Note : Many Aetna pharmacy benefit plans exclude coverage of drugs for lifestyle enhancement or performance. Please check benefit plan descriptions for details. Under these plans, sildenafil citrate (Viagra), vardenafil hydrochloride (Levitra) and tadalafil (Cialis) are covered only when required by state regulation or when a plan sponsor has elected an optional rider under the pharmacy plan, or, for indemnity or PPO plans without a separate pharmacy benefit, when the plan sponsor has added optional coverage under the medical plan.
A focal blockage of arterial inflow is demonstrated by duplex Doppler ultrasonography or arteriography; and Diagnostic work-up reveals normal corporeal venous function; and Member is not actively smoking; and Member is not diabetic and has no evidence of systemic vascular occlusive disease; and The erectile dysfunction is the direct result of an arterial injury caused by blunt trauma to the pelvis and/or perineum.
UroLume endourethral prosthesis is also considered medically necessary for the treatment of recurrent bulbar urethral stenoses/strictures when previous therapeutic approaches such as dilation, urethrotomy or urethroplasty have failed (i.e., treatment was ineffective or there is recurrent stricture requiring additional treatment).
Number: 0079.
Treprostinil is available as Orenitram in 0.125 mg, 0.25 mg, 1 mg, and 2.5 mg extended-release tablets. The dose of Orenitram should be increased as tolerated to achieve optimal clinical response. Orenitram is dosed twice a day with food, but the total daily dose can be divided and given three times daily with food. The recommended starting dose is 0.25 mg BID or 0.125mg TID with food. Orenitram dose must be titrated. Titrate by 0.25 mg or 0.5 mg BID or 0.125 mg TID every 3‐4 days as tolerated. The maximum dose is determined by tolerability. In the Freedom M trial, the max dose of Orenitram allowed was 12 mg BID.
Patients should seek medical attention if a sudden decrease or loss of vision or hearing occurs.
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