Subject: Specialty Quantity Limit Nucala 2467-H P2021b
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
|
|
Nucala 100 mg single-dose vial
|
3 vials per 28 days
|
Severe asthma:
• Age 12 years or older: 100 mg
every 4 weeks
• Age 6 to 11 years: 40 mg every 4
weeks
Eosinophilic granulomatosis with
polyangiitis (EGPA) or
hypereosinophilic syndrome (HES):
300 mg (three 100 mg injections)
every 4 weeks
Chronic rhinosinusitis with nasal
polyps:
100 mg every 4 weeks
|
|
Nucala 100 mg/mL single-dose prefilled safety syringe
|
3 syringes per 28 days
|
|
Nucala 100 mg/mL single-dose prefilled autoinjector
|
3 autoinjector’s per 28
days
|
|
Nucala 40mg/0.4mL, single-dose prefilled syringe
|
1 syringe per 28 days
|
Place of Service:
Outpatient
The above policy is based on the following references:
- Nucala [package insert]. Research Triangle Park, NC: GlaxoSmithKline; January 2022.
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.
March 20, 2022
