Subject: Specialty Quantity Limit Lynparza 2237-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
|
|
Lynparza (olaparib)
100 mg tablets
|
120 per 30 days
|
300 mg orally twice daily
Dose modifications due to adverse
reactions, drug interactions, or renal
impairment: 100 mg orally twice daily
to 250 mg orally twice daily
|
|
Lynparza (olaparib)
150 mg tablets
|
120 per 30 days
|
Place of Service:
Outpatient
The above policy is based on the following references:
- Lynparza® Tablets [package insert]. Wilmington, DE: AstraZeneca Pharmaceuticals LP; August 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.
February 17, 2023
