Subject: Specialty Quantity Limit Venclexta 2997-H P2023
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
|
|
Venclexta (venetoclax)
10 mg tablets
|
120 per 30 days
|
Chronic Lymphocytic
Leukemia/Small Lymphocytic
Lymphoma: Dose according
to a weekly ramp-up
schedule over 5 weeks
starting at 20 mg daily
up to 400 mg daily
Acute Myeloid Leukemia:
Dose and ramp-up depend
upon the combination agent,
starting at 100 mg daily up
to 600 mg daily
|
|
Venclexta (venetoclax)
50 mg tablets
|
120 per 30 days
|
|
Venclexta (venetoclax)
100 mg tablets
|
180 per 30 days
|
|
Venclexta (venetoclax)
Starting Pack
• Week 1 (14 x 10 mg
tablets)
• Week 2 (7 x 50 mg
tablets)
• Week 3 (7 x 100 mg
tablets)
• Week 4 (14 x 100 mg
tablets)
|
1 pack (42 tablets)
per 28 days
|
Place of Service:
Outpatient
The above policy is based on the following references:
- Venclexta [package insert]. North Chicago, IL: AbbVie 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.
June 18, 2023
