Subject: Specialty Quantity Limit Jynarque 2571-H P2022a
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
|
|
Jynarque Carton
15mg-15mg tablets
|
56 per 28 days
|
Initial dose is 60 mg orally daily (45mg
on waking and 15mg 8 hours later).
Titrate to 90mg daily (60mg on waking
and 30mg 8 hours later) and then to
120mg daily (90mg on waking and
30mg 8 hours later) if tolerated with at
least weekly intervals between
titrations. Patients may down-titrate
based on tolerability.
Co-Administration with Moderate CYP
3A Inhibitors:
Reduce dose per below. Consider
further reductions if patient cannot
tolerate the reduced dose.
• 120mg daily: reduce to 60mg
daily (45mg on waking and 15mg
8 hours later)
• 90mg daily: reduce to 45mg
daily (30mg on waking and 15mg
8 hours later)
• 60mg daily: reduce to 30mg daily
(15mg on waking and 15mg
8 hours later)
|
|
Jynarque Carton
30mg-15mg tablets
|
56 per 28 days
|
|
Jynarque Carton
45mg-15mg tablets
|
56 per 28 days
|
|
Jynarque Carton
60mg-30mg tablets
|
56 per 28 days
|
|
Jynarque Carton
90mg-30mg tablets
|
56 per 28 days
|
|
Jynarque 30mg
tablets (30 count bottle)
|
30 per 30 days
|
|
Jynarque 15mg
tablets (30 count bottle)
|
60 per 30 days
|
Place of Service:
Outpatient
The above policy is based on the following references:
- Jynarque [package insert]. Rockville, MD: Otsuka America Pharmaceutical, Inc.; October 2020.
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.
April 11, 2023
