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2019 Aetna Pharmacy Drug Guide Aetna Premier Plus Plan

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2019 Aetna Pharmacy Drug Guide

Aetna Premier Plus Plan

aetna.com

05.02.414.1 O (12/19)

Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company and its affiliates (Aetna). Aetna Pharmacy Management refers to an internal business unit of Aetna Health Management, LLC. Aetna Pharmacy Management administers, but does not offer, insure or otherwise underwrite the prescription drug benefits portion of your health plan and has no financial responsibility therefor.

2019 Aetna Commercial Plan (Premier Plus)
Table of Contents

INFORMATIONAL SECTION..................................................................................................................7 *5-HT4 RECEPTOR AGONISTS*** - DRUGS FOR THE STOMACH................................................ 18 *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS* - DRUGS FOR THE NERVOUS SYSTEM.................................................................................................................................18 *AGENTS FOR NARCOTIC WITHDRAWAL*** - DRUGS FOR ADDICTION...............................22 *AGENTS FOR OPIOID WITHDRAWAL*** - DRUGS FOR ADDICTION......................................22 *AMEBICIDES* - DRUGS FOR INFECTIONS.....................................................................................22 *AMINO ACIDS*** - DRUGS FOR NUTRITION................................................................................ 22 *AMINOGLYCOSIDES* - DRUGS FOR INFECTIONS.......................................................................22 *AMINOMETHYLCYCLINES*** - DRUGS FOR INFECTIONS....................................................... 22 *ANALGESICS - ANTI-INFLAMMATORY* - DRUGS FOR PAIN AND FEVER............................22 *ANALGESICS - NONNARCOTIC* - DRUGS FOR PAIN AND FEVER.......................................... 26 *ANALGESICS - OPIOID* - DRUGS FOR PAIN AND FEVER.......................................................... 27 *ANDROGENS-ANABOLIC* - HORMONES........................................................................................35 *ANORECTAL AGENTS* - RECTAL PREPARATIONS..................................................................... 36 *ANTHELMINTICS* - DRUGS FOR INFECTIONS............................................................................ 36 *ANTIANGINAL AGENTS* - DRUGS FOR THE HEART................................................................. 37 *ANTIANXIETY AGENTS* - DRUGS FOR THE NERVOUS SYSTEM.............................................38 *ANTIARRHYTHMICS* - DRUGS FOR THE HEART....................................................................... 39 *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* - DRUGS FOR THE LUNGS............ 39 *ANTICOAGULANTS* - DRUGS FOR THE BLOOD..........................................................................44 *ANTICONVULSANTS* - DRUGS FOR THE NERVOUS SYSTEM.................................................. 45 *ANTIDEMENTIA AGENT COMBINATIONS*** - DRUGS FOR THE NERVOUS SYSTEM........50 *ANTIDEPRESSANTS* - DRUGS FOR THE NERVOUS SYSTEM....................................................50 *ANTIDIABETICS* - HORMONES........................................................................................................53 *ANTIDIARRHEALS* - DRUGS FOR THE STOMACH..................................................................... 61 *ANTIDOTES AND SPECIFIC ANTAGONISTS* - DRUGS FOR OVERDOSE OR POISONING...61 *ANTIDOTES* - DRUGS FOR OVERDOSE OR POISONING............................................................ 61 *ANTIEMETICS* - DRUGS FOR THE STOMACH..............................................................................62 *ANTIFUNGALS* - DRUGS FOR INFECTIONS.................................................................................63 *ANTIHEMOPHILIC PRODUCTS - MONOCLONAL ANTIBODIES*** - DRUGS FOR THE BLOOD...................................................................................................................................................... 64 *ANTIHISTAMINES* - DRUGS FOR THE LUNGS.............................................................................64 *ANTIHYPERLIPIDEMICS* - DRUGS FOR THE HEART.................................................................66 *ANTIHYPERTENSIVES* - DRUGS FOR THE HEART.....................................................................68 *ANTI-INFECTIVE AGENTS - MISC.* - DRUGS FOR INFECTIONS...............................................73 *ANTIMALARIALS* - DRUGS FOR INFECTIONS............................................................................ 74 *ANTIMYASTHENIC AGENTS* - DRUGS FOR NERVES AND MUSCLES....................................74 *ANTIMYASTHENIC/CHOLINERGIC AGENTS* - DRUGS FOR NERVES AND MUSCLES.......75 *ANTIMYCOBACTERIAL AGENTS* - DRUGS FOR INFECTIONS................................................ 75 *ANTINEOPLASTIC - BCL-2 INHIBITORS*** - DRUGS FOR CANCER......................................... 76 *ANTINEOPLASTIC - FGFR KINASE INHIBITORS*** - DRUGS FOR CANCER......................... 76 *ANTINEOPLASTIC - TROPOMYOSIN RECEPTOR KINASE INHIBITORS*** - DRUGS FOR CANCER....................................................................................................................................................76 *ANTINEOPLASTIC - XPO1 INHIBITORS*** - DRUGS FOR CANCER.......................................... 76 *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* - DRUGS FOR CANCER......................76 *ANTIPARKINSON AGENTS* - DRUGS FOR THE NERVOUS SYSTEM....................................... 82

TOC-3
*ANTIPSYCHOTICS/ANTIMANIC AGENTS* - DRUGS FOR THE NERVOUS SYSTEM..............84 *ANTIRETROVIRALS ADJUVANTS*** - DRUGS THAT ALTER METABOLISM.........................87 *ANTISENSE OLIGONUCLEOTIDE (ASO) INHIBITOR AGENTS*** - HORMONES....................88 *ANTISEPTICS & DISINFECTANTS* - ANTISEPTICS AND DISINFECTANTS.............................88 *ANTIVIRALS* - DRUGS FOR INFECTIONS..................................................................................... 88 *ANTI-VON WILLEBRAND FACTOR AGENTS*** - DRUGS FOR THE BLOOD.......................... 93 *ASSORTED CLASSES* - VITAMINS AND MINERALS.................................................................... 93 *ATOPIC DERMATITIS - MONOCLONAL ANTIBODIES*** - DRUGS FOR THE LUNGS.......... 96 *BETA BLOCKERS* - DRUGS FOR THE HEART...............................................................................96 *BILE ACID SYNTHESIS DISORDER AGENTS*** - DRUGS FOR THE STOMACH.....................98 *BIOLOGICALS MISC* - BIOLOGICAL AGENTS...............................................................................98 *CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG*** - DRUGS FOR THE NERVOUS SYSTEM........................................................................................................................98 *CALCIUM CHANNEL BLOCKERS* - DRUGS FOR THE HEART..................................................98 *CARDIOTONICS* - DRUGS FOR THE HEART...............................................................................100 *CARDIOVASCULAR AGENTS - MISC.* - DRUGS FOR THE HEART......................................... 100 *CEPHALOSPORINS* - DRUGS FOR INFECTIONS.........................................................................101 *CHEMICALS*....................................................................................................................................... 102 *CIC AGENTS - GUANYLATE CYCLASE-C (GC-C) AGONISTS*** - DRUGS FOR THE STOMACH...............................................................................................................................................102 *CONTRACEPTIVES* - DRUGS FOR WOMEN.................................................................................102 *CORTICOSTEROIDS* - HORMONES................................................................................................111 *COUGH/COLD/ALLERGY* - DRUGS FOR THE LUNGS.............................................................. 112 *CYCLIN-DEPENDENT KINASES (CDK) INHIBITORS*** - DRUGS FOR CANCER.................114 *CYSTIC FIBROSIS AGENT - COMBINATIONS*** - DRUGS FOR THE LUNGS........................ 114 *DERMATOLOGICALS* - DRUGS FOR THE SKIN......................................................................... 114 *DIAGNOSTIC PRODUCTS*................................................................................................................127 *DIGESTIVE AIDS* - DRUGS FOR THE STOMACH........................................................................135 *DIRECT-ACTING P2Y12 INHIBITORS*** - DRUGS FOR THE BLOOD...................................... 136 *DIURETICS* - DRUGS FOR THE HEART........................................................................................136 *DOPAMINE AND NOREPINEPHRINE REUPTAKE INHIBITORS (DNRIS)*** - DRUGS FOR THE NERVOUS SYSTEM......................................................................................................................137 *ENDOCRINE AND METABOLIC AGENTS - MISC.* - HORMONES............................................ 137 *ESTROGENS* - HORMONES............................................................................................................. 142 *ESTROGEN-SELECTIVE ESTROGEN RECEPTOR MODULATOR COMB*** - HORMONES.. 143 *FARNESOID X RECEPTOR (FXR) AGONISTS*** - DRUGS FOR THE LIVER.......................... 143 *FLUOROQUINOLONES* - DRUGS FOR INFECTIONS................................................................. 143 *GASTROINTESTINAL AGENTS - MISC.* - DRUGS FOR THE STOMACH.................................144 *GENERAL ANESTHETICS* - DRUGS FOR PAIN AND FEVER................................................... 147 *GENITOURINARY AGENTS - MISCELLANEOUS* - DRUGS FOR THE URINARY SYSTEM 147 *GLYCOPEPTIDES*** - DRUGS FOR INFECTIONS........................................................................148 *GOUT AGENTS* - DRUGS FOR PAIN AND FEVER...................................................................... 148 *HEMATOLOGICAL AGENTS - MISC.* - DRUGS FOR THE BLOOD........................................... 149 *HEMATOPOIETIC AGENTS* - DRUGS FOR NUTRITION........................................................... 153 *HEMOSTATICS* - DRUGS FOR THE BLOOD.................................................................................155 *HEPATITIS C AGENT - COMBINATIONS*** - DRUGS FOR INFECTIONS............................... 155 *HEREDITARY OROTIC ACIDURIA TREATMENT - AGENTS** - DRUGS THAT ALTER METABOLISM........................................................................................................................................156 *HYPNOTICS* - DRUGS FOR THE NERVOUS SYSTEM.................................................................156 *HYPOPHOSPHATASIA (HPP) AGENTS*** - DRUGS FOR METABOLIC DISEASE...................157

TOC-4 *IBS AGENT - 5-HT4 RECEPTOR PARTIAL AGONISTS*** - DRUGS FOR THE STOMACH.....157 *IBS AGENT - MU-OPIOID RECEPTOR AGONISTS*** - DRUGS FOR THE STOMACH........... 157 *IN VITRO/LOCK ANTICOAGULANTS*** - DRUGS FOR THE BLOOD......................................157 *INSULIN-INCRETIN MIMETIC COMBINATIONS*** - HORMONES..........................................157 *INTEGRIN RECEPTOR ANTAGONISTS*** - DRUGS FOR THE STOMACH.............................157 *INTERLEUKIN ANTAGONISTS*** - DRUGS FOR THE STOMACH...........................................157 *INTERLEUKIN-5 ANTAGONISTS (IGG1 KAPPA)*** - DRUGS FOR THE LUNGS...................157 *INTERLEUKIN-5 ANTAGONISTS (IGG4 KAPPA)*** - DRUGS FOR THE LUNGS...................158 *ISOCITRATE DEHYDROGENASE-1 (IDH1) INHIBITORS*** - DRUGS FOR CANCER........... 158 *ISOCITRATE DEHYDROGENASE-2 (IDH2) INHIBITORS*** - DRUGS FOR CANCER........... 158 *LAXATIVES* - DRUGS FOR THE STOMACH.................................................................................158 *LEPTIN ANALOGUES*** - HORMONES......................................................................................... 159 *LHRH/GNRH AGONIST ANALOG COMBINATIONS*** - HORMONES.................................... 159 *LYMPHOCYTE FUNCTION-ASSOCIATED ANTIGEN-1 (LFA-1) ANTAG*** - DRUGS FOR THE EYE..................................................................................................................................................159 *LYSOSOMAL ACID LIPASE (LAL) DEFICIENCY - AGENTS*** - DRUGS FOR METABOLIC DISEASE..................................................................................................................................................159 *MACROLIDES* - DRUGS FOR INFECTIONS................................................................................. 159 *MEDICAL DEVICES* - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT........160 *MELANOCORTIN RECEPTOR AGONISTS*** - DRUGS FOR THE NERVOUS SYSTEM.........180 *MIGRAINE PRODUCTS* - DRUGS FOR THE NERVOUS SYSTEM............................................ 180 *MINERALS & ELECTROLYTES* - DRUGS FOR NUTRITION.....................................................182 *MIXED ALLERGENIC EXTRACTS*** - BIOLOGICAL AGENTS.................................................183 *MONOBACTAMS*** - DRUGS FOR INFECTIONS.........................................................................184 *MOUTH/THROAT/DENTAL AGENTS* - DRUGS FOR THE MOUTH AND THROAT..............184 *MUCOPOLYSACCHARIDOSIS IV (MPS IV) - AGENTS*** - DRUGS FOR METABOLIC DISEASE..................................................................................................................................................184 *MULTIPLE SCLEROSIS AGENTS - ANTIMETABOLITES*** - DRUGS FOR THE NERVOUS SYSTEM...................................................................................................................................................185 *MULTIPLE VITAMINS W/ MINERALS & FLUORIDE-IRON-FOLIC ACID*** - DRUGS FOR NUTRITION............................................................................................................................................185 *MULTIPLE VITAMINS WITH FOLIC ACID*** - DRUGS FOR NUTRITION............................. 185 *MULTIVITAMINS* - DRUGS FOR NUTRITION............................................................................ 185 *MUSCULOSKELETAL THERAPY AGENTS* - DRUGS FOR MUSCLES, LIGAMENTS, TENDONS, AND BONES.......................................................................................................................192 *NASAL AGENTS - SYSTEMIC AND TOPICAL* - DRUGS FOR THE NOSE................................194 *NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB*** - DRUGS FOR THE HEART............................................................................................................................................195 *NEUROGENIC ORTHOSTATIC HYPOTENSION (NOH) - AGENTS*** - DRUGS FOR THE HEART.....................................................................................................................................................195 *NEUROMUSCULAR AGENTS* - DRUGS FOR NERVES AND MUSCLES................................. 195 *OPHTHALMIC AGENTS* - DRUGS FOR THE EYE....................................................................... 195 *OPHTHALMIC KINASE INHIBITORS - COMBINATIONS*** - DRUGS FOR THE EYE...........202 *OPHTHALMIC NERVE GROWTH FACTORS*** - DRUGS FOR THE EYE................................ 202 *OPHTHALMIC RHO KINASE INHIBITORS*** - DRUGS FOR THE EYE................................... 202 *OREXIN RECEPTOR ANTAGONISTS*** - DRUGS FOR THE NERVOUS SYSTEM................. 202 *OTIC AGENTS* - DRUGS FOR THE EAR........................................................................................ 202 *OXABOROLE-RELATED ANTIFUNGALS - TOPICAL*** - DRUGS FOR THE SKIN............... 203 *OXYTOCICS* - HORMONES.............................................................................................................. 203 *PA ENDONUCLEASE INHIBITORS*** - DRUGS FOR INFECTIONS..........................................203

TOC-5
*PASSIVE IMMUNIZING AGENTS - COMBINATIONS*** - BIOLOGICAL AGENTS................. 203 *PASSIVE IMMUNIZING AGENTS* - BIOLOGICAL AGENTS.......................................................203 *PCSK9 INHIBITORS*** - DRUGS FOR THE HEART..................................................................... 205 *PENICILLINS* - DRUGS FOR INFECTIONS...................................................................................206 *PHARMACEUTICAL ADJUVANTS*.................................................................................................206 *PHOSPHATIDYLINOSITOL 3-KINASE (PI3K) INHIBITORS*** - DRUGS FOR CANCER........206 *PHOSPHODIESTERASE 4 (PDE4) INHIBITORS - TOPICAL*** - DRUGS FOR THE SKIN....... 207 *PHOSPHODIESTERASE 4 (PDE4) INHIBITORS*** - DRUGS FOR PAIN AND FEVER.............207 *PLASMA KALLIKREIN INHIBITORS - MONOCLONAL ANTIBODIES*** - DRUGS FOR THE HEART............................................................................................................................................207 *POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS** - DRUGS FOR CANCER..........207 *POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS*** - DRUGS FOR CANCER......... 207 *POSTHERPETIC NEURALGIA (PHN)/NEUROPATHIC PAIN AGENTS*** - DRUGS FOR THE NERVOUS SYSTEM......................................................................................................................208 *POTASSIUM REMOVING AGENTS*** - DRUGS FOR NUTRITION...........................................208 *PRENATAL MV & MINERALS W/ FA-OMEGA FATTY ACIDS W/O IRON*** - DRUGS FOR NUTRITION............................................................................................................................................208 *PRENATAL MV & MINERALS W/FA WITHOUT IRON*** - DRUGS FOR NUTRITION......... 208 *PROGESTINS* - HORMONES............................................................................................................ 209 *PROTEASE-ACTIVATED RECEPTOR-1 (PAR-1) ANTAGONISTS*** - DRUGS FOR THE BLOOD.....................................................................................................................................................209 *PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.* - DRUGS FOR THE NERVOUS SYSTEM...............................................................................................................................209 *PULMONARY FIBROSIS AGENTS - KINASE INHIBITORS*** - DRUGS FOR CANCER........ 213 *PULMONARY FIBROSIS AGENTS*** - DRUGS FOR THE LUNGS............................................ 213 *PULMONARY HYPERTENSION - PROSTACYCLIN RECEPTOR AGONIST*** - DRUGS FOR THE HEART............................................................................................................................................213 *RESPIRATORY AGENTS - MISC.* - DRUGS FOR THE LUNGS...................................................213 *SCLEROSTIN INHIBITORS*** - HORMONES.................................................................................214 *SEROTONIN MODULATORS*** - DRUGS FOR THE NERVOUS SYSTEM................................214 *SGLT2 INHIBITOR - DPP-4 INHIBITOR COMBINATIONS*** - HORMONES............................ 214 *SINUS NODE INHIBITORS** - DRUGS FOR THE HEART........................................................... 215 *SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE COMB*** - HORMONES........................................................................................................................................... 215 *SPLEEN TYROSINE KINASE (SYK) INHIBITORS*** - DRUGS FOR THE BLOOD...................215 *STEROIDS - MOUTH/THROAT/DENTAL*** - DRUGS FOR THE MOUTH AND THROAT.... 215 *SULFONAMIDES*............................................................................................................................... 215 *TETRACYCLINES* - DRUGS FOR INFECTIONS...........................................................................215 *THYROID AGENTS* - HORMONES................................................................................................. 217 *TOPICAL ANESTHETIC GASES*** - DRUGS FOR THE SKIN..................................................... 218 *TRANSTHYRETIN STABILIZERS*** - HORMONES..................................................................... 218 *TRYPTOPHAN HYDROXYLASE INHIBITORS*** - DRUGS FOR THE STOMACH..................218 *ULCER DRUGS* - DRUGS FOR THE STOMACH...........................................................................218 *URINARY ANTI-INFECTIVES* - DRUGS FOR THE URINARY SYSTEM................................. 221 *URINARY ANTISPASMODICS* - DRUGS FOR THE URINARY SYSTEM.................................221 *VAGINAL PRODUCTS* - DRUGS FOR WOMEN........................................................................... 222 *VASOPRESSORS* - DRUGS FOR THE HEART............................................................................... 223 *VITAMINS* - DRUGS FOR NUTRITION......................................................................................... 223

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  • Picture As Pdfoctober 2020: Reminder Specific Medications

    Picture As Pdfoctober 2020: Reminder Specific Medications

    OCTOBER 2020: REMINDER SPECIFIC MEDICATIONS REQUIRE PRIOR AUTHORIZATION As a part of our continuous efforts to improve the quality of care for our members, Highmark Health Options wanted to send a reminder about the prior authorization process for the following medications. Failure to obtain authorization will result in a claim denial. The prior authorization process applies to all Highmark Health Options Members. Medical necessity criteria for each of the medications listed below are outlined in the specific medication policies available online. To access Highmark Health Options’ medical policies, please paste the following link in your internet browser: https://www.highmarkhealthoptions.com/providers/medication-information.html. PROCEDURE CODES REQUIRING AUTHORIZATION DRUG NAME CODE DESCRIPTION HCPCS DE Medicaid Injection, abatacept, 10 mg (code may be used for Medicare when drug administered under J0129 11/4/2019 the direct supervision of a physician, not for abatacept (Orencia) use when drug is self administered aflibercept (Eylea) Injection, aflibercept, 1 mg J0178 10/1/2018 agalsidase beta (Fabrazyme) Injection, agalsidase beta, 1 mg J0180 6/3/2019 alemtuzumab (Lemtrada) Injection, alemtuzumab, 1 mg J0202 11/4/2019 alglucosidase alfa (Lumizyme) Injection, alglucosidase alfa, (lumizyme), 10 mg J0221 10/1/2018 aprepitant (Cinvanti) Injection, aprepitant, 1 mg J0185 11/4/2019 asparaginase (Erwinaze) Injection, asparaginase (erwinaze), 1,000 iu J9019 11/4/2019 atezolizumab (Tecentriq) Injection, atezolizumab, 10 mg J9022 11/4/2019 Axicabtagene
  • Age-Related Macular Degeneration (Amd)

    Age-Related Macular Degeneration (Amd)

    EUnetHTA Joint Action 3 WP4 Relative effectiveness assessment of pharmaceutical technologies BROLUCIZUMAB FOR THE TREATMENT OF ADULTS WITH NEOVASCULAR (WET) AGE-RELATED MACULAR DEGENERATION (AMD) Project ID: PTJA09 Version 1.0, 12/03/2020 Dec2015 ©EUnetHTA, 2015. Reproduction is authorised provided EUnetHTA is explicitly acknowledged 1 PTJA09 - Brolucizumab for patients with neovascular (wet) AMD DOCUMENT HISTORY AND CONTRIBUTORS Version Date Description V0.1 28/01/2020 First draft V0.2 24/2/2020 Input from dedicated reviewers has been processed V0.3 10/03/2020 Input from medical editor and manufacturer(s) has been processed V1.0 12/03/2020 Final assessment report Disclaimer This Joint Assessment is part of the project / joint action ‘724130 / EUnetHTA JA3’ which has received funding from the European Union’s Health Programme (2014-2020). The content of this Assessment Report represents a consolidated view based on the consensus within the Authoring Team; it cannot be considered to reflect the views of the European Network for Health Technology Assessment (EUnetHTA), EUnetHTA’s participating institutions, the European Commission and/or the Consumers, Health, Agriculture and Food Executive Agency or any other body of the European Union. The European Commission and the Agency do not accept any responsibility for use that may be made of the information it contains. Assessment team Author(s) Finnish Medicines Agency (Fimea), Finland Co-Author(s) Spanish Agency of Medicine and Sanitary Products (AEMPS), Spain Andalusian Unit for Health Technology Assessment (AETSA), Spain Dedicated French National Authority for Health (HAS), France Reviewer(s) Agency for Health Technology Assessment and Tariff System (AOTMiT), Poland Regione Emilia-Romagna (RER), Italy Association of Austrian Social Insurance Institutions (DVSV), Austria Observer HTA Department/EC Ukraine, Ukraine March 2020 EUnetHTA Joint Action 3 WP4 1 PTJA09 - Brolucizumab for patients with neovascular (wet) AMD Further contributors External experts Prof.
  • DRUG COVERAGE GUIDELINES Policy Number: PHARMACY 098.175 T0 Effective Date: June 1, 2018

    DRUG COVERAGE GUIDELINES Policy Number: PHARMACY 098.175 T0 Effective Date: June 1, 2018

    UnitedHealthcare® Oxford Clinical Policy DRUG COVERAGE GUIDELINES Policy Number: PHARMACY 098.175 T0 Effective Date: June 1, 2018 Table of Contents Page Related Policies INSTRUCTIONS FOR USE ......................................................................... 1 Refer to Payment Guidelines below CONDITIONS OF COVERAGE ..................................................................... 1 DESCRIPTION OF SERVICES ..................................................................... 2 DEFINITIONS ......................................................................................... 3 PAYMENT GUIDELINES ............................................................................. 3 POLICY HISTORY/REVISION INFORMATION ............................................ 161 INSTRUCTIONS FOR USE This Clinical Policy provides assistance in interpreting Oxford benefit plans. Unless otherwise stated, Oxford policies do not apply to Medicare Advantage members. Oxford reserves the right, in its sole discretion, to modify its policies as necessary. This Clinical Policy is provided for informational purposes. It does not constitute medical advice. The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies. When deciding coverage, the member specific benefit plan document must be referenced. The terms of the member specific benefit plan document [e.g., Certificate of Coverage (COC), Schedule of Benefits (SOB), and/or Summary Plan Description (SPD)] may differ greatly from the standard benefit plan
  • Treatment of Intractable Diabetic Macular Edema with Pegaptanib Versus Bevacizumab, Both in Combination with Dexamethasone Diana M

    Treatment of Intractable Diabetic Macular Edema with Pegaptanib Versus Bevacizumab, Both in Combination with Dexamethasone Diana M

    Kansas Journal of Medicine 2012 Intractable Diabetic Macular Edema Treatment of Intractable Diabetic Macular Edema with Pegaptanib Versus Bevacizumab, Both in Combination with Dexamethasone Diana M. Leitner, M.D.1, David M. Chacko, M.D., Ph.D.1,2, Philip Twumasi-Ankrah, Ph.D.3, Elizabeth Ablah, Ph.D., M.P.H.3 1University of Kansas School of Medicine-Wichita Department of Internal Medicine 2Grene Vision Group, Wichita, KS 3 University of Kansas School of Medicine-Wichita Department of Preventive Medicine and Public Health Abstract Background . Diabetic macular edema is a significant cause of vision loss, and some patients do not respond optimally to existing treatments. This study compared the response of intractable diabetic macular edema to intravitreal injection of two anti-VEGF drugs, bevacizumab and pegaptanib, both in combination with dexamethasone. Methods . A retrospective chart review was conducted to examine patients from an ophthalmology practice in one year with diabetic macular edema (DME), recurrent or persistent, after focal laser or intravitreal bevacizumab. Patients received bevacizumab/dexamethasone or pegaptanib/dexamethasone. Outcome measures were improvement in best corrected visual activity (converted to LogMAR) and central macular thickness (CRT). Data on adverse effects also were collected. Results. The bevacizumab/dexamethasone group included 25 eyes which had pre-treatment LogMAR = 0.69 ± 0.49 (mean ± SD) and CRT = 419 ± 131. Post-treatment LogMAR was 0.70 ± 0.48 and CRT = 377 ± 107. The pegaptanib/dexamethasone group included 14 eyes; pre- treatment LogMAR = 0.80 ± 0.55 and CRT = 520 ± 108. Post-treatment LogMAR was 0.77 ± 0.49 and CRT = 46 4 ± 106.