Subject: Specialty Quantity Limit Pemazyre 3795-H P2023

Drug

PEMAZYRE  (pemigatinib))

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
Pemazyre   (pemigatinib)   4.5 mg tablets	30 per 30 days	Cholangiocarcinoma: 13.5 mg orally once daily for 14 consecutive   days followed by 7 days off therapy, in 21 day cycles.   Myeloid/lymphoid neoplasms with FGFR1 rearrangement: 13.5 mg   orally once daily on a continuous basis.   Dose reduction may be required for adverse reactions, drug   interactions with strong or moderate CYP3A inhibitors, severe   renal impairment or severe hepatic impairment.
Pemazyre   (pemigatinib)   9 mg tablets	30 per 30 days
Pemazyre   (pemigatinib)   13.5 mg tablets	30 per 30 days

 

Place of Service:

Outpatient

The above policy is based on the following references:

1. Pemazyre [package insert]. Wilmington, DE: Incyte Corporation; June 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.

December 31, 2023