Subject: Ophthalmic Anti-Allergy Agents

Status	Drug	PR	PR-QL	PR-AL	ST	M EX‡
P	cromolyn
P	Alomide®  (lodoxamide)
P	Optivar ®  (azelastine)
P	Pataday®  (olopatadine)
P	Patanol®  (olopatadine)
FE	Alamast®  (pemirolast)					X
FE	Alocril®  (nedocromil)					X
FE	Elestat®  (epinastine)					X
FE	Emadine®  (emedastine)					X
FE	Livostin®  (levocabastine)					X
Non-prescription (OTC) products (Not covered under the standard benefit plans)
OTC	Zaditor®  (ketotifen fumarate )

Policy:

1. Medical Exception Criteria

Alamast, Alocril, Elestat, Emadine, and Livostin   are currently listed on the Aetna Formulary Exclusions List.* Therefore, they are excluded from coverage for members enrolled in prescription drug benefits plans that use a closed formulary, unless a medical exception is granted.  Aetna considers Alamast, Alocril, Elestat, Emadine,  and Livostin to be medically necessary for those members who meet any of the following criteria:

     A.  A documented:

• Contraindication to one preferred ophthalmic anti-allergy agent OR,
• Intolerance to one preferred ophthalmic anti-allergy agent OR,
• Allergy to one preferred ophthalmic anti-allergy agent OR,
• Failure of an adequate trial of one week of one preferred ophthalmic anti-allergy agent
  

Place of Service:

Outpatient

The above policy is based on the following references:

1. Drug Facts and Comparisons on-line. (www.drugfacts.com), Wolters Kluwer Health, St. Louis, MO. 2006.
2. USP DI® Drug Information For The Health Care Professional - 26th Ed. (online from www.statref.com) Thomson Micromedex, Greenwood Village, CO. 2006.
3. AHFS Drug Information® with AHFSfirstReleases®. (online from www.statref.com), American Society Of Health-System Pharmacists®, Bethesda, MD. 2006.
4. DRUGDEX^® System: Klasco RK (Ed):DRUGDEX^® System. Online edition. Thomson Micromedex, Greenwood Village, CO.
5. PDR^® Electronic Library, Thomson Micromedex, Greenwood Village, Colorado (Edition expires 2006).
6. Berdy GJ, Stoppel JO, Epstein AB.  Comparison of the clinical efficacy and tolerability of olopatadine hydrochloride 0.1% ophthalmic solution and loteprednol etabonate 0.2% ophthalmic suspension in the conjunctival allergen challenge model.  Clin Ther. 2002;24:918-29.
7. Spangler DL, Abelson MB, Ober A, Gomes PJ.  Randomized, double-masked cmparison of olopatadine ophthalmic solution, mometasone furoate monohydrate nasal spray, and fexofenadine hydrochloride tablets using the conjunctival and nasal allergen challenge models.  Clin Ther.  2003;25:2245-67.
8. Abelson MB, Pratt S, Mussoline JF, Townsend D.  One-visit, randomized, placebo-controlled, conjunctival allergen challenge study of scanning and imaging technology for objective quantification of eyelid swelling in the allergic reaction with contralateral use of olopatadine and artificial tears.  Clin Ther.  2003;25:2070-84.
9.  Pataday product information accessed at http://pataday.com/.

 

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.

August 01, 2007