Subject: Specialty Quantity Limit Jaypirca 5768-H P2023a

Drug

JAYPIRCA  (pirtobrutinib)

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
Jaypirca   (pirtobrutinib)   100 mg tablets	60 per 30 days	90 per 30      days	The recommended dosage of Jaypirca is 200 mg once   daily.   Dose modifications are recommended for adverse   reactions, severe renal impairment and concomitant use   with strong CYP3A inhibitors and moderate CYP3A   inducers.              First dose reduction: 100 mg once daily              Second dose reduction: 50 mg once daily   Dose increase: 300mg once daily if concomitant use with   moderate CYP3A inducers.
Jaypirca   (pirtobrutinib)   50 mg tablets	30 per 30 days	N/A

  *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. Jaypirca [package insert]. Indianapolis, IN: Eli Lilly and Company; 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.

December 26, 2023