Under some plans, including plans that use an open or closed formulary, Avelox, Cipro, Cipro XR, Factive, Floxin, Levaquin, Maxaquin, Negram, Noroxin, Proquin XR, Tequin, generic ciprofloxacin and ofloxacin are subject to precertification for members less than 10 years of age.  Aetna considers Avelox, Cipro, Cipro XR, Factive, Floxin, Levaquin, Maxaquin, Negram, Noroxin, Proquin XR, Tequin, generic ciprofloxacin and ofloxacin to be medically necessary for those members who meet ANY of the following precertification criteria:

A.  Documented diagnosis of cystic fibrosis 

OR

B.  Documented diagnosis of a life-threatening infection untreatable by other first line antibiotics

OR

C.  Documented diagnosis of recurrent resistant urinary tract infection

OR

D.  Member needs prophylaxis or treatment of anthrax after known or suspected exposure (Cipro/ciprofloxacin only)

OR

E.  Documented diagnosis of complicated UTI or Pyelonephritis due to E. coli and is being used as second line treatment (Cipro/ciprofloxacin^, Negram† only) 

Cipro, Cipro XR, Factive, Floxin, Levaquin, Maxaquin, Negram, Noroxin, Proquin XR and Tequin 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 Cipro, Cipro XR, Factive, Floxin, Levaquin, Maxaquin, Negram, Noroxin, Proquin XR and Tequin to be medically necessary for those members who meet the following criteria:

A.  A documented:

• Contraindication to two covered fluoroquinolones OR
• Intolerance to two covered fluoroquinolones OR
• Lack of bacterial sensitivity to two covered fluoroquinolones OR
• History of failure of an adequate trial of three days each of two covered fluoroquinolones