Subject: Specialty Quantity Limit Lytgobi 5639-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
|
|
Lytgobi (futibatinib) 4 mg
tablet (20 mg daily DosePak)
|
140 tablets per 28 days
|
20 mg (5 x 4mg tablets) orally once daily
Dose adjustments due to adverse reactions:
• First reduction: 16 mg once daily
• Second reduction: 12 mg once daily
|
|
Lytgobi (futibatinib) 4 mg
tablet (16 mg daily DosePak)
|
112 tablets per 28 days
|
|
Lytgobi (futibatinib) 4 mg
tablet (12 mg daily DosePak)
|
84 tablets per 28 days
|
Place of Service:
Outpatient
The above policy is based on the following references:
- Lytgobi [package insert]. Princeton, NJ: Taiho Pharmaceutical Co., Ltd.; September 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
