Subject: Specialty Quantity Limit Alunbrig 1829-H P2022

Drug

ALUNBRIG  (brigatinib)

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
Alunbrig (brigatinib) 30 mg tablets	120 per 30 days	150 per 30 days	•   90 mg once daily for the first 7       days; if tolerated, increase to       180 mg once daily   •  The following dosage       adjustments may be       necessary:       –  120 mg daily       –  90 mg daily       –  60 mg daily   •  Up to a maximum of twice the       dose may be necessary when       coadministered with certain       CYP inducers
Alunbrig   (brigatinib) 90 mg   tablets	30 per 30 days	Not applicable
Alunbrig     (brigatinib) 180   mg tablets	30 per 30 days	60 per 30 days
Alunbrig   (brigatinib)   Initiation Pack   [180 mg tablets   (#23), 90 mg   tablets (#7)]	30 per 30 days	Not applicable

*Coverage up to the exception limits may be provided with prior authorization via the Specialty Post Limit

Quantity Exception Criteria for approval.

Place of Service:

Outpatient

The above policy is based on the following references:

1. Alunbrig [package insert]. Lexington, MA: Takeda Pharmaceuticals America, Inc.; February 2022.

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.

August 24, 2022