Subject: Specialty Quantity Limit Piqray 3091-H P2023

Drug

PIQRAY  (alpelisib)

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
Piqray (alpelisib)   300 mg daily dose   (packaged as Piqray   150 mg tablets)	56 tablets   per 28 days	The recommended dose of Piqray is   300 mg once daily.     Dose reductions as needed for adverse   reactions.
Piqray (alpelisib) 250   mg daily dose   (packaged as Piqray   200 mg and Piqray   50 mg tablets)	56 tablets (28- 200   mg tablets + 28- 50   mg tablets)   per 28 days
Piqray (alpelisib) 200   mg daily dose   (packaged as Piqray   200 mg tablets)	28 tablets   per 28 days

 

Place of Service:

Outpatient

The above policy is based on the following references:

1. Piqray [package insert]. East Hanover, NJ: Novartis Pharmaceuticals Corporation; May 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