity limits:      Opana - 180 tablets per 30 days
                                      
For coverage of additional tablets, member's treating physician must request prior authorization through the Aetna Pharmacy Management Precertification Unit.  Additional quantities of Opana will be considered medically necessary for those members who meet the following criterion:

• Member's physician provides documentation (controlled clinical trial) from the peer-reviewed medical literature for use of a higher dose
  
    *For a diagnosis of cancer, the quantity limits on Opana do not apply.

B.  For Balacet, Darvocet-N, Darvon-N, Demerol, meperidine, pentazocine/acetaminophen, pentazocine/naloxone, propoxyphene HCL, propoxyphene/aspirin/caffeine, propoxyphene napsylate/acetaminophen, Talacen, Talwin NX and Trycet 

Age limit for members equal to or greater than 65 years of age:

A.  Member has tried and failed alternative drugs that are appropriate in the elderly     
      to treat the condition. OR
B.  Member has been stabilized on the drug for an extended period of time OR
C.  Discontinuation of the drug or change in drug therapy might result in physical and/or                       
      mental impairment OR
D.  Member is in a critical or terminal state and disruption of therapy would be                         
      inappropriate OR
E.  It is medically necessary that the member receive the drug AND Member is being monitored  
      AND Member has no known history of emergency department visits and/or hospital admissions  
     from use of the drug OR
F.  Member received a prescription for the drug from an emergency room physician or from a
     physician in an acute care setting and will only be using the drug for a short duration of time.

Under some plans, including plans that use an open or closed formulary, Alcet, Bancap HC,Capital/Codeine, Combunox, Darvocet-N, Darvon-N, Fioricet/Codeine, Fiorinal/Codeine, Lorcet/Lorcet Plus, Lortab, Lynox, Magnacet, Norco, Opana, Percocet, Percodan, Primalev, Reprexain, Talacen, Trycet, Tylenol #3/#4, Tylox,  Ultracet, Ultram, Vicodin, Vicodin ES, Vicoprofen, Xodol, and Zydone are subject to step-therapy.  Aetna considers, Alcet, Bancap HC, Capital/Codeine, Combunox, Darvocet-N, Darvon-N, Fioricet/Codeine, Fiorinal/Codeine, Lorcet/Lorcet Plus, Lortab, Lynox, Magnacet, Norco, Opana, Percocet, Percodan, Primalev, Reprexain, Talacen, Trycet, Tylenol #3, Tylox,  Ultracet, Ultram, Vicodin, Vicodin ES, Vicoprofen, Xodol and Zydone to be medically necessary for those members who meet the following step-therapy criterion:

For Alcet, Bancap HC,Capital/Codeine, Combunox, Darvocet-N, Fioricet/Codeine, Fiorinal/Codeine, Lorcet/Lorcet Plus, Lortab, Norco, Percocet, Percodan, Talacen, Trycet, Tylenol #3/#4, Tylox, Ultracet, Ultram, Vicodin, Vicodin ES and Vicoprofen

A documented trial of two days of the corresponding covered generic equivalent
 
For  Darvon-N, Reprexain, Xodol and Zydone

A documented trial of two days of a covered generic alternative

For Lynox, Magnacet and Primalev

A documented trial of two days of any covered generic oxycodone/acetaminophen product

For Opana

A documented trial of two days of any covered generic oxycodone product

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.)

Alcet, Bancap HC, Capital/Codeine, Combunox, Darvocet N, Darvon-N, Fioricet/Codeine, Fiorinal/Codeine, Lorcet/Lorcet Plus, Lortab, Lynox, Magnacet, Norco, Opana, Percocet, Percodan, Primalev, Reprexain, Talacen, Trycet, Tylenol #3/#4, Tylox, Ultracet, Ultram, Vicodin, Vicodin ES, Vicoprofen, Xodol, Zamicet and Zydone are Not Covered Part D drugs under the Aetna Medicare Prescription Drug Plan* and are on the Aetna Step-Therapy List.*   Therefore, they are excluded from coverage for members enrolled in prescription drug benefit plans that use a closed formulary or that require step therapy criteria, unless a medical exception is granted.  Aetna considers these to be medically necessary for those members who meet the following criteria:

For Alcet, Bancap HC, Capital/Codeine, Combunox, Darvocet N, Fioricet/Codeine, Fiorinal/Codeine, Lorcet/Lorcet Plus, Lortab, Norco, Percocet, Percodan, Talacen, Trycet, Tylenol #3/#4, Tylox, Ultracet, Ultram, Vicodin, Vicodin ES and Vicoprofen

A.  A documented:

• Contraindication to the corresponding covered generic equivalent OR
• Intolerance to the corresponding covered generic equivalent OR
• Allergy to the corresponding covered generic equivalent OR
• Failure of an adequate trial of two days of the corresponding covered generic equivalent     
   

For Darvon-N, Reprexain, Xodol and Zydone

A.  A documented:

• Contraindication to one covered generic alternative indicated for the member's condition OR
• Intolerance to one covered generic alternative indicated for the member's condition OR
• Allergy to one covered generic alternative indicated for the member's condition OR
• Failure of an adequate trial of two days of one covered generic alternative indicated for the member's condition
  

For Lynox, Magnacet and Primalev

A.  A documented:

• Contraindication to one preferred generic oxycodone/acetaminophen product indicated for the member's condition OR
• Intolerance to one preferred generic oxycodone/acetaminophen product indicated for the member's condition OR
• Allergy to one preferred generic oxycodone/acetaminophen product indicated for the member's condition OR
• Failure of an adequate trial of two days of one preferred generic oxycodone/acetaminophen product indicated for the member's condition
  

For Opana

A.  A documented:

• Contraindication to one preferred generic oxycodone product indicated for the member's condition OR
• Intolerance to one preferred generic oxycodone product indicated for the member's condition OR
• Allergy to one preferred generic oxycodone product indicated for the member's condition OR
• Failure of an adequate trial of two days of one preferred generic oxycodone product indicated for the member's condition

Avinza, Dazidox, Demerol, Dilaudid, Dolophine, Duragesic, Liquicet, Maxidone, MS Contin, Opana inj, Oramorph SR, OxyIR, Panlor DC, Panlor SS, Roxanol, Roxicet solution and 5/500 tablet, Roxicodone, Synalgos DC, Talwin NX, Ultram ER and Zamicet 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 Avinza, Dazidox, Demerol, Dilaudid, Dolophine, Duragesic,  Liquicet, Maxidone, MS Contin, Opana inj, Oramorph SR, OxyIR, Panlor DC, Panlor SS, Roxicet solution and 5/500 tablet, Roxanol, Roxicodone, Synalgos DC, Talwin NX, Ultram ER and Zamicet to be medically necessary for those members who meet the following criteria: 

A.  A documented:

• Contraindication to two preferred alternative narcotic analgesics (single entity or combination products) OR
• Intolerance to two preferred alternative narcotic analgesics (single entity or combination products) OR
• Allergy to two preferred alternative narcotic analgesics (single entity or combination products) OR
• Failure of an adequate clinical trial of two days each of at least two preferred alternative narcotic analgesics (single entity or combination products) OR
• Member is unable to use a covered generic hydrocodone/APAP liquid due to the higher strength of APAP in the covered generic alternative (Liquicet ONLY)