Subject: Specialty Quantity Limit Enbrel 2268-H P2021

Drug

ENBREL  (etanercept)

Policy:

      I.  PROGRAM DESCRIPTION

          The standard limit is designed to allow a quantity sufficient for the most
          common uses of the medication. If the member’s plan allows a quantity
          limit exception review for the requested medication, coverage of an
          additional quantity may be provided up to the exception limit with prior
          authorization.  

    II. COVERED QUANTITIES  

Medication	Standard Limit	Exception Limit	FDA-recommended                dosing
Enbrel (etanercept) 25   mg per 0.5 mL prefilled   syringe	4 syringes per 28   days	None	RA/PsA/AS   •  50 mg every week   PsO   •  Loading dose: 50        mg twice a week for       3 months   •  Maintenance dose:       50 mg every week   Pediatric PsO/PJIA   •  Weight < 63 kg: 0.8       mg per kg every       week   •  Weight  ≥ 63 kg: 50       mg every week
Enbrel (etanercept) 25   mg /0.5 mL single-dose   vial, or 25 mg multi   dose vial	4 vials per 28 days	8 vials per 28   days
Enbrel (etanercept) 50   mg per 1 mL prefilled   syringe/cartridge	4 syringes per 28   days	8 syringes per 28   days
Enbrel (etanercept) 50   mg per mL SureClick   Autoinjector	4 cartridges per 28   days	8 cartridges per   28 days

Abbreviations: RA = rheumatoid arthritis; PsA = psoriatic arthritis; AS = ankylosing spondylitis; PsO = plaque psoriasis; PJIA = polyarticular juvenile idiopathic arthritis

Place of Service:

Outpatient

The above policy is based on the following references:

1. Enbrel [package insert]. Thousand Oaks, CA: Immunex Corporation; April 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.

March 16, 2022