Subject: Specialty Quantity Limit Tysabri 1940-H P2022a

Drug

TYSABRI  (natalizumab)

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
Tysabri (natalizumab)   300mg/ 15mL vial	15 mL per 28 days	Multiple Sclerosis   300 mg every four weeks   Crohn’s Disease   300 mg every four weeks

Place of Service:

Outpatient

The above policy is based on the following references:

1. Tysabri [package insert]. Cambridge, MA: Biogen Inc.; June 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.

March 28, 2023