Subject: Specialty Quantity Limit Cibinqo 5143-H P2023

Drug

CIBINQO  (abrocitinib)

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
Cibinqo (abrocitinib)   50 mg tablets	30 tablets   per 30 days	Atopic dermatitis: 100 mg once daily    •   If an adequate response is not achieved         after 12 weeks, consider increasing dosage         to 200 mg once daily.    •   Dose adjustments: Reduce to 50 mg once         daily for patients:         °  With moderate renal impairment (not             recommended for patients with severe             renal impairment).         °  Who are known or suspected to be             CYP2C19 poor metabolizers or who are             receiving strong CYP2C19 inhibitors.         °  If an adequate response is not achieved             after 12 weeks, consider increasing             dosage to 100 mg once daily.
Cibinqo (abrocitinib)   100 mg tablets	30 tablets   per 30 days
Cibinqo (abrocitinib)   200 mg tablets	30 tablets   per 30 days

 

Place of Service:

Outpatient

The above policy is based on the following references:

1. Cibinqo [package insert]. New York, NY: Pfizer Inc.; February 2023.

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