Subject: Specialty Quantity Limit VPRIV 1697-H P2022

Drug

VPRIV  (velaglucerase alfa)

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.

 
     II.  COVERED QUANTITIES  

Medication	Standard Limit	Exception Limit*	FDA-recommended dosing
VPRIV (velaglucerase   alfa) injection 400   units single-dose vial	15 vials   per 14 days	30 vials per 14 days	60 units/kg infusion every   other week

*Coverage up to the exception limits may be provided with prior authorization via the Specialty Post Limit Quantity Exception Criteria for approval.

Place of Service:

Outpatient

The above policy is based on the following references:

VPRIV [package insert]. Lexington, MA: Takeda Pharmaceuticals U.S.A., Inc.; September 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.

June 26, 2022