Under some plans, including plans that use an open or closed formulary, butorphanol nasal spray , Combunox, Darvocet-N, Darvon Compound, Demerol, meperidine,  pentazocine/acetaminophen, pentazocine/naloxone, propoxyphene HCL, propoxyphene/aspirin/caffeine, propoxyphene napsylate/acetaminophen, Stadol NS, Talacen, Talwin NX, Trycet and Wygesic are subject to precertification.   If precertification requirements apply Aetna considers butorphanol nasal spray, Combunox, Darvocet-N-100, Darvon Compound, Demerol, meperidine, meperidine/promethazine, pentazocine, pentazocine/acetaminophen, pentazocine/naloxone, propoxyphene HCL, propoxyphene/aspirin/caffeine, propoxyphene napsylate/acetaminophen, Stadol NS, Talacen, Talwin NX, Trycet and Wygesic to be medically necessary for those members who meet the following precertification criteria:

A.  Quantity limits:

For butorphanol nasal spray and Stadol NS

Quantity limits:  2 vials/30 day supply increments

For coverage of additional quantities, a member's treating physician must request prior authorization through the Aetna Pharmacy Management Precertification Unit.  Additional quantities of butorphanol nasal spray or Stadol NS will be considered medically necessary for those members who meet the following criterion:

• Member's physician provides documentation (controlled clinical trial) from the peer-reviewed medical literature for use of a higher dose.

For Combunox

Quantity limits:  5 mg/400 mg - 120 tablets per 30 days

For coverage of additional tablets, member's treating physician must request prior authorization through the Aetna Pharmacy Management Precertification Unit.  Additional quantities of Combunox will be considered medically necessary for those members who meet the following criterion:

• Member's physician provides documentation (controlled clinical trial) from the peer-reviewed medical literature for use of a higher dose

B.  Age limits:

For Darvocet-N, Darvon Compound, Demerol, meperidine, pentazocine/acetaminophen, pentazocine/naloxone, propoxyphene HCL, propoxyphene/aspirin/caffeine, propoxyphene napsylate/acetaminophen, Talacen, Talwin NX, Trycet and Wygesic

Age limit for members greater than or equal to 65 years of age:

• Member has tried and failed alternative drugs that are appropriate in the elderly to treat the condition OR
• Member has been stabilized on the drug for an extended period and discontinuation or change in the drug might result in physical and/or mental impairment  OR
• Member is in a critical or terminal state and disruption of therapy at this point would be inappropriate  AND
• Member is being monitored  AND
• Member has no known history of emergency department visits and/or hospital admissions from use of the drug in the member
  

Under some plans, including plans that use an open or closed formulary, Bancap HC,Capital/Codeine, Combunox, Darvocet-N, Fioricet/Codeine, Fiorinal/Codeine, Lorcet/Lorcet HD/Lorcet Plus, Lortab, Norco, Percocet, Percodan, Reprexain, Talacen, Trycet, Tylenol #3, Tylox, Vicodin, Vicodin ES, Vicoprofen, Xodol, and Zydone are subject to step-therapy.  Aetna considers, Bancap HC, Capital/Codeine, Combunox, Darvocet-N, Fioricet/Codeine, Fiorinal/Codeine, Lorcet/Lorcet HD/Lorcet Plus, Lortab, Norco, Percocet, Percodan, Reprexain, Talacen, Trycet, Tylenol #3, Tylox, Vicodin, Vicodin ES, Vicoprofen, Xodol and Zydone to be medically necessary for those members who meet the following step-therapy criterion:

A documented trial of two days of the corresponding covered generic equivalent

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 III below.)

Bancap HC, Capital/Codeine, Combunox, Darvocet N, Fioricet/Codeine, Fiorinal/Codeine, Lorcet/Lorcet HD/Lorcet Plus, Lortab, Norco, Percocet, Percodan, Reprexain, Talacen, Trycet, Tylenol #3, Tylox, Vicodin, Vicodin ES, Vicoprofen, Xodol, and Zydone are currently Not Covered Part D drugs under the Aetna Medicare Prescription Drug Plan* and are on the Aetna Step-Therapy List.*   Therefore, they are excluded from coverage for members enrolled in prescription drug benefit plans that use a closed formulary or that require step therapy criteria, unless a medical exception is granted.  Aetna considers these to be medically necessary for those members who meet the following criteria:

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

Avinza, Darvon Compound, Demerol, Dilaudid inj, Dolophine, Duragesic, Maxidone, MS Contin, Oramorph SR, pentazocine/naloxone, propoxyphene HCl, propoxyphene/aspirin/caffeine, propoxyphene napsylate/APAP, Roxicet, Stadol NS, Synalgos DC, Talwin NX, Ultracet, Ultram, Ultram ER, Vicodin HP and Wygesic 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 Avinza, Darvon Compound, Demerol, Dilaudid inj, Dolophine, Duragesic, Maxidone, MS Contin, Oramorph SR, pentazocine/naloxone, propoxyphene Hcl, propoxyphene/aspirin/caffeine, propoxyphene napsylate/APAP, Roxicet, Stadol NS, Synalgos DC, Talwin NX, Ultracet, Ultram, Ultram ER, Vicodin HP and Wygesic to be medically necessary for those members who meet the following criteria:

A.  A documented:

• Contraindication to two preferred alternative narcotic analgesics (single entity or combination products) OR
• Intolerance to two preferred alternative narcotic analgesics (single entity or combination products) OR
• Allergy to two preferred alternative narcotic analgesics (single entity or combination products) OR
• Failure of an adequate clinical trial of two days each of at least two preferred alternative narcotic analgesics (single entity or combination products).