Subject: Specialty Quantity Limit Iressa 2904-H P2022
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
|
|
Iressa (gefitinib)
250 mg tablet
|
30 per 30 days
|
60 per 30 days
|
Standard dosing: 250 mg once daily
Drug Interaction, coadministration with a strong CYP3A4 inducer: 500 mg (two 250 mg tablets) per day
|
*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:
- Iressa [package insert]. Wilmington, DE: AstraZeneca Pharmaceuticals LP; May 2021.
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.
August 24, 2022
