Subject: Specialty Quantity Limit Enbrel 2268-H P2022

Drug

ENBREL  (etanercept)

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
Enbrel (etanercept)   25 mg per 0.5 mL   prefilled syringe	8 syringes   per 28 days	None	RA/PsA/AS   •  50 mg every week     PsO   •  Loading dose: 50 mg       twice a week for       3 months   •  Maintenance dose:      50 mg every week   Pediatric PsO/PJIA   •  Weight < 63 kg:       0.8 mg per kg       every week   •  Weight  ≥ 63 kg:       50 mg every week
Enbrel (etanercept)   25 mg /0.5 mL   single-dose vial	8 vials per 28 days	16 vials per 28 days
Enbrel (etanercept)   50 mg per 1 mL   prefilled   syringe/cartridge	4 syringes   per 28 days	8 syringes   per 28 days
Enbrel (etanercept)   50 mg per mL   SureClick Autoinjector	4 cartridges per   28 days	8 cartridges   per 28 days

Abbreviations: RA = rheumatoid arthritis; PsA = psoriatic arthritis; AS = ankylosing spondylitis; PsO = plaque psoriasis; PJIA = polyarticular juvenile idiopathic arthritis

 

Place of Service:

Outpatient

The above policy is based on the following references:

1. Enbrel [package insert]. Thousand Oaks, CA: Immunex Corporation; June 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.

March 28, 2023