Under some plans, including plans that use an open or closed formulary, angiotensin-converting enzyme inhibitors Accupril, Aceon, Altace, benazepril, Capoten, captopril, enalapril, fosinopril, lisinopril, Lotensin, Mavik, Monopril, Prinivil, quinapril, Univasc, Vasotec, and Zestril are subject to precertification.  If precertification requirements apply, Aetna considers these to be medically necessary for those members who meet the following precertification criteria:

A.  Quantity limits: 

According to the manufacturer, the angiotensin converting enzyme inhibitors Accupril, Aceon, Altace, benazepril, Capoten, captopril, enalapril, fosinopril, lisinopril, Lotensin, Mavik, Monopril, Prinivil, quinapril, Univasc, Vasotec and Zestril 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 Pharmacy Management Precertification Unit. Additional quantities of these angiotensin-converting enzyme inhibitors will be considered medically necessary for those members who meet ANY of the following criteria:

• Member requires a dose including half tablets OR
• Member's dose is being titrated by physician (3-month limit) OR
• Member has had intolerance to drug administered as a single daily dose OR
• Member has failed the maximum labeled dose AND has a therapeutic response to a higher dose OR
• Member's physician provides documentation (controlled clinical trial) from the peer-reviewed medical literature for use of a higher dose.

Under some plans, including plans that use an open or closed formulary, Aceon, Accupril, Accuretic, Capoten, Capozide, Lotensin, Lotensin HCT, Mavik, Monopril, Monopril HCT, Prinivil, Prinzide, Uniretic, Univasc, Vasotec, Vaseretic, Zestril and Zestoretic are subject to step-therapy.  Aetna considers Aceon, Accupril, Accuretic, Capoten, Capozide, Lotensin, Lotensin HCT, Mavik, Monopril, Prinivil, Prinzide, Univasc, Vasotec, Vaseretic, Zestril and Zestoretic to be medically necessary for those members who meet the following step-therapy criterion:

A documented trial of one month of a covered generic alternative on the Aetna Medicare Preferred Drug List.

If it is medically necessary for a member to be treated initially with a medication subject to step-therapy, or if the member meets transition of coverage (TOC) criteria for a medication subject to TOC, 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 III below.)

Aceon, Accupril, Accuretic, Capoten, Capozide, Lotensin, Lotensin HCT, Mavik, Monopril, Monopril HCT, Prinivil, Prinzide, Uniretic, Univasc, Vasotec, Vaseretic, Zestril and Zestoretic 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 benefit plans that use a closed formulary, unless a medical exception is granted.  Aetna considers Aceon, Accupril, Accuretic, Capoten, Capozide, Lotensin, Lotensin HCT, Mavik, Monopril, Monopril HCT, Prinivil, Prinzide, Uniretic, Univasc, Vasotec, Vaseretic, Zestril or Zestoretic to be medically necessary for those members who meet the criteria as specified below:

For Accupril, Accuretic, Capoten, Capozide, Lotensin, Lotensin HCT, Monopril, Monopril HCT, Prinivil, Prinzide, Vasotec, Vaseretic, Zestril and Zestoretic:

A documented:

• Contraindication to the drug's generic equivalent indicated for the member's condition OR
• Intolerance to the drug's generic equivalent indicated for the member's condition OR
• Allergy to the drug's generic equivalent indicated for the member's condition OR
• Failure of an adequate trial of one month the drug's generic equivalent indicated for the member's condition

For Aceon, Mavik, and Univasc:

A.   A documented:

• Intolerance to two covered angiotensin-converting enzyme inhibitor (ACEI) alternative indicated for the member's condition OR
• Contraindication to two covered angiotensin-converting enzyme inhibitor (ACEI) alternative indicated for the member's condition OR
• Allergy to two covered angiotensin-converting enzyme inhibitor (ACEI) alternative indicated for the member's condition OR
• Failure of an adequate trial of one month of two covered angiotensin-converting enzyme inhibitor (ACEI) alternative indicated for the member's condition. 

     OR

B.  Transition of Coverage:

• Member is within 90 days of his or her effective date of enrollment
• Member is stable on Aceon, Mavik, or Univasc for 30 days or longer

If applicable, quantity limits, age or gender edits will apply.  Approval is valid one year from the date of request.

If the member has been a Medicare member for 91 days or longer and is not residing in a LTC facility then standard precertification, step-therapy, or medical exception criteria will apply.

For Uniretic:

A.   A documented:

• Contraindication to two covered generic combination alternative indicated for the member's condition OR
• Intolerance to two covered generic combination alternative indicated for the member's condition OR
• Allergy to two covered generic combination alternative indicated for the member's condition OR
• Failure of an adequate trial of two month of one covered generic combination alternative indicated for the member's condition. 

OR

B.    Transition of Coverage:

• Member is within 90 days of his or her effective date of enrollment
• Member is stable on Uniretic for 30 days or longer

If applicable, quantity limits, age or gender edits will apply.  Approval is valid one year from the date of request.

If the member has been a Medicare member for 91 days or longer and is not residing in a LTC facility then standard precertification, step-therapy, or medical exception criteria will apply.