Subject: Specialty Quantity Limit Taltz 1739-H P2023

Drug

TALTZ  (ixekizumab)

Policy:

      I.  PROGRAM DESCRIPTION

           The standard limit is designed to allow a quantity sufficient for
           the most common uses of the medication. If 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
Taltz    (ixekizumab)   80 mg/mL   prefilled    syringe/   autoinjector	1 syringe/   autoinjector   per 28 days	8 syringes/   autoinjectors   per 84 days	Plaque psoriasis with or   without coexistent psoriatic   arthritis, adults:   •     160 mg at week 0, followed          by 80 mg at weeks 2, 4, 6,          8, 10, and 12, then 80 mg          every 4 weeks   Plaque psoriasis, pediatric (6   years and older):   •     Less than 25 kg: 40 mg at          week 0, then 20 mg every 4          weeks   •     25 kg to 50 kg: 80 mg at          week 0, then 40 mg every 4          weeks   •     Greater than 50 kg: 160 mg          at week 0, then 80 mg every          4 weeks   Psoriatic arthritis:   •     160 mg at week 0, followed          by 80 mg every 4 weeks   Ankylosing spondylitis:   •     160 mg at week 0, followed          by 80 mg every 4 weeks   Non-radiographic axial   spondyloarthritis:   •     80 mg every 4 weeks

  *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:

1. Taltz [package insert]. Indianapolis, IN: Eli Lilly and Company; September 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 11, 2023