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

According to the manufacturer, Ranexa can be dosed up to a maximum daily dose at the interval
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 Ranexa will be considered medically necessary for those members who meet ANY of the following criteria:

• Member's dose is being titrated by physician (3-month limit) OR
• Member's physician provides documentation (controlled clinical trial) from the peer-reviewed medical literature for use of a higher dose.
  

Under some plans, including plans that use an open or closed formulary, Ranexa is subject to step-therapy.  Aetna considers Ranexa to be medically necessary for those members who meet the following step-therapy criteria:

Use of Norvasc or amlodipine, a beta-blocker (BUT NOT sotalol AF, sotalol, sorine, Betapace, or Betapace AF), AND a nitrate.

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. (See criteria under section III below.)

Ranexa is currently listed on the Aetna Formulary Exclusions and Step Therapy List.* Therefore, it is 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 Ranexa  to be medically necessary for those members who meet the criteria specified below

A. A documented:

• Contraindication to three preferred alternatives - Norvasc or amlodipine, a beta-blocker (BUT NOT sotalol AF, sotalol, sorine, Betapace, or Betapace AF), AND a nitrate -- indicated for the member's condition OR,
• Intolerance to three preferred alternatives - Norvasc or amlodipine, a beta-blocker (BUT NOT sotalol AF, sotalol, sorine, Betapace, or Betapace AF), AND a nitrate -- indicated for the member's condition OR,
• Allergy to three preferred alternatives -- Norvasc or amlodipine, a beta-blocker (BUT NOT sotalol AF, sotalol, sorine, Betapace, or Betapace AF), AND a nitrate -- indicated for the member's condition OR, 
• Failure of an adequate trial of two-weeks each of the three preferred alternatives -- Norvasc or amlodipine, a beta-blocker (BUT NOT sotalol AF, sotalol, sorine, Betapace, or Betapace AF), AND a nitrate -- indicated for the member's condition.
  
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Beta-Blocker Examples

Nitrate Examples