Subject: Specialty Quantity Limit Xuriden 2999-H P2022

Drug

XURIDEN  (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
Xuriden oral granules,   2 gram packet	4 packets per day	Starting dosage: 60 mg/kg   once daily; dose may be   increased to 120 mg/kg (not   to exceed 8 grams) once    daily for insufficient efficacy

Place of Service:

Outpatient

The above policy is based on the following references:

1. Xuriden [package insert]. Rockville, MD: Wellstat Therapeutics Corporation; December 2019.

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