Subject: Angiotensin II Receptor Antagonists (AIIRAs, ARBs)/Renin Combinations

Status	Drug	PR	PR-QL	PR-AL	ST	M EX‡
P	losartan		X
P	losartan/hydrochlorothiazide		X
P	Diovan HCT®  (valsartan/hydrochlorothiazide)		X
P	Diovan®  (valsartan)		X
P	Exforge®  (amlodipine and valsartan)		X
P	Exforge HCT®  (amlodipine/valsartan/hydrochlorothiazide)		X
P	Tekamlo®  (aliskiren-amlodipine)		X
P	Tekturna™  (aliskiren fumarate)		X
P	Tekturna HCT™  (aliskiren/hydrochlorothiazide)		X
P	Valturna®  (aliskiren/valsartan)		X
FE	Atacand HCT®  (candesartan/ hydrochlorothiazide)		X		X	X
FE	Atacand®  (candesartan)		X		X	X
FE	Avalide®  (irbesartan/ hydrochlorothiazide)		X		X	X
FE	Avapro®  (irbesartan)		X		X	X
FE	Azor®  (amlodipine besylate-olmesartan medoxomil)		X			X
FE	Benicar HCT™  (olmesartan medoxomil/hydrochlorothiazide)		X		X	X
FE	Benicar®  (olmesartan)		X		X	X
FE	Cozaar®  (losartan)		X		X	X
FE	Hyzaar®  (losartan/hydrochlorothiazide)		X		X	X
FE	Micardis HCT®  (telmisartan/hydrochlorothiazide)		X			X
FE	Micardis®  (telmisartan)		X			X
FE	Teveten HCT®  (eprosartan/hydrochlorothiazide)				X	X
FE	Teveten®  (eprosartan)		X		X	X
FE	Tribenzor®  (olmesartan-amlodipine-hydrochlorothiazide)		X		X	X
FE	Twynsta®  (telmisartan/amlodipine)		X		X	X

Policy:

1. Precertification Criteria

Under some plans, including plans that use an open or closed formulary, Atacand, Atacand HCT, Avalide, Avapro, Azor, Benicar, Benicar HCT, Cozaar, Diovan, Diovan HCT, Exforge, Exforge HCT, Hyzaar, losartan, losartan/hydrochlorothiazide, Micardis, Micardis HCT, Tekamlo, Tekturna, Tekturna HCT, Teveten, Tribenzor, Twynsta and Valturna are subject to precertification.   If precertification requirements apply Aetna considers Atacand, Atacand HCT, Avalide, Avapro, Azor, Benicar, Benicar HCT, Cozaar, Diovan, Diovan HCT, Exforge, Exforge HCT, Hyzaar, losartan, losartan/hydrochlorothiazide, Micardis, Micardis HCT, Tekamlo, Tekturna, Tekturna HCT, Teveten, Tribenzor, Twynsta and Valturna to be medically necessary for those members who meet the following precertification criteria: 



According to the manufacturer, the angiotensin II receptor antagonists, angiotensin II receptor antagonist combination and renin inhibitors can be dosed up to a maximum daily dose at the interval(s) as indicated in the table below. A quantity of each drug will be  considered medically necessary as indicated in the table below:


Drug	Maximum Daily Dose/ Dosing Interval	Dosage Strength	Quantity Limits
Atacand	32 mg/ Once or twice daily	4, 8, 16 mg	Up to 60 tablets in 30 days
Atacand	32 mg/ Once daily	32 mg	None
Atacand HCT	32 mg/ Once or twice daily daily	16/12.5 mg	Up to 60 tablets in 30 days
Atacand HCT	32 mg/ Once daily	32 / 12.5 mg; 32 / 25 mg	None
Avalide	300 mg/ Once daily	150/12.5 mg	Up to 30 tablets in 30 days
Avalide	300 mg/ Once daily	300/12.5 mg	None
Avalide	300 mg/ Once daily	300/ 25 mg	None
Avapro	300 mg/ Once daily	75 mg; 150 mg	Up to 30 tablets in 30 days
Avapro	300 mg/ Once daily	300 mg	None
Azor	10/40 / Once daily	5/20 mg; 5/40 mg; 10/20 mg; 10/40 mg	Up to 30 tablets in 30 days
Benicar	40 mg/ Once daily	5 mg; 20 mg	Up to 30 tablets in 30 days
Benicar	40 mg/ Once daily	40 mg	None
Benicar HCT	40 mg/ Once daily	20/12.5 mg	Up to 30 tablets in 30 days
Benicar HCT	40 mg/ Once daily	40/12.5 mg; 40/25 mg	None
losartan, Cozaar	100 mg/ Once and twice daily	25 mg; 50 mg	Up to 60 tablets in 30 days
losartan, Cozaar	100 mg/ Once daily	100 mg	None
Diovan	320 mg/ Once or twice daily	40, 80, 160 mg	Up to 60 tablets in 30 days
Diovan	320 mg/ Once daily	320 mg	None
Diovan HCT	320 mg/ Once daily	80/12.5 mg	Up to 30 tablets in 30 days
Diovan HCT	320 mg/ Once daily	160/12.5mg; 160/25 mg	Up to 30 tablets in 30 days
Diovan HCT	320 mg/ Once daily	320/ 12.5 mg; 320/ 25 mg	None
Exforge	10/320/ Once daily	5/160 mg; 10/160 mg; 5/320 mg; 10/320 mg	Up to 30 tablets in 30 days
Exforge HCT	10/320/25/ Once daily	5/160/12.5 mg; 5/160/25 mg; 10/160/12.5 mg; 10/160/25 mg; 10/320/25 mg	Up to 30 tablets in 30 days
losartan/ hydrochlorothiazide; Hyzaar	100 mg/ Once daily	50/12.5 mg	Up to 30 tablets in 30 days
losartan/ hydrochlorothiazide; Hyzaar	100 mg/ Once daily	100/12.5; 100/25 mg	None
Micardis	80 mg/ Once daily	20 mg; 40 mg	Up to 30 tablets in 30 days
Micardis	80 mg/ Once daily	80 mg	None
Micardis HCT	80 mg/ Once daily	40/12.5 mg	Up to 30 tablets in 30 days
Micardis HCT	80 mg/ Once daily	80/12.5 mg; 80/25 mg	None
Tekamlo	300 mg/10mg/Once daily	150/5mg; 150/10mg; 300/5mg; 300/10mg	Up to 30 tablets in 30 days
Tekturna	300 mg/ Once daily	150 mg; 300 mg	Up to 30 tablets in 30 days
Tekturna HCT	300 mg- 25mg / Once daily	150/ 12.5 mg; 150/ 25 mg	Up to 30 tablets in 30 days
Tekturna HCT	300 mg- 25mg / Once daily	300/ 12.5 mg; 300/ 25 mg	None
Teveten	800 mg/ Once or twice daily	400 mg	Up to 60 tablets in 30 days
Teveten	800 mg/ Once daily	600 mg	None
Tribenzor	40/10/25 Once daily	20/5/12.5 mg; 40/5/12.5 mg; 40/5/25 mg; 40/10/12.5 mg; 40/10/25 mg;	Up to 30 tablets in 30 days
Twynsta	80 mg-10 mg / Once daily	40/ 5 mg; 40/ 10 mg; 80/ 5 mg; 80/ 10 mg	Up to 30 tablets in 30 days
Valturna	300 mg- 320 mg / Once daily	150/ 160 mg; 300/ 320 mg	Up to 30 tablets in 30 days





For coverage of additional quantities, a member's treating physician must request prior authorization through the Pharmacy Management Precertification Unit. Additional quantities of these angiotensin II receptor antagonists will be considered medically necessary for those members who meet ANY of the following criteria:

• Member requires a dose including half tablets OR 
• Member's dose is being titrated by physician (3-month limit) OR 
• Member has had intolerance to drug administered as a single daily dose OR
• Member has failed the maximum labeled dose AND has a therapeutic response to a higher dose OR
• Member has a diagnosis of heart failure, NYHA class II-IV or left ventricular dysfunction, post-myocardial infarction (Diovan only) OR
• Member's physician provides documentation (controlled clinical trial) from the peer-reviewed medical literature for use of a higher dose.
  



2. Step Therapy Criteria

Under some plans, including plans that use an open or closed formulary, Atacand, Atacand HCT, Avalide, Avapro, Benicar, Benicar HCT, Cozaar, Hyzaar, Teveten, Teveten HCT, Tribenzor and Twynsta are subject to step-therapy.  Aetna considers Atacand, Atacand HCT, Avalide, Avapro, Benicar, Benicar HCT, Cozaar, Hyzaar, Teveten, Teveten HCT, Tribenzor and Twynsta to be medically necessary for those members who meet the following step-therapy criterion:

For Atacand, Atacand HCT, Avalide, Avapro, Benicar, Benicar HCT, Cozaar, Hyzaar, Teveten and Teveten HCT

A documented trial of one month of losartan or losartan-hydrochlorothiazide AND Diovan or Diovan-HCT

For Tribenzor

A documented trial of one month each of two preferred products: amlodipine, losartan, losartan-hydrochlorothiazide, Diovan, Diovan-HCT, or Exforge

OR

A documented trial of one month of Exforge HCT


For Twynsta

A documented trial of one month of Exforge – an alternative on the Preferred Drug List


If it is medically necessary for a member to be treated initially with a medication subject to step-therapy, the member, a person appointed to manage the member’s care, or the member's treating physician may contact the Aetna Pharmacy Management Precertification Unit to request coverage as a medical exception at 1-800-414-2386. (See criteria under section III below).

 



3. Medical Exception Criteria

Azor, Micardis and Micardis HCT 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 Azor, Micardis and Micardis HCT to be medically necessary for those members who meet ANY of the criteria specified below:

Atacand, Atacand HCT, Avalide, Avapro, Benicar, Benicar HCT, Cozaar, Hyzaar, Teveten, Teveten HCT, Tribenzor, and Twynsta are currently listed on the Aetna Formulary Exclusions and Step-Therapy lists.* Therefore, they are 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 these drugs to be medically necessary for those members who meet the criteria specified below:

For Atacand, Atacand HCT, Avalide, Avapro, Azor, Benicar, Benicar HCT, Cozaar, Hyzaar, Micardis, Micardis HCT, Teveten, and Teveten HCT

A documented:

• Contraindication to losartan or losartan-hydrochlorothiazide AND Diovan or Diovan-HCT OR
• Intolerance to losartan or losartan-hydrochlorothiazide AND Diovan or Diovan-HCT OR 
• Allergy to losartan or losartan-hydrochlorothiazide AND Diovan or Diovan-HCT OR 
• Failure of an adequate trial of one month of losartan or losartan-hydrochlorothiazide, AND Diovan or Diovan-HCT
  

For Tribenzor

A documented:

• Contraindication to two preferred products:  amlodipine, losartan, losartan-hydrochlorothiazide, Diovan, Diovan-HCT, Exforge, or Exforge HCT, OR 
• Intolerance to two preferred products:  amlodipine, losartan, losartan-hydrochlorothiazide, Diovan, Diovan-HCT, Exforge, or Exforge HCT OR 
• Allergy to two preferred products:  amlodipine, losartan, losartan-hydrochlorothiazide, Diovan, Diovan-HCT, Exforge, or Exforge HCT OR 
• Failure of an adequate trial of one month each of two preferred alternatives amlodipine, losartan, losartan-hydrochlorothiazide, Diovan, Diovan-HCT, Exforge, OR 
• Failure of an adequate one month trial of Exforge HCT
  

For Twynsta

A documented:

• Contraindication to the preferred alternative Exforge OR 
• Intolerance to the preferred alternative Exforge OR 
• Allergy to the preferred alternative Exforge OR 
• Failure of an adequate trial of one month of the preferred alternative Exforge

Place of Service:

Outpatient

The above policy is based on the following references:

1. DrugPoints® System ( www.statref.com) Thomson Micromedex, Greenwood Village, CO. Updated periodically.
2. AHFS Drug Information® with AHFSfirstReleases®. ( www.statref.com), American Society Of Health-System Pharmacists®, Bethesda, MD. Updated periodically.
3. DRUGDEX® System [Internet database]. Greenwood Village, Colo: Thomson Micromedex. Updated periodically.
4. Drug Facts and Comparisons on-line. (www.drugfacts.com), Wolters Kluwer Health, St. Louis, MO. Updated periodically.
5. PDR® Electronic Library™ [Internet database]. Greenwood Village, Colo: Thomson Micromedex. Updated periodically.
6. Clinical Pharmacology [Internet database]. Gold Standard Inc. Tampa, FL. Updated periodically.
7. Cohn JN, et al. A Randomized Trial of the Angiotensin-Receptor Blocker Valsartan in Chronic Heart Failure. New Eng J Med. Dec 6, 2001; 345(23(:1667-75.
8. Lewis ED, et al.  Renoprotective effect of the Angiotensin-Receptor Antagonist Irbesartan in Patients with Nephropathy Due to Type 2 Diabetes.  New Eng J Med. Sept. 20, 2001; 345(12):851-60.
9. Viberti G, Wheeldon, NM for the MARVAL Investigators.  Microalbuminuria with valsartan in patients with type 2 diabetes mellitus.  A blood pressure independent effect.  Circulation. 2002;106:672-678.
10. Kjeldsen SE, et al. for the LIFE Study Group.  Effects of Losartan on Cardiovascular Morbidity and Mortality in Patients with Isolated Systolic Hypertension and Left Ventricular Hypertrophy, A Losarten Intervention for Endpoint Reduction (LIFE) Substudy. JAMA. 2002;288:1491-1498.
11. Dickstein K, Kjekshus J, and the OPTIMAAL Steering Committee, for the OPTIMAAL Study Group, Effects of losartan and captopril on mortality and morbidity in high-risk patients after acute myocardial infarction: the OPTIMAAL randomised trial. Lancet. 2002;360:752-60.
12. Wong M, et al, for the Val-HeFT Heart Failure Trial Investigators. Valsartan Benefits Left Ventricular Structure and Function in Heart Failure: Val-HeFT Echocaardiographic Study.  J Amer Coll Cardiology. September 2002; 40(5):970-5.
13. Graham MR, Allcock NM.  Irbesartan Substitution for Valsartan or Losartan in Treating Hypertension.  Ann Pharmacother. 2002 December; 36:1840-4.
14. Sicea DA, Weber M. The Losartan Intervention for Endpoint Reduction (LIFE) Trial – Have Angiotensin-Receptor Blockers Come of Age? J Clin Hypertens. 2002; 4(4):301-305.
15. Pitt B et al.  Randomized trial of losartan versus captopril in patients over 65 with heart failure (Evaluation of  Losartan in the Elderly Study, ELITE).  Lancet. 1997; 349:747-52.
16. Kalus JS, White CM.  Amlodipine vs Angiotensin-Receptor Blockers for Nonhypertension Indications. Ann Pharmacother. 2002 November; 2002; 36:1759-66.
17. Levine B.  Effect of eprosartan and enalapril in the treatment of black hypertensive patients: Subgroup analysis of a 26-week, double-blind, multicenter study.  Curr Med Res Opin 1999; 15(1): 25-32.
18. Mckelvie R et al.  Comparison of candesartan, enalapril, and their combination in congestive heart failure: Randomized Evaluation of Strategies for Left Ventricular Dysfunction (RESOLVD pilot study).  Eur Hear J 1998; 19 (Suppl): 133.
19. Song J. Review of Therapeutics, Pharmacologic, Pharmacokinetic and Therapeutic Differences Among Angiotensin II Receptor Antagonists. Pharmacotherapy. 2000;20(2):130-139.
20. Kaplan N. Should New Drugs Be Used Without Outcome Data?  Implications of the ALLHAT and ELITE II. Arch Intern. Med. 2001;161:511-512.
21. Cohn JN, et al.  A Randomized Trial of the Angiotensin-Receptor Blocker Valsartan in Chronic Heart Failure Trial (Val-HeFT).  New Eng J Med. December 6, 2001; 245:1667-75.
22. Thurmann PA, et al. Influence of the Angiotensin II Antagonist Valsartan on Left Ventricular Hypertrophy in Patients with Essential Hypertension. Circulation. 1998:2037-2042.
23. Fogari R et al.  Comparative Efficacy of Losartan and Valsartan in Mild-to-Moderate Hypertension:  Results of 24-Hour Ambulatory Blood Pressure Monitoring. Current Therapeutic Research. April 1999;60(4):195-205.
24. Baruch L, et al.  Augmented Short and Long Term Hemodynamic and Hormonal Effects of an Angiotensin Receptor Blocker Added to Angiotensin Converting Enzyme Inhibitor Therapy in Patients with Heart Failure. Circulation. May 1999;99(20):2658-2664.
25. Mazayev VP, et al. Valsartan in Heart Failure Patients Previously Untreated with an ACE Inhibitor. International Journal of Cardiology. 1998;65:239-246.
26. Burnier M, Brunner HR. Comparative Antihypertensive Effects of Angiotensin II Receptor Antagonists.  Journal of the Amer. Society of Nephrology. April 1999, 10(Suppl 12):S278-S282.
27. Carson PE. Rationale for the Use of Combination Angiotensin-Converting Enzyme Inhibitor/Angiotensin II Receptor Blocker Therapy in Heart Failure. American Heart Journal. September 2000, 140(3).
28. Martineua P, Goulet J.  New Competition in the Realm of Renin-Angiotensin Axis Inhibition; the Angiotensin II Receptor Antagonists in Congestive Heart Failure. Ann Pharmacother. 2001;35:71-84.
29. Struckman DR, Rivey MP. Combined Therapy with an Antiotensin II Receptor Blocker and an Angiotensin-Converting Enzyme Inhibitor in Heart Failure. Ann Pharmacother.  2001;35:242-8.
30. Califf RM, Cohn JN.  Cardiac Protection: The Evolving Role of ARBS, Cardiac Protection: Evolving role of angiotensin receptor blockers. American Heart Journal. 2000 Jan;139(1 Pt 2):S15-22.
31. Pfeffer MA.  Cardiac Protection: The Evolving Role of ARBs, Enhancing Cardiac Protection After Myocardial Infarction: Rationale for Newer Clinical Trials of Angiotensin Receptor Blockers. American Heart Journal. 2000 Jan;139(1 Pt 2):S23-8..
32. Barbe SJ.  Comparison Between Angiotensin Receptor Antagonism and Converting Enzyme Inhibition in Heart Failure.  Differential Acute Effects According to the Renin-Angiotensin System Activation. Basic Res Cardiol. April 1999;94(2):128-35.
33. Pfeffer MA, et al.  Valsartan in Acute Myocardial Infarction Trial (VALIANT). Am Heart J. 2000 Nov;140(5):727-50
34. Konstam MA et al.  Effects of Losartan and captopril on Left Ventricular Volumes in Elderly Patients with Heart Failure: Results of the ELITE Ventricular Function Substudy. American Heart Journal. June 2000;39(6).
35. Brenner BM, et al.  Effects of Losartan on Renal and Cardiovascular Outcomes in Patients with Type 2 Diabetes and Nephropathy. New Eng J Med. September 20, 2001;345:891-9.
36. Miller AB, Srivastava P.  Angiotensin Receptor Blockers and Aldosterone Antagonists in Chronic Heart Failure. Cardiology Clinics. May 2001; 19(2).
37. Palmieri V, et al.  Left Ventricular Function and Hemodynamic Features of Inappropriate Left Ventricular Hypertrophy in Patients with Systemic Hypertension; The LIFE Study. AHJ. May 2001;141(5).
38. Granger CB, et al.  Clinical Investigations, Congestive Heart Failure, Randomized Trial of Candesartan cilexetil in the Treatment of Patients with Congestive Heart Failure and a History of Intolerance to Angiotensin-Converting Enzyme Inhibitors. AHJ. April 2000; 139(4).
39. Kassler-Taub K, et al.  Comparative Efficacy of Two Angiotensin II Receptor Antagonists, Irbesartan and Losartan, in Mild to Moderate Hypertension. Amer J Hypertension. April 1998; 11:445-453.
40. See S.  Angiotensin II Receptor Blockers for the Treatment of Hypertension. Expert Opin Pharmacother. November 2001; 2(11): 1795-804.
41. Warnock DG.  Prevention, Protection, and the Intrarenal Renin-Angiotensin Systems. Semin Nephrol. November 1, 2001; 21(6):593-602.
42. Gradman AH. Comparative Effects of Candesartan cilexetil and Losartan in Patients with Systemic Hypertension, Candesartan Versus Losartan Efficacy Comparison (CANDLE) Study Group. Heart Dis. May-Jun 1999; 1(2):52-7.
43. Kloner RA, Comparative Effects of Candesartan cilexetil and Amlodipine in Patients with Mild Systemic Hypertension.  Comparison of Candesartan and Amlodipine for Safety, Tolerability and Efficacy (CASTLE) Study Investigators. Am J Cardiol. March 15, 2001;87(6):727-31.
44. Elliott WJ.  Losartan Versus Valsartan in the Treatment of Patients with Mild to Moderate Essential Hypertension: Data from a Multicenter, randomized, double-blind, 12-week trial. Clin Ther.  August 1, 2001; 23(8):1166-79.
45. Oparil S, et al.  Comparative Efficacy of Olmesartan, Losartan, Valsartan, and Irbesartan in the Control of Essential Hypertension. J Clin Hypertens. Sep/Oct 2001; 3(5):283-292.
46. Ball K, et al.  A multi-center, double-blind, efficacy, tolerability and safety study of the oral angiotensin II-antagonist Olmesartan medoxomil versus losartan potassium in patients with mild to moderate essential hypertension (Study 866/19). J Hypertension. June 2001; 19(Suppl 1):S49-S56.
47. Yusuf Salim.  From the HOPE to the ONTARGET and the TRANSCEND Studies: Challenges in Improving Prognosis. Am J Cardiol. January 24, 2002; 89(Suppl):18A-26A.
48. Laeis P, Puchler K, Kirch W. The pharmacokinetic and metabolic profile of olmesartan medoxomil limits the risk of clinically relevant drug interaction. J Hypertension. June 2001; 19(suppl 1):S21-S32.
49. Dahlof B, et al.  Cardiovascular morbidity and mortality in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): a randomized trial against atenolol. Lancet. March 23, 2002; 359:995-1003.
50. Mogensen CE, et al.  Randomised controlled trials of dual blockade of renin-angiotensin system in patients with hypertension, microalbuminuria, and non-insulin dependent diabetes: the candesartan and lisinopril microalbuminuria (CALM) study. BMJ. December 9, 2000; 321:1440-4.
51. Jong P, et al.  Angiotensin Receptor Blockers in Heart Failure: Meta-Analysis of Randomized Controlled Trials. J Am Coll Cardiol. February 2, 2002; 39(3):463-70.
52. Conlin PR, et al.  Angiotensin II Antagonists for Hypertension: Are There Differences in Efficacy?  Am J Hypertens. April 2000; 13(4, part 1), 418-426.
53. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, Jones DW, Materson BJ, Oparil S, Wright JT Jr, Roccella EJ. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003 Dec;42(6):1206-52.
54. K/DOQI clinical practice guidelines on hypertension and antihypertensive agents in chronic kidney disease. Am J Kidney Dis 2004 May;43(5 Suppl 1):S1-290.
55. Anderson JL, Adams CD, Antman EM, et al: ACC/AHA 2007 guidelines for the management of patients with unstable angina/non ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction): developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons: endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. Circulation 2007; 116(7):e148-e304.
56. Hunt  SA et al. 2009 focused update incorporated into the ACC/AHA 2005 guidelines for the diagnosis and management of heart failure in adult. JACC. 2009;53:e1-90.

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.

December 01, 2010