Subject: Specialty Quantity Limit Thalomid 2389-H P2021
Policy:
I. PROGRAM DESCRIPTION
The standard limit is designed to allow a quantity sufficient for the most
common uses of the medication. If the member’s plan allows a quantity
limit exception review for the requested medication, coverage of an
additional quantity may be provided up to the exception limit with prior
authorization. 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
|
Exception Limit*
|
FDA-recommended dosing
|
|
Thalomid
(thalidomide)
capsules 50mg
|
28 per 28 days
|
Not applicable
|
Multiple myeloma: 200 mg orally
once daily
Erythema nodosum leprosum (ENL):
100 to 300 mg/day for an episode of
cutaneous ENL. Up to 400 mg/day for
severe cutaneous ENL
|
|
Thalomid
(thalidomide)
capsules 100mg
|
28 per 28 days
|
Not applicable
|
|
Thalomid
(thalidomide)
capsules 150mg
|
56 per 28 days
|
Not applicable
|
|
Thalomid
(thalidomide)
capsules 200mg
|
56 per 28 days
|
168 per 28 days*
|
* Exception limit to address chronic graft-versus-host disease (GVHD).
Place of Service:
Outpatient
The above policy is based on the following references:
- Thalomid [package insert]. Summit, NJ: Celgene Corporation; February 2021.
- American Society of Health System Pharmacists. AHFS Drug Information. (Adult and Pediatric) Bethesda, MD. Electronic version, 2021. Available with subscription. URL: http://online.lexi.com/lco. Accessed October 5, 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
