Under some plans, including plans that use an open or closed formulary, Calan SR, Cardizem CD, Cardizem LA, Cartia xt, Covera HS, Dilacor XR, Diltia xt, diltiazem CD/CR/ER/XT, diltiazem SR, diltiazem extended release beads SR, Isoptin SR, Taztia xt, Tiazac, verapamil CR/ER/SR, Verelan and Verelan PM are subject to precertification.   If precertification requirements apply Aetna considers these medications to be medically necessary for those members who meet any of the following precertification criteria:

A.  Quantity limits: 

According to the manufacturers, the calcium channel blockers (non-dihydropyridines) 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 Aetna Pharmacy Management Precertification Unit.  Additional quantities of these calcium channel blockers (non-dihydropyridines) will be considered medically necessary for those members who meet the following criteria:

• 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 peer-reviewed medical literature for use of a higher dose.
  

Under some plans, including plans that use an open or closed formulary, Calan, Calan SR, Cardizem, Cardizem CD, Covera HS, Dilacor XR, Isoptin SR, Tiazac and Veralan are subject to step-therapy.  Aetna considers Calan, Calan SR, Cardizem, Cardizem CD, Covera HS, Dilacor XR, Isoptin, Isoptin SR, Tiazac and Veralan to be medically necessary for those members who meet the following step-therapy criterion:

A. A documented trial of one month of one of the corresponding generic alternative agents 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, 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.)

Calan, Calan SR, Cardizem, Cardizem CD, Covera HS, Dilacor XR, Isoptin SR, Tiazac and Verelan 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 drugs to be medically necessary for those members who meet the criteria below:  

A.  A documented:

• Contraindication to one covered alternative non-dihydropyridine indicated for the member's condition OR
• Intolerance to one covered alternative non-dihydropyridine indicated for the member's condition OR
• Allergy to one covered alternative non-dihydropyridine indicated for the member's condition OR
• Failure of an adequate trial of one month of one covered alternative non-dihydropyridine indicated for the member's condition

Verelan PM 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 benefit plans that use a closed formulary, unless a medical exception is granted.  Aetna considers this medication to be medically necessary for those members who meet the criteria below:

A.  A documented:

• Contraindication to the covered generic verapamil SR/ER/CR OR
• Intolerance to the covered generic verapamil SR/ER/CR OR
• Allergy to the covered generic verapamil SR/ER/CR OR
• Failure of an adequate trial of one month of the covered generic verapamil SR/ER/CR