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Specialty Pharmacy Clinical Policy Bulletins
Aetna Non-Medicare Prescription Drug Plan
Subject: Specialty Quantity Limit Jakafi 2284-H P2021a

Drug
JAKAFI  (ruxolitinib)


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 all FDA-approved indications 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

 Jakafi (ruxolitinib)
 5mg tablets

60 per 30 days

 Intermediate or high-risk myelofibrosis, including
 primary  myelofibrosis, post-polycythemia vera
 myelofibrosis and post-essential thrombocythemia
 myelofibrosis:

 ·   The recommended starting dose of Jakafi is  based on
     platelet count. Doses may be titrated based on safety and
     efficacy.

 ·   The starting dose for platelet count of > 200 x 109/L is
     20 mg orally twice daily.

 ·   The starting dose for platelet count of 100 x 109/L to
     200 x 109/L is 15 mg orally twice daily.

 ·   The starting dose for platelet count of 50 x 109/L to < 100 x
     109/L is 5 mg orally twice daily.

 ·   If the response is insufficient and platelet and neutrophil
     counts are adequate, doses may be increased in 5 mg twice
     daily increments to a maximum of 25 mg twice daily. 

 Polycythemia vera:

 ·   The recommended starting dose of Jakafi is 10 mg orally
     twice daily. Doses may be titrated based on safety and
     efficacy.

 ·   If response is insufficient and platelet, hemoglobin, and
     neutrophil counts are adequate, doses may be increased in
     5 mg twice daily increments to a maximum of 25 mg twice
     daily.

 Acute graft-versus-host disease:

 ·   The recommended starting dose of Jakafi is 5 mg orally
     twice daily.

 ·   Consider increasing the dose to 10 mg twice daily after at
     least 3 days of treatment if the ANC and platelet counts are
     not decreased by 50% or more relative to the first day of
     dosing with Jakafi.

 ·   Doses may be titrated based on safety and efficacy.

 Chronic graft-versus-host disease:

 ·   The recommended starting dose of Jakafi is 10 mg orally
     twice daily.

 ·   Consider tapering Jakafi after 6 months of treatment in
     patients with response who have discontinued therapeutic
     doses of corticosteroids.

 

 

 

 

 

 

 

 Jakafi (ruxolitinib)
 10mg tablets

 

 

 

60 per 30 days

 

 

 

 Jakafi (ruxolitinib)
 15mg  tablets

60 per 30 days

 Jakafi (ruxolitinib)
 20mg tablets

60 per 30 days

 Jakafi (ruxolitinib)
 25mg tablets

 

 

 

 

 

 

 

 

 

 

 

 

 

60 per 30 days

 

 

 

 

 

 

 

 

 

 

 

 

 

Place of Service:

Outpatient

The above policy is based on the following references:

1.   Jakafi [package insert]. Wilmington, DE: Incyte Corporation; September 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.

October 22, 2021
Aetna
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