Close Window
|
Pharmacy Clinical Policy Bulletins
Aetna Non-Medicare Prescription Drug Plan
Subject: Seborrhea Agents
Policy:
Capitrol, Extina, Ovace, Rosula NS, Sebizon, Tersi foam and Xologel gel/kit are currently listed on the Aetna Formulary Exclusions List.* Therefore, Capitrol , Extina, Ovace, Rosula NS, Sebizon Tersi foam and Xolegel gel/kit 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 Capitrol, Extina, Ovace and Sebizon,Tersi foam Xolegel gel/kit be medically necessary for those members who meet any of the following: A. A documented: Place of Service: Outpatient 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. September 26, 2007 |
|
Additional Information
*P = Preferred
FE = Formulary Excluded NP = Nonpreferred PR = Precertification QL = Quantity Limits AL = Age Limits ST = Step-Therapy ‡M EX = Medical Exception *The lists above are subject to change. Not all programs - for example step-therapy, precertification, and quantity limits - are available in all service areas. |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Company Information | Site Map | Aetna.com Home | Help | Contact Us | Search |
|
Web Privacy Statement | Legal Statement | Privacy Notices | Member Disclosure
|