Subject: Specialty Quantity Limit Repatha-Praluent 1777-H P2023
Policy:
I. PROGRAM DESCRIPTION
The standard limit is designed to allow a quantity sufficient for
the most common uses of the medication. If the member’s plan
allows a quantity limit exception review for the requested
medication, coverage of an additional quantity may be provided
up to the exception limit with prior authorization.
II. COVERED QUANTITIES
|
Medication
|
Standard Limit
|
Exception Limit*
|
FDA-recommended dosing
|
|
Repatha 140 mg
syringe or
SureClick
autoinjector
|
3 syringes/
SureClick
per 28 days
|
6 syringes/
SureClick
per 28 days
|
Established cardiovascular
disease or primary
hyperlipidemia: 140 mg every
2 weeks or 420 mg once
monthly.
Homozygous familial
hypercholesterolemia:
420 mg once monthly
If a clinically meaningful
response is not achieved in
12 weeks, the dosage can be
increased to 420 mg every
2 weeks. Patients on lipid
apheresis may initiate
treatment with 420 mg
every 2 weeks to correspond
with their apheresis schedule.
|
|
Repatha 420 mg
Pushtronex
system
|
1 injection
per 28 days
|
2 injections
per 28 days
|
|
Praluent
75 mg pen
|
2 pens
per 28 days
|
N/A
|
Established cardiovascular
disease or primary
hyperlipidemia, including
HeFH: 75 mg once every 2
weeks or 300 mg once every
4 weeks.
If the LDL-C response is
inadequate, dosage may be
adjusted to 150 mg every 2
weeks.
HeFH undergoing LDL
apheresis or HoFH:
150 mg once every 2 weeks.
|
|
Praluent
150 mg
syringe/pen
|
2 syringes/pens
per 28 days
|
N/A
|
* Coverage up to the exception limits may be provided with prior authorization via the Specialty Post Limit Quantity Exception Criteria for approval.
Place of Service:
Outpatient
The above policy is based on the following references:
- Repatha [package insert]. Thousand Oaks, CA: Amgen, Inc.; September 2021.
- Praluent [package insert]. Tarrytown, NY: Regeneron Pharmaceuticals, Inc.; April 2021.
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 11, 2023
