Subject: Specialty Quantity Limit Cometriq 1858-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 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
|
|
Cometriq
(cabozantinib) Kit
60 mg daily dose
blister cards Kit
|
1 Kit (84 capsules of
20 mg) per 28 days
|
n/a
|
140 mg orally once daily
Dose may need to be modified based
on adverse reactions, hepatic
impairment, or drug interactions with
strong CYP3A4 inducers or inhibitors.
When used with a strong CYP3A4
inducer, increase the daily Cometriq
dose by 40mg (for example, from 140
mg to 180 mg daily or from 100 mg
to 140 mg daily) as tolerated.
|
|
Cometriq
(cabozantinib) Kit
100 mg daily dose
blister cards Kit
|
1 Kit (28 capsules of
20 mg, 28 capsules of
80 mg) per 28 days
|
2 Kits per 28 days
|
|
Cometriq
(cabozantinib) Kit
140 mg daily dose
blister cards Kit
|
1 Kit (84 capsules of
20 mg, 28 capsules of
80 mg) per 28 days
|
2 Kits per 28 days
|
*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:
- Cometriq [package insert]. South San Francisco, CA: Exelixis; October 2020.
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.
April 16, 2022
