Pharmacy Clinical Policy Bulletins Aetna Medicare Prescription Drug Plan
Subject: Antipsoriatics
Status
Drug
PR-B/D
PR
PR-QL
PR-AL
ST
M EX‡
TOC§
C
calcipotriene solution
C
Tazorac®(tazarotene)
CS
8-MOP®(methoxsalen)
CS
Oxsoralen-UL®(methoxsalen capsule)
CS
Soriatane CK Kit®(acitretin w/moisturizer kit)
NC
Dovonex®(calcipotriene)
X
NC
Oxsoralen®(methoxsalen lotion)
X
NC
Taclonex®(calcipotriene/betamethasone)
X
X
NC
Taclonex Scalp™(calcipotriene/betamethasone)
X
X
NC
Vectical™(calcitriol)
X
X
Policy:
Step Therapy Criteria
Under some plans, including plans that use an open or closed formulary, Taclonex,Taclonex Scalp and Vectical is subject to step-therapy. Aetna considers Taclonex, Taclonex Scalp and Vectical to be medically necessary for those members who meet the following step-therapy criteria:
For Taclonex and Taclonex Scalp
A documented trial of one month of concurrent use of BOTHcalcipotriene solution /Dovonex or Tazorac AND topical betamethasone (either betamethasone dipropionate or betamethasone dipropionate, augmented).
For Vectical
A documented trial of one month of calcipotriene solution or Tazorac.
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 IV below.)
Medical Exception Criteria
Dovonex, Oxsoralen (lotion), Taclonex Scalp, Taclonex and Vectical 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 Dovonex, Oxsoralen (lotion), Taclonex Scalp, Taclonex and Vectical to be medically necessary for those members who meet the following criteria:
For Dovonex and Oxsoralen (lotion)
A. A documented:
Contraindication to one preferred alternative agent indicated for the member's condition OR
Intolerance to one preferred alternative agent indicated for the member's condition OR
Allergy to one preferred alternative agent indicated for the member's condition OR
Failure of an adequate trial of one month of one preferred alternative agent indicated for the member's condition
For Taclonex and Taclonex Scalp
A. A documented:
Contraindication to BOTHcalcipotriene solution /Dovonex or Tazorac ANDbetamethasone (either betamethasone dipropionate or betamethasone dipropionate, augmented ) OR
Intolerance to BOTHcalcipotriene solution /Dovonex or Tazorac ANDbetamethasone (either betamethasone dipropionate or betamethasone dipropionate, augmented ) OR
Allergy to BOTHcalcipotriene solution /Dovonex or Tazorac ANDbetamethasone (either betamethasone dipropionate or betamethasone dipropionate, augmented ) OR
Failure of an adequate trial of one month of concurrent use of BOTHcalcipotriene solution/Dovonex or Tazorac ANDbetamethasone (either betamethasone dipropionate or betamethasone dipropionate, augmented)
For Vectical
A. A documented:
Contraindication to one alternative agent -- calcipotriene solution or Tazorac -- indicated for the member's condition OR
Intolerance to one alternative agent -- calcipotriene solution or Tazorac -- indicated for the member's condition OR
Allergy to one alternative agent -- calcipotriene solution or Tazorac -- indicated for the member's condition OR
Failure of an adequate trial of one month of one alternative agent -- calcipotriene solution or Tazorac -- indicated for the member's condition
Place of Service:
Outpatient
The above policy is based on the following references:
DrugPoints® System ( www.statref.com) Thomson Micromedex, Greenwood Village, CO. Updated periodically.
AHFS Drug Information® with AHFSfirstReleases®. ( www.statref.com), American Society Of Health-System Pharmacists®, Bethesda, MD. Updated periodically.
DRUGDEX® System [Internet database]. Greenwood Village, Colo: Thomson Micromedex. Updated periodically.
Drug Facts and Comparisons on-line. (www.drugfacts.com), Wolters Kluwer Health, St. Louis, MO. Updated periodically.
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.
Lebwohl M, Tyring SK, Hamilton TK, et al: A novel targeted T-cell modulator, efalizumab, for plaque psoriasis. N Engl J Med 2003; 349:2004-2013.
Papp K, Bissonnette R, Krueger JG, et al: The treatment of moderate to severe psoriasis with a new anti-CD11a monoclonal antibody. J Am Acad Dermatol 2001; 45:665-674.
Lebwohl M, Drake L, Menter A, et al: Consensus conference: Acitretin in combination with UVB or PUVA in the treatment of psoriasis. J Am Acad Dermatol 2001; 45:544-553.
Singh F & Weinberg JF: Oral tazarotene and oral pimecrolimus: novel oral therapies in development for psoriasis. J Drugs Dermatol 2004; 3(2):141-143.
Hanauer L: Treatment of plaque psoriasis. N Engl J Med 2001; 345(25):1854.
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
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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