Subject: Specialty Quantity Limit Nuplazid 4802-H P2022

Drug

NUPLAZID  (pimavanserin)

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 hallucinations and
          delusions associated with Parkinson’s disease psychosis 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
Nuplazid 34 mg   capsules	30 per 30 days	Standard dosing: 34 mg orally one time daily    Coadministration with a strong CYP3A4    inhibitor: 10 mg orally one time daily
Nuplazid 10 mg   tablets	30 per 30 days

 

 

Place of Service:

Outpatient

The above policy is based on the following references:

1. Nuplazid [package insert]. San Diego, CA: Acadia Pharmaceuticals Inc.; November 2020.

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