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Pharmacy Clinical Policy Bulletins
Aetna Non-Medicare Prescription Drug Plan
Subject: LMWH

Status Drug PR PR-QL PR-AL ST M EX‡
P enoxaparin          
P fondaparinux          
FE Arixtra®  (fondaparinux)         X
FE Fragmin®  (dalteparin)         X
FE Lovenox®  (enoxaparin)       X X


Policy:

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

    A documented trial of one week of the drug’s generic equivalent enoxaparin

    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 II below.)

  3. Medical Exception Criteria
  4. Lovenox is currently listed on the Aetna Step-Therapy and and Formulary Exclusions Lists.* If it is medically necessary for a member to be treated initially with this medication subject to step-therapy, Aetna considers this drug to be medically necessary for those members who meet the criteria specified below:  

    Arixtra and Fragmin 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 these medications to be medically necessary  for those members who meet the criteria specified below:

    For Arixtra and Lovenox

    • A documented contraindication or intolerance or allergy or failure of an adequate trial of one week of the drug’s generic equivalent

    For Fragmin

    • A documented contraindication or intolerance or allergy or failure of an adequate trial of one week of one of the preferred generics

Place of Service:

Outpatient

The above policy is based on the following references:

1. AHFS Drug Information® with AHFSfirstReleases®. ( www.statref.com), American Society Of Health-System Pharmacists®, Bethesda, MD. Updated periodically.
2. DRUGDEX® System [Internet database]. Greenwood Village, Colo: Thomson Micromedex. Updated periodically.
3. Drug Facts and Comparisons on-line. (www.drugfacts.com), Wolters Kluwer Health, St. Louis, MO. Updated periodically.
4. PDR® Electronic Library™ [Internet database]. Greenwood Village, Colo: Thomson Micromedex. Updated periodically.
5. Clinical Pharmacology [Internet database]. Gold Standard Inc. Tampa, FL. Updated periodically

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.

January 01, 2013
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