Subject: Specialty Quantity Limit Rasuvo 2273-H P2022
|
RASUVO
(methotrexate injection)
|
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
|
|
Rasuvo (methotrexate
injection) single-dose
auto-injector for
subcutaneous injection in
7.5, 10, 12.5, 15, 17.5,
20, 22.5, 25, 27.5, and
30 mg
|
4 injections per 28 days
|
Rheumatoid arthritis
• 7.5 mg every week (adjust
gradually to achieve an
optimal response); up to
20 mg per week
Polyarticular juvenile
idiopathic arthritis
• 10 mg per m2 every week
(adjust gradually to achieve
an optimal response); up to
20 mg per m2 per week
Psoriasis
• 10 to 25 mg every week
(adjust gradually to achieve
an optimal response); up to
30 mg per week
|
Place of Service:
Outpatient
The above policy is based on the following references:
- Rasuvo [package insert]. Chicago, IL: Medexus Pharma Inc.; March 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
