Subject: Specialty Quantity Limit Inbrija 2864-H P2021

Drug

INBRIJA  (levodopa inhalation powder)

Policy:

I.     PROGRAM DESCRIPTION
       The standard limit is designed to allow a quantity sufficient for the most common uses of the medication. The recommended
       dosing parameters for the intermittent treatment of “off” episodes in patients with Parkinson’s disease fall within the standard 
       limits. Coverage of an additional quantity may be reviewed on a case-by-case basis upon request.


II.   COVERED QUANTITIES 

Medication	Standard Limit	FDA-recommended dosing
Inbrija 42 mg (for oral inhalation) 60-capsule carton	5 cartons per 30 days	Inhale the contents of two capsules as needed for off symptoms, up to 5 times daily.
Inbrija 42 mg (for oral inhalation) 92-capsule carton	4 cartons per 30 days

Place of Service:

Outpatient

The above policy is based on the following references:

1. Inbrija [package insert]. Ardsley, NY: Acorda Therapeutics, Inc.; August 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.

February 14, 2022