Subject: Specialty Quantity Limit Cometriq 1858-H P2023

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.


III.  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.

December 31, 2023