Subject: Specialty Quantity Limit Zykadia 1754-H P2022

Drug

ZYKADIA  (ceritinib)

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
Zykadia (ceritinib)     150 mg tablets	90 per 30 days	450 mg once daily with food

Place of Service:

Outpatient

The above policy is based on the following references:

1. Zykadia [package insert]. East Hanover, NJ: Novartis Pharmaceuticals Corp; 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.

August 24, 2022