Subject: Specialty Quantity Limit Kisqali 1652-H P2023

Drug

KISQALI  (ribociclib)

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
Kisqali (ribociclib) 600   mg daily dose carton   [contains three blister   packs with 21 200-mg   tablets each]	63 tablets   per 28 days	Breast Cancer: The recommended   dose is 600 mg taken orally once   daily for 21 consecutive days   followed by 7 days off treatment   resulting in a complete cycle of   28 days.   Dose modifications may be required   for adverse reactions, moderate to   severe hepatic impairment, severe   renal impairment or use with strong   CYP3A4 inhibitors.
Kisqali (ribociclib) 400   mg daily dose carton   [contains three blister   packs with 14 200-mg   tablets each]	42 tablets   per 28 days
Kisqali (ribociclib) 200   mg daily dose carton   [contains one blister   pack with 21 200-mg   tablets each]	21 tablets   per 28 days

 

Place of Service:

Outpatient

The above policy is based on the following references:

 

1. Kisqali [package insert]. East Hanover, NJ: Novartis Pharmaceuticals Corporation; October 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.

June 18, 2023