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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:

  1. Medical Exception Criteria

    2. 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.



     Examples of AGENTS FOR GLAUCOMA

    Brand Name

    º  Alpha Adrenergic Agonists

     

                                                 ■  APRACLONIDINE HCl

    Iopidine

                                                 ■  BRIMONIDINE TARTRATE

    Alphagan-P

    º  Alpha-Adrenergic Antagonist

     

                                                 ■  DAPIPRAZOLE HCl

    Rev-Eyes

    º  Beta-Adrenergic Blocking Agents

     

                                                 ■  BETAXOLOL HCl

    Betoptic S

                                                 ■  LEVOBUNOLOL HCl

    Betagan

                                                 ■  METIPRANOLOL HCl

    Optipranolol

                                                 ■  TIMOLOL

    Betimol, Timoptic, Istalol, Timpotic XE,

    º  Carbonic Anhydrase Inhibitors

     

                                           ■  BRINZOLAMIDE

    Azopt

                                                 ■  DORZOLAMIDE HYDROCHLORIDE

    Trusopt

    º  Combinations

     

                                      ■  DORZOLAMIDE HCl AND TIMOLOL MALEATE

    Cosopt

    º  Miotics, Direct-Acting

     

                                                 ■  CARBACHOL, TOPICAL

    Iso carbachol;

                                                 ■  PILOCARPINE HCl

    Isopto Carpine; Pilopine HS

    º  Prostaglandin Agonists

     

                                                 ■  BIMATOPROST

    Lumigan

                                                 ■  LATANOPROST

    Xalatan

                                                 ■  TRAVOPROST

    Travatan

    º  Sympathomimetics

     

                                         ■  DIPIVEFRIN HCl (Dipivalyl epinephrine)

    Propine

Place of Service:

Outpatient

The above policy is based on the following references:
  1. Drug Facts and Comparisons on-line. (www.drugfacts.com), Wolters Kluwer Health, St. Louis, MO. 2006.
  2. USP DI® Drug Information For The Health Care Professional - 26th Ed. (online from www.statref.com) Thomson Micromedex, Greenwood Village, CO. 2006.
  3. AHFS Drug Information® with AHFSfirstReleases®. (online from www.statref.com), American Society Of Health-System Pharmacists®, Bethesda, MD. 2006.
  4. DRUGDEX® System: Klasco RK (Ed):DRUGDEX® System. Online edition. Thomson Micromedex, Greenwood Village, CO.
  5. PDR® Electronic Library, Thomson Micromedex, Greenwood Village, Colorado (Edition expires 2006).
  6. 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
  7. Katz LJ. Twelve-month evaluation of brimonidine-purite versus brimonidine in patients with glaucoma or ocular hypertension. J Glaucoma. 2002;11:119-26
  8. 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
  9. 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
  10. 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 J Ophthalmol 2003;135(5):688-703
  11. 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
  12. 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.

November 27, 2007
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