Subject: Specialty Quantity Limit Prolia 1715-H P2022

Drug

PROLIA  (denosumab)

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
Prolia (denosumab)   60 mg/mL prefilled syringes	60 mg per   6 months	60 mg subcutaneously   every 6 months

           

Place of Service:

Outpatient

The above policy is based on the following references:

1. Prolia [package insert]. Thousand Oaks, CA: Amgen Inc.; 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.

April 11, 2023