Subject: Specialty Quantity Limit Firdapse 2828-H P2023
Policy:
I. PROGRAM DESCRIPTION
The standard limit is designed to allow a quantity sufficient for the most common uses of the medication. The recommended dosing parameters for Lambert-Eaton myasthenic syndrome (LEMS) fall within the standard limits. Coverage of an additional quantity may be reviewed on a case-by-case basis upon request.
II. COVERED QUANTITIES
|
Medication
|
Standard Limit
|
FDA-recommended dosing
|
|
Firdapse
10 mg tablets
|
240 tablets
per 30 days
|
Adult and pediatric members weighing 45 kg or more:
Recommended starting dose is 15 mg to 30 mg daily in divided
doses (3 to 4 times daily). The dosage can be increased by 5 mg
daily every 3 to 4 days. The maximum single dose is 20 mg. The
maximum daily maintenance dosage is 80 mg.
Pediatric members weighing less than 45 kg: Recommended
starting dose is 5 mg to 15 mg daily in divided doses (3 to 4 times
daily). The dosage can be increased by 2.5 mg daily every 3 to 4
days. The maximum single dose is 10 mg. The maximum daily
maintenance dosage is 40 mg.
|
Place of Service:
Outpatient
The above policy is based on the following references:
- Firdapse [package insert]. Coral Gables, FL: Catalyst Pharmaceuticals, Inc.; May 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 09, 2023
