Subject: Valtoco Limit Policy 3518-H 06-2022

Drug

BALTOCO  (diazepam nasal spray)

Policy:

FDA-APPROVED INDICATIONS         
Valtoco is indicated for the acute treatment of intermittent, stereotypic episodes of frequent seizure activity (i.e., seizure clusters, acute repetitive seizures) that are distinct from a patient’s usual seizure pattern in patients with epilepsy 6 years of age and older. 

LIMIT CRITERIA Limits should accumulate across all drugs and strengths up to highest quantity listed depending on the order the claims are processed.
Drug	1 Month Limit*	3 Month Limit*
Valtoco	10 blister packs (5 cartons) / 25 days	30 blister packs (15 cartons) / 75 days
*The duration of 25 days is used for a 30-day fill period and 75 days is used for a 90-day fill period to allow time for refill processing.

 

Place of Service:

Outpatient

The above policy is based on the following references:

1. Valtoco [package insert]. San Diego, CA: Neurelis, Inc.; February 2022.
2. Lexicomp Online, AHFS DI (Adult and Pediatric) Online, Hudson, Ohio: UpToDate, Inc.; 2022; Accessed April 7, 2022.
3. Micromedex (electronic version). IBM Watson Health, Greenwood Village, Colorado, USA. Available at: https://www.micromedexsolutions.com. Accessed April 7, 2022.

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 15, 2022