Subject: Specialty Quantity Limit Tavalisse 2561-H P2023

Drug

TAVALISSE  (fostamatinib disodium hexahydrate)

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 the treatment of chronic or persistent immune thrombocytopenia (ITP) 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
Tavalisse 100 mg tablets	60 per 30 days	Initiate at 100 mg orally twice daily with or without food.   After a month, increase to 150 mg twice daily, if needed, to   achieve a platelet count of at least 50 x 109/L as necessary   to reduce the risk of bleeding.
Tavalisse 150 mg tablets	60 per 30 days

 

Place of Service:

Outpatient

The above policy is based on the following references:

1. Tavalisse [package insert]. South San Francisco, CA: Rigel Pharmaceuticals, Inc.; November 2020.

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 09, 2023