Under some plans, including plans that use an open or closed formulary, Helidac, Prevpac, and Pylera are subject to precertification.  If precertification requirements apply, Aetna considers Helidac, Prevpac, Pylera to be medically necessary for those members who meet the following precertification criteria:

According to the manufacturer, the H. pylori drugs Helidac, Prevpac , Pylera 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:

For coverage of additional quantities, a member's treating physician must request prior authorization through the Pharmacy Management Precertification Unit. Additional quantities of H. pylori drugs Helidac, Prevpac, and Pylera will be considered medically necessary for those members who meet the following criterion:

• Member's physician provides documentation (controlled clinical trial) from the peer-reviewed medical literature for use of a higher dose.
  

Helidac and Pylera 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 Helidac and Pylera to be medically necessary for those members who meet any of the following criteria: 

A.  A documented:

• Contraindication to one preferred alternative combination agent indicated for the member's condition OR
• Intolerance to one preferred alternative combination agent indicated for the member's condition OR
•  Allergy to one preferred alternative combination agent indicated for the member's condition OR
• Failure of an adequate trial of one course of one preferred alternative combination agent indicated for the member's condition