Subject: Specialty Quantity Limit Cometriq 1858-H P2022a

Drug

COMETRIQ  (cabozantinib)

Policy:

       I.  PROGRAM DESCRIPTION

           The standard limit is designed to allow a quantity sufficient for
           the most common uses of the medication. If 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
Cometriq   (cabozantinib) Kit 60   mg daily dose blister   cards Kit	1 Kit (84   capsules of 20   mg) per 28 days	n/a	140 mg orally once daily     Dose may need to be   modified based on adverse   reactions, hepatic   impairment, or drug   interactions with strong   CYP3A4 inducers or   inhibitors.     When used with a strong   CYP3A4 inducer, increase   the daily Cometriq dose by   40mg (for example, from   140 mg to 180 mg daily or   from 100 mg to 140 mg   daily) as tolerated.
Cometriq   (cabozantinib) Kit 100   mg daily dose blister   cards Kit	1 Kit (28   capsules of 20   mg, 28 capsules   of 80 mg) per   28 days	2 Kits per 28 days
Cometriq   (cabozantinib) Kit 140   mg daily dose blister   cards Kit	1 Kit (84   capsules of 20   mg, 28 capsules   of 80 mg) per   28 days	2 Kits per 28 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. Cometriq [package insert]. Alameda, CA: Exelixis Inc.; October 2020.

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