Subject: Specialty Quantity Limit Tafinlar 1684-H P2022

Drug

TAFINLAR  (dabrafenib)

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
Tafinlar   (dabrafenib)  50 mg capsule	120 capsules per 30  days	Standard: 150 mg twice daily  First dose reduction: 100 mg twice  daily  Second dose reduction: 75 mg  twice daily  Third dose reduction: 50 mg twice  daily
Tafinlar (dabrafenib) 75 mg capsule	120 capsules per 30 days

Place of Service:

Outpatient

The above policy is based on the following references:

1. Tafinlar [package insert]. East Hanover, NJ: Novartis Pharmaceutical Corporation; May 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.

April 16, 2022