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