Subject: Specialty Quantity Limit Vistogard 2998-H P2022

Drug

VISTOGARD  (uridine triacetate)

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
Vistogard   (uridine triacetate)   10 gram oral granules   packet	20 packets per 5 days	Adults: 10 grams (1 packet)    orally every 6 hours for 20    doses    Pediatric: 6.2 grams/m2 of    body surface area (not to    exceed 10 grams per dose)    orally every 6 hours for 20    doses

Place of Service:

Outpatient

The above policy is based on the following references:

1. Vistogard [package insert]. Rockville, MD: Wellstat Therapeutics Corporation; February 2017.

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.

August 24, 2022