Subject: Specialty Quantity Limit Hetlioz 2429-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 the treatment of all FDA approved
indications 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
|
|
Hetlioz 20 mg capsules
|
30 capsules per 30 days
|
Adults and patients 16 years of
age and older:
20 mg daily before bedtime
|
|
Hetlioz LQ oral suspension
4 mg/mL
|
5 mL per day
|
Pediatric patients 3 to 15 years
of age:
Weight less than or equal to 28
kg: 0.7 mg/kg daily one hour
before bedtime
Weight greater than 28 kg: 20
mg daily one hour before
bedtime
|
Place of Service:
Outpatient
The above policy is based on the following references:
- Hetlioz [package insert]. Washington, D.C.: Vanda Pharmaceuticals, Inc.; January 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.
October 15, 2023
