Cephalosporins cefaclor cefaclor SRcefadroxilcefuroximecephalexincephradine Cedax (ceftibuten) Lorabid (loracarbef) Omnicef (cefdinir) Spectracef (cefditoren pivoxil)

Fluoroquinolones Avelox (moxifloxacin) PR < 10 yr old

Cipro (ciprofloxacin) PR < 10 yr old

Cipro XR (ciprofloxacin) PR < 10 yr old

Macrolides erythromycin base erythromycin EC pelletserythromycin ethylsuccinate erythromycin stearate Biaxin (clarithromycin) Biaxin XL (clarithromycin) Zithromax (azithromycin)

Penicillins amoxicillin amoxicillin/K clavulanateampicillin cloxacillin dicloxacillin penicillin VK Augmentin ES

(amoxicillin/K clavulanate)Augmentin XR

(amoxicillin/K clavulanate)

Sulfonamidessulfamethoxazole/trimethoprim sulfisoxazole sulfisoxazole/erythromycin

Tetracyclines doxycycline hyclate PR 8 yr old

doxycycline pellets PR 8 yr old

minocycline PR 8 yr old

tetracycline PR 8 yr old

Uppercase = Brand-name medicationlowercase = Generic medication

PR = Precertification required under most plans

Intranasal Decongestantsoxymetazoline HCl (e.g. Afrin, Dristan, others)phenylephrine (e.g. Neo-Synephrine, Vicks, others)

Oral Decongestantsphenylephrine (AH-chew D)pseudoephedrine (Sudafed, Actifed, others)

Oral Antihistaminesdiphenhydramine (e.g. Benadryl, others)clemastine fumarate (e.g. Tavist Allergy, others)chlorpheniramine maleate (e.g. Chlor-Trimeton Allergy, others)loratadine (e.g. Alavert, others)

Antitussives dextromethorphan (Robitussin Cough, Rondec DM, Benylin DM)Expectorantsguaifenesin (e.g. Robitussin, Scot-Tussin, generics)

Multiple combination products are availablewithin the Sudafed, Benadryl, Robitussin, andTriaminic product families.

If viral infection is suspected, consider Nonprescription Cough/Cold Medications^^Nonprescription medications are not covered under Aetna pharmacy benefits plans.

Formulary

FORMULARY EXCLUSIONS

CephalosporinsCefzil (cefprozil)

Duricef (cefadroxil)

Vantin (cefpodoxime)

FluoroquinolonesFloxin (ofloxacin) PR < 10 yr old

Levaquin (levofloxacin) PR < 10 yr old

Maxaquin (lomefloxacin) PR < 10 yr old

MacrolidesDynabac (dirithromycin)PCE (erythromycin base dispertabs)Tao (troleandomycin)

PenicillinsGeocillin (carbenicillin)

TetracyclinesAdoxa (doxycycline) PR 8 yr old

FORMULARY ALTERNATIVES

Cephalosporinscefuroxime

cefadroxilcephalexin

CedaxOmnicef

FluoroquinolonesAvelox PR < 10 yr old

Cipro PR < 10 yr old

MacrolideserythromycinBiaxinBiaxin XL

Penicillinsamoxicillin

Tetracyclinesdoxycycline PR 8 yr old

Noroxin (norfloxacin) PR < 10 yr old

Tequin (gatifloxacin) PR < 10 yr old

Zagam (sparfloxacin) PR < 10 yr old

Lorabid

cephradine

Spectracef (cefditoren pivoxil)

Cipro XR PR < 10 yr old

Zithromax

ampicillinSpectrobid (bacampicillin)

Quick Guide to Antibiotics2004 Aetna Formulary

05.03.869.1-INT (07/04) 2004 Aetna Inc.

All member care and related decisions are the sole responsibility of the physician, and this information does not dictate or control physicians clinicaldecisions regarding the appropriate care of members. Pharmacy benefits are not limited to the drugs on the formulary. Drugs on the Formulary ExclusionsList may be excluded from coverage under some pharmacy benefit plans unless a medical exception is obtained. Many drugs on the formulary are sub-ject to manufacturer rebate arrangements between Aetna and the manufacturer of those drugs. The formulary is subject to change.

In accordance with state law, California HMO members enrolled in a closed formulary benefits plan who are receiving coverage for medications that aremoved to the Formulary Exclusions List, and California HMO members who are receiving coverage for medications that are added to the Precertificationor Step-Therapy Lists will continue to have those medications covered, for as long as the treating physician continues to prescribe the medication.

Not all programs, for example step-therapy, precertification and quantity limits, are available in all service areas.

For members in Texas, additions to the 2004 formulary will be effective no later than January 1, 2004. In accordance with state law, full-risk membersin Texas who are receiving coverage for medications that are removed from the formulary during the plan year will continue to have those medicationscovered at the same benefit level until their plans renewal date.

The term Precertification here means the utilization review process to determine whether the requested service, procedure, prescription drug or medicaldevice meets the companys clinical criteria for coverage. It does not mean precertification as defined by Texas law, as a reliable representation of pay-ment of care or services to fully insured HMO and PPO members.

Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies. The Aetna companiesthat offer, underwrite or administer benefit coverage include Aetna Health Inc., Aetna Health of California Inc., Aetna Health of the Carolinas Inc., AetnaHealth of Illinois Inc., Aetna Health Insurance Company of Connecticut, Aetna Health Insurance Company of New York, Corporate Health InsuranceCompany and/or Aetna Life Insurance Company. Aetna Pharmacy Management refers to an internal business unit of Aetna Health Management, LLC.

This card may not be used after 12/31/04.

To submit medical exception or precertification requests for prescription medications: Fax the precertification unit, toll free at 1-800-408-2386 Call the precertification unit, toll free at 1-800-414-2386 To submit requests online, go to: www.aetna.com, put your cursor on "Doctors & Hospitals" and select "Physician Self-Service" toregister for the secure website for physicians, hospitals and health care professionals. Once registered, you will be able to submit yourrequests online.

Current formulary information is available online at www.aetna.com/formulary

CAREFUL ANTIBIOTIC USE

Diagnosis CDC/AAP Principles of Appropriate Antibiotic Use

1. Classify episodes of OM as acute otitis media (AOM) or otitis media with effusion (OME). Only treat proven AOM.

2. Antibiotics are indicated for treatment of AOM, however, diagnosis requires documented middle ear infection. and, signs or symptoms of acute local or systemic illness.

3. Dont prescribe antibiotics for initial treatment of OME treatment may be indicated if bilateral effusions persist for 3 months or more.

Otitis Media

Rhinitis andSinusitis

Rhinitis:1. Antibiotics should not be given for viral rhinosinusitis.2. Mucopurulent rhinitis (thick, opaque, or discolored nasal discharge) frequently accompanies viral rhinosinusitis.

It is not an indication for antibiotic treatment unless it persists without improvement for more than 10-14 days.

Sinusitis:1. Diagnose as sinusitis only in the presence of:

prolonged nonspecific upper respiratory signs and symptoms (e.g. rhinorrhea and cough without improvement for >10-14 days), or

more severe upper respiratory tract signs and symptoms (e.g. fever >39 C, facial swelling, facial pain).2. Initial antibiotic treatment of acute sinusitis should be with the most narrow-spectrum agent which is active

against the likely pathogens.

Pharyngitis 1. Diagnose as group A streptococcal pharyngitis using a laboratory test in conjunction with clinical and epidemiological findings.

2. Antibiotics should not be given to a child with pharyngitis in the absence of diagnosed group A streptococcal infection.

3. A penicillin remains the drug of choice for treating group A streptococcal pharyngitis.

Cough Illness andBronchitis

Stemming the tide of antibiotic resistance: Recommendations by the CDC /AAP to promote appropriate antibiotic use in children.1

APPROPRIATE TREATMENT SUMMARY

1. Cough illness/bronchitis in children rarely warrants antibiotic treatment.2. Antibiotic treatment for prolonged cough (>10 days) may occasionally be warranted:

Pertussis should be treated according to established recommendations. Mycoplasma pneumoniae infection may cause pneumonia and prolonged cough

(usually in children older than 5 years); a macrolide agent (or tetracycline in children 8 years or older) may be used for treatment.

Children with underlying chronic pulmonary disease (not including asthma) may occasionally benefit from antibiotic therapy for acute exacerbations.

When parents demand antibiotics...

Provide educational materials and share your treatment rules to explain when the risks of antibiotics outweigh the benefits.

Build cooperation and trust:- dont dismiss the illness as only a viral infection - explicitly plan treatment of

symptoms with parents.- give parents a realistic time course for resolution - prescribe analgesics and

decongestants, if appropriate.

References1. Dowell SF, Editor. Principals of judicious use of antimicrobial agents for childrens upper respiratory tract infections. Pediatrics. Vol 1. January 1998 Supplement.

This guideline is provided for informational purposes only and is not intended to direct individual treatment decisions. All patient care and related decisions are the sole responsi-bility of providers, and this guideline does not dictate or control a providers clinical judgment regarding the appropriate treatment of any individual patient.

Guidelines developed by the Centers for Disease Control and Prevention (CDC). Reprinted with permission of CDC.