Subject: Specialty Quantity Limit Cerezyme 1695-H P2022
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
|
|
Cerezyme (imiglucerase)
injection 400 units vial
|
15 vials
per 14 days
|
30 vials
per 14 days
|
Dosing range: 2.5 U/kg infusion
three times a week to 60 U/kg
per 14 days (once every 2
weeks)
|
*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:
- Cerezyme [package insert]. Cambridge, MA: Genzyme Corporation; April 2018.
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 26, 2022
