Subject: Specialty Quantity Limit Enspryng 4101-H P2023

Drug

Enspryng  (satralizumab-mwge)

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
Enspryng 120   mg/mL single-   dose prefilled   syringe	1 single-dose   prefilled syringe   (120 mg) per 28   days	3 single-dose prefilled   syringes (360 mg) per   29 days	Administer 120 mg by   subcutaneous injection at   Weeks 0, 2, and 4, followed by   a maintenance dosage of 120   mg every 4 weeks.

*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. Enspryng [package insert]. South San Francisco, CA: Genentech, Inc.; March 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.

October 22, 2023