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Pharmacy Clinical Policy Bulletins
Aetna Medicare Prescription Drug Plan
Subject: Antilipidemic Agents - Caduet
Policy:
Under some plans, including plans that use an open or closed formulary, Caduet is subject to precertification. If precertification requirements apply Aetna considers Caduet to be medically necessary for those members who meet the following precertification criteria: A. Quantity limits: According to the manufacturer, Caduet 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 Caduet will be considered medically necessary for those members who meet ANY of the following criteria: Under some plans, including plans that use an open or closed formulary, Caduet is subject to step-therapy. Aetna considers Caduet to be medically necessary for those members who meet the step-therapy criteria as specified below: A documented trial of one month of concurrent use of both amlodipine and one of the following: Lipitor, Crestor, simvastatin (at a dose of 40mg/day or higher) OR Vytorin (any dose) -
Caduet is currently a Not Covered Part D drug under the Aetna Medicare Prescription Drug Plan.* Therefore, it is excluded from coverage for members enrolled in prescription drug benefit plans that use a closed formulary, unless a medical exception is granted. Aetna considers Caduet to be medically necessary for those members who meet ANY of the following criteria: OR B. Member is documented to be currently on Caduet OR C. Member is receiving amlodipine and has a documented: Place of Service: Outpatient The above policy is based on the following references: 1. DrugPoints® System ( www.statref.com) Thomson Micromedex, Greenwood Village, CO. Updated periodically. January 01, 2009 |
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Additional Information
*C = Covered, copay amount depends on benefits plan
CS = Covered under Specialty Tier 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. |
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