Subject: Specialty Quantity Limit Sprycel 1722-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
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Medication
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Standard Limit
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FDA-recommended dosing
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Sprycel (dasatinib) 20 mg tablets
|
90 tablets per 30 days
|
Adult patients:
· Chronic phase CML: 100 mg orally once daily
· Accelerated phase CML, myeloid or lymphoid blast
phase CML: 140 mg orally once daily
· Ph+ ALL: 140 mg orally once daily
Pediatric patients with chronic phase CML or Ph+ ALL:
· 40 mg -100 mg orally once daily based on body weight
|
|
Sprycel (dasatinib) 50 mg tablets
|
30 tablets per 30 days
|
|
Sprycel (dasatinib) 70 mg tablets
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30 tablets per 30 days
|
|
Sprycel (dasatinib) 80 mg tablets
|
30 tablets per 30 days
|
|
Sprycel (dasatinib) 100 mg tablets
|
30 tablets per 30 days
|
|
Sprycel (dasatinib) 140 mg tablets
|
30 tablets per 30 days
|
* ALL: acute lymphoblastic leukemia; CML: chronic myeloid leukemia; Ph+: Philadelphia chromosome positive
Place of Service:
Outpatient
The above policy is based on the following references:
- Sprycel [package insert]. Princeton, NJ: Bristol-Myers Squibb Company; June 2021.
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.
October 22, 2022
