Subject: Specialty Quantity Limit Natpara 3063-H P2022

Drug

NATPARA  (parathyroid hormone)

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
Natpara (parathyroid   hormone) cartridge for   injection, 25 mcg   (containing 14 doses)	2 per 28 days	Starting dose: 50 mcg   subcutaneously once daily     The dose may be increased in   increments of 25 mcg every four   weeks up to a maximum daily dose   of 100 mcg if serum calcium cannot   be maintained above 8 mg/dL   without an active form of vitamin D   and/or oral calcium supplementation.     The dose may be decreased to as low   as 25 mcg per day if total serum   calcium is repeatedly above 9 mg/dL   after the active form of vitamin D   has been discontinued and calcium   supplement has been decreased to a   dose sufficient to meet daily   requirements.
Natpara (parathyroid   hormone) cartridge for   injection, 50 mcg   (containing 14 doses)	2 per 28 days
Natpara (parathyroid   hormone) cartridge for   injection, 75 mcg   (containing 14 doses)	2 per 28 days
Natpara (parathyroid   hormone) cartridge for   injection, 100 mcg   (containing 14 doses)	2 per 28 days

 

Place of Service:

Outpatient

The above policy is based on the following references:

1. Natpara [package insert]. Lexington, MA: Shire-NPS Pharmaceuticals, Inc.; April 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