Specialty Pharmacy Clinical Policy Bulletins
Aetna Non-Medicare Prescription Drug Plan
Subject: Bile Acid Synthesis Disorder Agents
Note: The provision of physician samples does not guarantee coverage under the provisions of the pharmacy benefit. All criteria below must be met in order to obtain coverage of each of these medications.
Under some plans, including those that use an open or closed formulary, cholic acid (Cholbam) is subject to precertification. If precertification requirements apply, Aetna considers this medication to be medically necessary for those members who meet the following precertification criteria:
Bile acid synthesis disorder (BASD)
Peroxisomal disorder (PD)
Appendix 1: Bile Acid Synthesis Disorder Subtypes
Appendix 2: Peroxisomal Disorder Subtypes
Place of Service:
The above policy is based on the following references:
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.
March 24, 2021
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