Aldactone, Bumex, Demadex, Dyrenium, Dyazide, Edecrin, Enduron, Inspra, Lasix, Lozol, Midamor, Moduretic, Maxzide, Naturetin, and Zaroxolyn 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 Aldactone, Bumex, Demadex, Dyrenium, Dyazide, Edecrin, Enduron, Inspra, Lasix, Lozol, Midamor, Moduretic, Maxzide, Naturetin, and Zaroxolyn to be medically necessary for those members who meet the criteria as specified below:

For Aldactone, Bumex, Demadex, Dyazide, Enduron, Lasix, Lozol, Maxzide, Midamor, Moduretic and Zaroxolyn

A.   A documented:

• Intolerance to the equivalent preferred generic diuretic OR
• Contraindication to the equivalent preferred generic diuretic OR
• Allergy to the equivalent preferred generic diuretic OR
• Failure of an adequate trial of one month of the equivalent preferred generic diuretic

For Dyrenium, Edecrin and Naturetin

A.    A documented:

• Intolerance to two preferred diuretics indicated for the member's condition OR
• Contraindication to two preferred diuretics indicated for the member's condition OR
• Allergy to two preferred diuretics indicated for the member's condition OR
• Failure of an adequate trial of one month each of two preferred diuretics indicated for the member's condition

For Inspra

A.     A documented:

• Intolerance to the preferred diuretic spironolactone OR
• Contraindication to the preferred diuretic spironolactone OR
• Allergy to the preferred diuretic spironolactone OR
• Failure of an adequate trial of the preferred diuretic spironolactone