Subject: Specialty Quantity Limit Adbry 5126-H P2023
|
ADBRY
(tralokinumab-ldrm)
|
Policy:
I. PROGRAM DESCRIPTION
The standard limit is designed to allow a quantity sufficient for
the most common uses of the medication. If the 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
|
|
Adbry
(tralokinumab-
ldrm) 150
mg/mL prefilled
syringe
|
4 syringes
per 28 days
|
4 syringes per 14
days
|
• Initial dose of 600 mg (four
150 mg injections), followed
by 300 mg (two 150 mg
injections) administered
every other week
• After 16 weeks of treatment,
for patients with body weight
below 100 kg who achieve
clear or almost clear skin, a
dosage of 300 mg every 4
weeks may be considered
|
*Coverage up to the exception limits may be provided with prior authorization via the Specialty Post Limit Quantity Exception Criteria for approval.
Place of Service:
Outpatient
The above policy is based on the following references:
- Adbry [package insert]. Madison, NJ: LEO Pharma Inc.; July 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.
April 11, 2023
