Subject: Specialty Quantity Limit Gattex 2245-H P2021

Drug

GATTEX  (teduglutide)

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
Gattex (teduglutide) Kit 5mg	One 30-vial kit per 30 days	Two 30-vial kits per 30 days	0.05 mg/kg/day SC once daily

 *Patients over 75kg qualify for the exception limit.

Place of Service:

Outpatient

The above policy is based on the following references:

1. Gattex [package insert]. Lexington, MA: Shire-NPS Pharmaceuticals, Inc.; January 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.

December 14, 2021