Subject: Specialty Quantity Limit Calquence 2411-H P2023

Drug

CALQUENCE  (acalabrutinib)

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
Calquence   (acalabrutinib)   100 mg capsules	60 per 30 days	120 per 30 days	Mantle cell lymphoma, chronic   lymphocytic leukemia, and small   lymphocytic lymphoma: 100 mg   twice daily   Administration with strong CYP3A   inducer: 200 mg twice daily
Calquence (acalabrutinib) 100 mg tablets	60 per 30 days	120 per 30 days

*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:

1. Calquence [package insert]. Wilmington, DE: AstraZeneca Pharmaceuticals LP; 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.

December 31, 2023