Subject: Specialty Quantity Limit erlotinib-Tarceva 1756-H P2022

Drug

TARCEVA  (erlotinib)

erlotinib

Policy:

       I.  PROGRAM DESCRIPTION

            The standard limit is designed to allow a quantity sufficient for
            the most common uses of the medication. If 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
Tarceva (erlotinib)   25 mg tablets	60 per 30 days	Not applicable	Non-small cell lung     cancer (NSCLC):     150 mg once daily      Pancreatic cancer:    100 mg once daily    -Up to 300 mg if    cigarette smoker    - Up to 450 mg if co-    administered with a    strong CYP3A4 inducer
Tarceva (erlotinib)   100 mg tablets	30 per 30 days	120 per 30 days
Tarceva (erlotinib)   150 mg tablets	30 per 30 days	90 per 30 days

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

 

Place of Service:

Outpatient

The above policy is based on the following references:

 

1. Tarceva [package insert]. South San Francisco, CA: Genentech USA, Inc.; October 2016.
2. Erlotininb [package insert]. Pennington, NJ: Zydus Pharmaceuticals USA, Inc.; April 2020.

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