Subject: Specialty Quantity Limit Mekinist 1682-H P2023a
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
|
|
Mekinist (trametinib)
0.5 mg tablet
|
90 tablets
per 30 days
|
Adults: 2 mg once daily
First dose reduction: 1.5 mg once
daily
Second dose reduction: 1 mg once
daily
Pediatric patients:
26-37 kg: 1 mg once daily
38-50 kg: 1.5 mg once daily
51 kg or greater: 2 mg once daily
|
|
Mekinist (trametinib)
2 mg tablet
|
30 tablets
per 30 days
|
|
Mekinist (trametinib)
4.7 mg (0.05 mg/mL
reconstituted)
for oral solution
|
12 bottles
per 28 days
|
Once daily based on body weight:
|
8 kg
|
6 mL (0.3 mg)
|
|
9 kg
|
7 mL (0.35 mg)
|
|
10 kg
|
7 mL (0.35 mg)
|
|
11 kg
|
8 mL (0.4 mg)
|
|
12-13 kg
|
9 mL (0.45 mg)
|
|
14-17 kg
|
11 mL (0.55 mg)
|
|
18-21 kg
|
14 mL (0.7 mg)
|
|
22-25 kg
|
17 mL (0.85 mg)
|
|
26-29 kg
|
18 mL (0.9 mg)
|
|
30-33 kg
|
20 mL (1 mg)
|
|
34-37 kg
|
23 mL (1.15 mg)
|
|
38-41 kg
|
25 mL (1.25 mg)
|
|
42-45 kg
|
28 mL (1.4 mg)
|
|
46-50 kg
|
32 mL (1.6 mg)
|
|
≥ 51 kg
|
40 mL (2 mg)
|
|
Place of Service:
Outpatient
The above policy is based on the following references:
- Mekinist [package insert]. East Hanover, NJ: Novartis Pharmaceuticals Corporation; May 2023.
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.
July 15, 2023
