Subject: Specialty Quantity Limit Jynarque 2571-H P2022
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
|
|
Jynarque Carton 15mg-
15mg tablets
|
56 per 28 days
|
Initial dose is 60mg orally daily (45mg on
waking and 15mg 8 hours later). Titrate to
90mg daily (60mg on waking and 30mg 8
hours later) and then to 120mg daily (90mg on
waking and 30mg 8 hours later) if tolerated
with at least weekly intervals between
titrations. Patients may down-titrate based on
tolerability.
Co-Administration with Moderate CYP 3A
Inhibitors:
Reduce dose per below. Consider further
reductions if patient cannot tolerate the
reduced dose.
• 120mg daily: reduce to 60mg daily (45mg
on waking and 15mg 8 hours later)
• 90mg daily: reduce to 45mg daily (30mg on
waking and 15mg 8 hours later)
• 60mg daily: reduce to 30mg daily (15mg on
waking and 15mg 8 hours later)
|
|
Jynarque Carton 30mg-
15mg tablets
|
56 per 28 days
|
|
Jynarque Carton 45mg-
15mg tablets
|
56 per 28 days
|
|
Jynarque Carton 60mg-
30mg tablets
|
56 per 28 days
|
|
Jynarque Carton 90mg-
30mg tablets
|
56 per 28 days
|
|
Jynarque 30mg tablets
(30 count bottle)
|
30 per 30 days
|
|
Jynarque 15mg tablets
(30 count bottle)
|
60 per 30 days
|
Place of Service:
Outpatient
The above policy is based on the following references:
- Jynarque [package insert]. Rockville, MD: Otsuka America Pharmaceutical, Inc.; 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 17, 2022
