Subject: Dronabinol Limit 137-H Policy 02-2022

Drug

DRONABINOL PRODUCTS

MARINOL  (dronabinol)

SYNDROS  (dronabinol oral solution)

Policy:

FDA-approved Indications      
Marinol and Syndros are indicated in adults for the treatment of:
   •   anorexia associated with weight loss in patients with Acquired Immune Deficiency Syndrome (AIDS).
   •   nausea and vomiting associated with cancer chemotherapy in patients who have failed to respond
        adequately to conventional antiemetic treatments. 

LIMIT CRITERIA
Limits do not accumulate together, patient is allowed the maximum limit for each drug and strength
Drug	1 Month Limit*	3 Month Limit*
Marinol 2.5 mg, 5 mg, 10 mg (dronabinol capsules)	60 capsules / 25 days	180 capsules / 75 days
Syndros (dronabinol oral solution)	120 mL / 25 days	360 mL / 75 days
*The duration of 25 days is used for a 30-day fill period and 75 days is used for a 90-day fill period to allow time for refill processing.

 

Place of Service:

Outpatient

The above policy is based on the following references:

1. Marinol [package insert]. Parsippany, NJ: ThePharmaNetwork, LLC; August 2017.
2. Syndros [package insert]. Chandler, AZ: Insys Therapeutics, Inc.; July 2020.
3. Lexicomp Online, AHFS DI (Adult and Pediatric) Online. Hudson, Ohio: UpToDate, Inc.; 2021; Accessed January 2022.
4. Micromedex (electronic version). IBM Watson Health, Greenwood Village, Colorado, USA. Available at: https://www.micromedexsolutions.com. Accessed January 2022.
5. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology. Antiemesis. V.1.2021. Available at: https://www.nccn.org/professionals/physician_gls/pdf/antiemesis.pdf. Accessed December 2021.

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.

June 12, 2022