Azasite, Blephamide, FML-S, Iquix, Poly Pred, Pred G, Pred G SOP, Quixin, Tobradex, Zylet and Zymar 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 Azasite, Blephamide, FML-S, Iquix, Poly Pred, Pred G, Pred G SOP, Quixin, Tobradex, Zylet and Zymar to be medically necessary for those members who meet any of the following criteria:

For Azasite, Blephamide, FML-S, Poly Pred, Pred G, Pred G SOP, Tobradex and Zylet

A. A documented:

• Contraindication to two preferred alternatives indicated for the member's condition OR
• Intolerance to two preferred alternatives indicated for the member's condition OR
• Allergy to two preferred alternatives indicated for the member's condition OR
• Lack of bacterial sensitivity to two preferred alternatives indicated for the member's condition OR
• Failure of an adequate trial of three days each of two preferred alternatives indicated for the member's condition OR
• Patient is a poorly controlled glaucoma patient; or patient has elevated intraocular pressure (Zylet-only )

For Iquix, Quixin, Zymar

A.  A documented:

• Contraindication to one preferred ophthalmic fluoroquinolone alternative indicated for the member's condition OR
• Intolerance to one preferred ophthalmic fluoroquinolone alternative indicated for the member's condition OR
• Allergy to one preferred ophthalmic fluoroquinolone alternative indicated for the member's condition OR
• Lack of bacterial sensitivity to one preferred ophthalmic fluoroquinolone alternative indicated for the member's condition OR
• Failure of an adequate trial of three days of one preferred ophthalmic fluoroquinolone alternative indicated for the member's condition