Under some plans, including plans that use an open or closed formulary, Penlac and Vusion are subject to precertification.  If precertification requirements apply Aetna considers Penlac and Vusion to be medically necessary for those members who meet ALL of the following precertification criteria: 

For Penlac

A.  Diagnosis of onychomycosis confirmed by either a positive KOH stain (potassium hydroxide), 
      positive PAS stain (para-aminosalicylic acid), or positive fungal culture
      AND

• Member is experiencing pain which limits normal activity OR
• Member has diabetes OR
• Member has an iatrogenically-induced or disease-associated immunosuppression, such as that due to AIDS, antirejection treatment for bone marrow or solid organ transplant, or chemotherapy for cancer OR
• Member has a systemic dermatosis with impaired skin integrity (for example, pemphigus, ichthyosis) OR
• Member has a significant vascular compromise (peripheral)

AND

B.  A documented:

• Contraindication to one systemic (oral) alternative OR
• Intolerance to one systemic (oral) alternative OR
• Failure of an adequate trial of six weeks of one systemic (oral) alternative OR
• Presence of hepatic dysfunction or increased risk for liver disease OR
• Member is female and is pregnant
• Member is < 12 yrs of age

AND

C. Member is NOT receiving a systemic (oral) antifungal agent for onychomycosis at the same time.

For Vusion

A.  A documented diagnosis of diaper dermatitis complicated by candidiasis confirmed by  microscopic evidence of pseudohyphae and/or budding yeast (e.g. KOH)

AND

B. Member is less than or equal to 5 years of age

Bensal HP, Loprox, Ertaczo, Exelderm, Lotrisone, Mentax, Monistat-Derm, Mycostatin, Naftin, Oxistat, Penlac and Vusion 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 Bensal HP, Loprox, Ertaczo, Exelderm, Lamisil spray, Lotrisone, Mentax, Monistat-Derm, Mycostatin, Naftin, Oxistat, Penlac Nail Lacquer and Vusion to be medically necessary for those members who meet any of the following criteria:

For Bensal HP, Loprox, Ertaczo, Exelderm, Lotrisone, Mentax, Monistat-Derm, Mycostatin, Naftin, Oxistat and Vusion

A documented:

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

For Penlac

A documented:

A.  Diagnosis of onychomycosis confirmed by either a positive KOH stain (potassium hydroxide), 
      positive PAS stain (para-aminosalicylic acid), or positive fungal culture
      AND

• Member is experiencing pain which limits normal activity OR
• Member has diabetes OR
• Member has an iatrogenically-induced or disease-associated immunosuppression, such as that due to AIDS, antirejection treatment for bone marrow or solid organ transplant, or chemotherapy for cancer OR
• Member has a systemic dermatosis with impaired skin integrity (for example, pemphigus, ichthyosis) OR
• Member has a significant vascular compromise (peripheral)

AND

B.  A documented:

• Contraindication to one covered systemic (oral) antifungal alternative OR
• Intolerance to one covered systemic (oral) antifungal alternative OR
• Failure of an adequate trial of six weeks of one covered systemic (oral) antifungal alternative OR
• Presence of hepatic dysfunction or increased risk for liver disease OR
• Member is female and is pregnant
• Member is < 12 yrs of age

AND

C. Member is NOT receiving a systemic (oral) antifungal agent for onychomycosis at the same time

For Vusion

A documented:

A.  Diagnosis of diaper dermatitis complicated by candidiasis confirmed by microscopic evidence
      of pseudohyphae and/or budding yeast (e.g. KOH)

AND

B.  Member is less than or equal to 5 years of age

AND

C.  A documented:

• Contraindication to one covered antifungal alternative OR
• Intolerance to one covered antifungal alternative OR
• Allergy to one covered antifungal alternative OR
• Failure of an adequate trial of six weeks of one covered antifungal alternative