Subject: Specialty Quantity Limit Verzenio 2344-H P2021a
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 the treatment of 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.
|
Medication
|
Standard Limit
|
FDA-recommended dosing
|
|
Verzenio
(abemaciclib) 50 mg tablet
|
56 tablets per 28 days
|
Breast Cancer:
• When used in combination
with fulvestrant, tamoxifen,
or aromatase inhibitor, the
recommended dose is 150
mg orally twice daily.
• When used as monotherapy,
the recommended dose is
200 mg orally twice daily.
Dose modifications may be
required for adverse reactions,
severe hepatic impairment, or
use with moderate or strong
CYP3A inhibitors.
|
|
Verzenio
(abemaciclib) 100
mg tablet
|
|
Verzenio
(abemaciclib) 150
mg tablet
|
|
Verzenio
(abemaciclib) 200
mg tablet
|
Place of Service:
Outpatient
The above policy is based on the following references:
- Verzenio [package insert]. Indianapolis, IN: Eli Lilly and Company; October 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 28, 2021
