Subject: Specialty Quantity Limit Livmarli 5006-H P2022
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
|
|
Livmarli
(maralixibat) oral
solution 9.5 mg/mL
|
90 mL (3 bottles)
per 30 days
|
380 mcg/kg once daily
Start dosing at 190 mcg/kg once daily. After
one week, increase to 380 mcg/kg once
daily, as tolerated. The maximum daily dose
volume for patients above 70 kg is 3 mL or
28.5 mg per day
|
Place of Service:
Outpatient
The above policy is based on the following references:
- Livmarli [package insert]. Foster City, CA: Mirum Pharmaceuticals, Inc.; September 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.
March 28, 2023
