Subject: Specialty Quantity Limit Natpara 3063-H P2021
|
NATPARA
(parathyroid hormone)
|
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
|
|
Natpara cartridge for injection, 25 mcg (containing 14 doses)
|
2 per 28 days
|
Starting dose: 50 mcg subcutaneously once daily
The dose may be increased in increments of 25 mcg every four weeks up to a maximum daily dose of 100 mcg if serum calcium cannot be maintained above 8 mg/dL without an active form of vitamin D and/or oral calcium supplementation.
The dose may be decreased to as low as 25 mcg per day if total serum calcium is repeatedly above 9 mg/dL after the active form of vitamin D has been discontinued and calcium supplement has been decreased to a dose sufficient to meet daily requirements.
|
|
Natpara cartridge for injection, 50 mcg (containing 14 doses)
|
2 per 28 days
|
|
Natpara cartridge for injection, 75 mcg (containing 14 doses)
|
2 per 28 days
|
|
Natpara cartridge for injection, 100 mcg (containing 14 doses)
|
2 per 28 days
|
Place of Service:
Outpatient
The above policy is based on the following references:
- Natpara [package insert]. Lexington, MA: Shire-NPS Pharmaceuticals, Inc.; July 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
