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Pharmacy Clinical Policy Bulletins
Aetna Medicare Prescription Drug Plan
Subject: Metabolic Modifiers
Policy:
Under some plans, including plans that use an open or closed formulary, Kuvan and Orfadin are subject to precertification. If precertification requirements apply Aetna considers Kuvan and Orfadin to be medically necessary for those members who meet the following precertification criterion: For Kuvan
Carnitor 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 benefits plans that use a closed formulary, unless a medical exception is granted. Aetna considers Carnitor to be medically necessary for those members who meet the criteria specified below: A. 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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