Subject: Specialty Quantity Limit Lenvima 1698-H P2022a
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
|
|
Lenvima (lenvatinib)
4 mg 30-day dose
carton
|
1 carton (30 capsules
total) per 30 days
|
Differentiated thyroid cancer: 24
mg once daily
Renal cell carcinoma: 18 mg once
daily when used in combination
with everolimus; 20 mg once daily
when used in combination with
pembrolizumab
Hepatocellular carcinoma: 8 mg
once daily for patients less than 60
kg; 12 mg once daily for patients
greater than or equal to 60 kg
Endometrial carcinoma: 20 mg
once daily
Dose reductions may be required
after adverse events or in patients
with severe renal or hepatic
impairment.
|
|
Lenvima (lenvatinib)
8 mg 30-day dose
carton
|
1 carton (60 capsules
total) per 30 days
|
|
Lenvima (lenvatinib)
10 mg 30-day dose
carton
|
1 carton (30 capsules
total) per 30 days
|
|
Lenvima (lenvatinib)
12 mg 30-day dose
carton
|
1 carton (90 capsules
total) per 30 days
|
|
Lenvima (lenvatinib)
14 mg 30-day dose
carton
|
1 carton (60 capsules
total) per 30 days
|
|
Lenvima (lenvatinib)
18 mg 30-day dose
carton
|
1 carton (90 capsules
total) per 30 days
|
|
Lenvima (lenvatinib)
20 mg 30-day dose
carton
|
1 carton (60 capsules
total) per 30 days
|
|
Lenvima (lenvatinib)
24 mg 30-day dose
carton
|
1 carton (90 capsules
total) per 30 days
|
*Lenvima is available in 4 mg and 10 mg capsules. These are packed in cards in various combinations to obtain the
desired dose.
Place of Service:
Outpatient
The above policy is based on the following references:
- Lenvima [package insert]. Nutley, NJ: Eisai Inc.; August 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.
February 17, 2023
