Subject: Specialty Quantity Limit Enjaymo 5200-H P2023
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ENJAYMO
(sutimlimab-jome)
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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
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Medication
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Standard Limit
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Exception Limit*
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FDA-Recommended Dosing
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Enjaymo
(sutimlimab-jome)
1,100 mg/22 mL
(50 mg/mL) single-dose vial
|
14 single-
dose vials
per 28 days
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21 single-dose
vials per 28 days
|
• Weight-based dosage weekly for two
weeks then every two weeks:
º For patients weighing 39 kg to less
than 75 kg: 6,500 mg by
intravenous infusion.
º For patients weighing 75 kg or
more: 7,500 mg by intravenous
infusion.
|
*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:
- Enjaymo [package insert]. Waltham, MA: Bioverativ USA Inc.; March 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.
December 31, 2023
