Subject: Specialty Quantity Limit Lenvima 1698-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
|
|
Lenvima (lenvatinib)
4 mg 30-day dose carton
|
1 carton (30 capsules total)
per 30 days
|
Differentiated thyroid cancer: 24 mg once daily
Renal cell carcinoma: 18 mg once daily when used
in combination with everolimus;20 mg once daily
when used in combination with pembrolizumab
Hepatocellular carcinoma: 8 mg once daily for
patients less than 60 kg; 12 mg once daily for
patients greater than or equal to 60 kg
Endometrial carcinoma: 20 mg once daily
Dose reductions may be required after adverse
events or in patients with severe renal or hepatic
impairment.
|
|
Lenvima (lenvatinib)
8 mg 30-day dose carton
|
1 carton (60 capsules total)
per 30 days
|
|
Lenvima (lenvatinib)
10 mg 30-day dose carton
|
1 carton (30 capsules total)
per 30 days
|
|
Lenvima (lenvatinib)
12 mg 30-day dose carton
|
1 carton (90 capsules total)
per 30 days
|
|
Lenvima (lenvatinib)
14 mg 30-day dose carton
|
1 carton (60 capsules total)
per 30 days
|
|
Lenvima (lenvatinib)
18 mg 30-day dose carton
|
1 carton (90 capsules total)
per 30 days
|
|
Lenvima (lenvatinib)
20 mg 30-day dose carton
|
1 carton (60 capsules total)
per 30 days
|
|
Lenvima (lenvatinib)
24 mg 30-day dose carton
|
1 carton (90 capsules total)
per 30 days
|
*Lenvima is available in 4 mg and 10 mg capsules. These are packed in cards in various combinations to obtain the desired dose.
Place of Service:
Outpatient
The above policy is based on the following references:
- Lenvima [package insert]. Nutley, NJ: Eisai Inc.; November 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.
December 31, 2023
