Subject: Specialty Quantity Limit Somavert 1711-H P2023
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
|
|
Somavert
(pegvisomant)
Inj 10mg
|
30 per 30 days
|
Recommended starting dose: A loading
dose of 40 mg (two 20mg subcutaneous
injections), followed by 10 mg daily.
Dose adjustment:
• Adjust dosage in 5 mg increments
or decrements every 4-6 weeks
until serum IGF-I concentrations
are maintained within age-adjusted
normal range.
• Dosage range is 10 to 30 mg once
daily
|
|
Somavert (pegvisomant)
Inj 15mg
|
30 per 30 days
|
|
Somavert (pegvisomant)
Inj 20mg
|
30 per 30 days
|
|
Somavert
(pegvisomant)
Inj 25mg
|
30 per 30 days
|
|
Somavert
(pegvisomant)
Inj 30mg
|
30 per 30 days
|
Place of Service:
Outpatient
The above policy is based on the following references:
- Somavert [package insert]. New York, NY: Pharmacia & Upjohn Company LLC; August 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.
April 15, 2023
