Subject: Specialty Quantity Limit Onureg 4195-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 treatment of acute myeloid leukemia 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
|
|
Onureg (azacitidine)
200 mg tablets
|
14 per 28 days
|
• Recommended dosing: 300 mg
orally once daily on Days 1 through
14 of each 28-day cycle.
• Dose modifications may be needed
based on adverse reactions.
|
|
Onureg (azacitidine)
300 mg tablets
|
14 per 28 days
|
Place of Service:
Outpatient
The above policy is based on the following references:
- Onureg [package insert]. Princeton, NJ: Celgene Corporation; October 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.
June 18, 2023
