Subject: Specialty Quantity Limit Kevzara 1953-H P2021
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
|
|
Kevzara (sarilumab)
150 mg/1.14 mL single dose pre-filled syringe
|
1 pack (2 x 150 mg syringe) per 4 weeks
|
Rheumatoid arthritis (adult):
• 200 mg once every two weeks
• Reduce dose to 150 mg once
every two weeks for management
of neutropenia, thrombocytopenia
and elevated liver enzymes
|
|
Kevzara (sarilumab) 150 mg/1.14 mL single dose pre-filled pen
|
1 pack (2 x 150 mg pen) per 4 weeks
|
|
Kevzara (sarilumab) 200 mg/1.14 mL single dose pre-filled syringe
|
1 pack (2 x 200 mg syringe) per 4 weeks
|
|
Kevzara (sarilumab) 200 mg/1.14 mL single-dose pre-filled pen
|
1 pack (2 x 200 mg pen) per 4 weeks
|
Place of Service:
Outpatient
The above policy is based on the following references:
- Kevzara [package insert]. Bridgewater, NJ: Sanofi-aventis, U.S. LLC /Regeneron Pharmaceuticals, Inc.; April 2018.
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 17, 2021
