Subject: Urinary Tract Anti-infectives

Status	Drug	PR-B/D	PR	PR-QL	PR-AL	ST	M EX‡	TOC§
C	amoxicillin
C	ampicillin
C	methenamine hippurate
C	nitrofurantoin
C	sulfamethoxazole/trimethoprim
C	trimethoprim
NC	Furadantin®  (nitrofurantoin)						X
NC	Hiprex®  (methenamine)						X
NC	Macrobid®  (nitrofurantoin)						X
NC	Macrodantin®  (nitrofurantoin)						X
NC	Monurol®  (fosfomycin)						X
NC	Primsol®  (trimethoprim)						X
NC	Proloprim®  (trimethoprim)						X
NC	Urex®  (methenamine hippurate)						X

Policy:

1. Medical Exception Criteria

Furadantin, Hiprex, Macrobid, Macrodantin, Monurol, Primsol, Proloprim and Urex 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 Furadantin, Hiprex, Macrobid, Macrodantin, Monurol, Primsol, Proloprim and Urex to be medically necessary for those members who meet any of the following criteria:

For Furadantin, Macrobid, Macrodantin, Monurol, Primsol and Proloprim

A. A documented:

• Contraindication to two preferred alternatives (see table below) indicated for urinary tract infections OR,
• Intolerance to two preferred alternatives (see table below) indicated for urinary tract infections OR,
• Allergy to two preferred alternatives (see table below) indicated for urinary tract infections OR,
• Failure of an adequate trial of two preferred alternatives (see table below) indicated for urinary tract infections:

For Hiprex and Urex

A. A documented:

• Contraindication to  the preferred generic methenamine hippurate alternative OR,
• Intolerance to the preferred generic methenamine hippurate alternative OR,
• Allergy to the preferred generic methenamine hippurate alternative OR
• Failure of an adequate trial of one month of  the preferred generic methenamine hippurate alternative.


 

 

 
 

Special Notes:

Indication	Covered alternatives
Urinary tract infection	amoxicillin amoxicillin/clavulanate ampicillin cefadroxil cefpodoxime proxetil cefuroxime cephalexin cephradine ciprofloxacin nitrofurantoin ofloxacin sulfamethoxazole/trimethoprim (cotrimoxazole) sulfisoxazole trimethoprim

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.
2. AHFS Drug Information® with AHFSfirstReleases®. ( www.statref.com), American Society Of Health-System Pharmacists®, Bethesda, MD. Updated periodically.
3. DRUGDEX® System [Internet database]. Greenwood Village, Colo: Thomson Micromedex. Updated periodically.
4. Drug Facts and Comparisons on-line. (www.drugfacts.com), Wolters Kluwer Health, St. Louis, MO. Updated periodically.
5. PDR® Electronic Library™ [Internet database]. Greenwood Village, Colo: Thomson Micromedex. Updated periodically.
6. Clinical Pharmacology [Internet database]. Gold Standard Inc. Tampa, FL. Updated periodically.
7. 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.
8. Zahn C, Sangl J, Bierman AS, et al.  Potentially inappropriate medication use in the community-dwelling elderly.  JAMA.  2001;286:2823-29.
9. Warren JW, Abrutyn E, Hebel JR, et al. Guidelines for antimicrobial treatment of uncomplicated acute bacterial cystitis and acute pyelonephritis in women. Infectious Diseases Society of America (IDSA). Clin Infect Dis. 1999 Oct;29(4):745-58.
10.  Lutters M, Vogt-Ferrier NB. Antibiotic duration for treating uncomplicated, symptomatic lower urinary tract infections in elderly women. Cochrane Database Syst Rev. 2008 Jul 16;(3):CD001535.
11.  American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 91: Treatment of urinary tract infections in nonpregnant women. Obstet Gynecol. 2008 Mar;111(3):785-94.

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.

January 01, 2009