Pharmacy Clinical Policy Bulletins Aetna Non-Medicare Prescription Drug Plan
Subject: Glaucoma agents
Status
Drug
PR
PR-QL
PR-AL
ST
M EX‡
P
acetazolamide (oral)
P
betaxolol
P
brimonidine tartrate
P
carbastat
P
carboptic
P
carteolol
P
dipivefrin
P
epinephrine
P
levobunolol
P
methazolamide (oral)
P
pilocarpine
P
timolol
P
timolol GFS
P
Alphagan-P®(brimonidine)
P
Azopt®(brinzolamide)
P
Betoptic S®(betaxolol)
P
Cosopt™(dorzolamide /timolol)
P
Lumigan®(bimatoprost)
P
Travatan®(travoprost)
P
Trusopt®(dorzolamide)
NP
Betagan®(levobunolol HCl)
NP
Isopto Carpine®(pilocarpine)
NP
Miochol-E®(acetylcholine chloride)
NP
Miostat ®(carbachol)
NP
Propine®(dipivefrin)
NP
Rev-Eyes®(dapiprazole HCl)
NP
Timoptic XE®(timolol)
NP
Timoptic®(timolol)
FE
Betimol®(timolol)
X
FE
Combigan®(brimonidine tartrate-timolol maleate)
X
FE
Iopidine®(apraclonidine)
X
FE
Isopto Carbachol®(carbachol)
X
FE
Istalol®(timolol maleate)
X
FE
metipranolol
X
FE
Optipranolol®(metipranolol)
X
FE
Phospholine®(echothiophate)
X
FE
Pilopine HS®(pilocarpine)
X
FE
Xalatan®(latanoprost))
X
Policy:
Medical Exception Criteria
Betimol, Iopidine, Isopto Carbachol, Combigan, Istalol, metipranolol, Optipranolol, Phospholine, Pilopine HS and Xalatan are currently listed on the Aetna Formulary Exclusions List.* 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 Betimol, Iopidine, Isopto Carbachol, Combigan, Istalol, metipranolol, Optipranolol, Phospholine, Pilopine HS, Rescula and Xalatan to be medically necessary for those members who meet ONE of the following criteria as specified below:
For Isopto Carbachol and Pilopine HS:
A documented:
Contraindication to the preferred alternative agent pilocarpine ophthalmic solution OR,
Intolerance to the preferred alternative agent pilocarpine ophthalmic solution OR,
Failure of an adequate trial of one week of the preferred alternative agent pilocarpine ophthalmic solution.
For metipranolol and Optipranolol:
A documented:
Intolerance to all of the preferred ophthalmic beta blockers OR
Failure of an adequate trial of at least 7 days each of ALL of the ophthalmic beta-blockers listed under preferred alternatives
For Betimol, Combigan, Iopidine, Istalol and Phospholine:
A documented:
Contraindication to one preferred ophthalmic sympathomimetic or beta blocker alternative indicated for the member's condition OR,
Intolerance to one preferred ophthalmic sympathomimetic or beta blocker alternative indicated for the member's condition OR,
Allergy to one preferred ophthalmic sympathomimetic or beta blocker alternative indicated for the member's condition OR,
Failure of an adequate trial of one week of one preferred ophthalmic sympathomimetic or beta blocker alternative indicated for the member's condition.
For Xalatan:
A documented:
Contraindication to one preferred ophthalmic prostaglandin alternative indicated for the member's condition OR,
Intolerance to one preferred ophthalmic prostaglandin alternative indicated for the member's condition OR,
Allergy to one preferred ophthalmic prostaglandin alternative indicated for the member's condition OR,
Failure of an adequate trial of one week of one preferred ophthalmic prostaglandin alternative indicated for the member's condition.
Elinarson TR, Kulin NA, Tingey D, Iskedjian M. Meta-analysis of the effect of latanoprost and brimonidine on intraocular pressure in the treatment of glaucoma. Clin Ther 2000;22(12):1502-15
Katz LJ. Twelve-month evaluation of brimonidine-purite versus brimonidine in patients with glaucoma or ocular hypertension. J Glaucoma. 2002;11:119-26
Coleman AL, Lerner SF, VanDenburg AM, et al. A 3-month comparison of bimatoprost (Lumigan) with timolol/dorzolamide (Cosopt) in patients with glaucoma or ocular hypertension. Ophthalmology 2003;110:2362-8
Kobayashi H, KobayashiK, and Okinami S. A comparison of intraocular pressure-lowering effect of prostaglandin F2-α analogues, latanoprost, and unoprostone isopropyl. J Glaucoma, 2001;10(6):487-92
Parrish RK, Palmberg P, Sheu WP, XLT Study Group. Comparison of latanoprost, bimatoprost, and travoprost in patients with elevated intraocular pressure: a 12-week, randomized, masked-evaluator multicenter study. Am JOphthalmol 2003;135(5):688-703
Noecker RS, Dirks MS, Choplin NT, et al. A six-month randomized clinical trial comparing the intraocular pressure-lowering efficacy of bimatoprost and latanoprost in patients with ocular hypertension or glaucoma.Am J Ophthalmol 2003;135:55-63
Sorensen SJ, Abel SR. Comparison of the ocular beta-blockers. Ann Pharmacother. 1996 Jan;30(1):43-54.
Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
*P = Preferred
FE = Formulary Excluded
NP = Nonpreferred
PR = Precertification
QL = Quantity Limits
AL = Age Limits
ST = Step-Therapy
‡M EX = Medical Exception
*The lists above are subject to change. Not all programs - for example step-therapy, precertification, and quantity limits - are available in all service areas.