Subject: Specialty Quantity Limit Cabometyx 1614-H P2023

Drug

CABOMETYX  (cabozantinib)

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
Cabometyx   (cabozantinib)   tablet 20mg	30 per 30 days	Recommended dose for hepatocellular       carcinoma: As a single agent: 60 mg once       daily       Recommended dose for renal cell       carcinoma:  As a single agent: 60 mg once       daily. In combination with nivolumab: 40       mg once daily.       Recommended dose for differentiated       thyroid cancer as a single agent:       Adults and pediatric patients 12 years and       older with BSA greater than or equal to 1.2       m2: 60 mg once daily.       Pediatric patients 12 years of age and older       with BSA less than 1.2 m2: 40 mg once       daily.       Can be dose adjusted as necessary.
Cabometyx   (cabozantinib)   tablet 40mg	30 per 30 days
Cabometyx   (cabozantinib)   tablet 60mg	30 per 30 days

Place of Service:

Outpatient

The above policy is based on the following references:

1. Cabometyx [package insert]. Alameda, CA: Exelixis, 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.

October 22, 2023