Subject: Specialty Quantity Limit Iclusig 1721-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 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
|
|
Iclusig (ponatinib)
10 mg tablet)
|
30 tablets
per 30 days
|
Initial dosing: 45 mg orally once daily.
Initial dosing with strong CYP3A inhibitors
or hepatic impairment (Child-Pugh A, B or
C): 30 mg once daily.
Dose adjustments may be required for
adverse reactions, hepatic impairment, or
use with strong CYP3A4 inhibitors.
|
|
Iclusig (ponatinib)
15 mg tablet
|
30 tablets
per 30 days
|
|
Iclusig (ponatinib)
30 mg tablet
|
30 tablets
per 30 days
|
|
Iclusig (ponatinib)
45 mg tablet
|
30 tablets
per 30 days
|
Place of Service:
Outpatient
The above policy is based on the following references:
- Iclusig [package insert]. Lexington, MA: Takeda Pharmaceuticals America, Inc.; February 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
