Subject: Specialty Quantity Limit Verzenio 2344-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 the treatment of 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
|
|
Verzenio
(abemaciclib)
50 mg tablet
|
56 tablets per 28 days
|
Breast Cancer:
• When used in combination with
fulvestrant, tamoxifen, or
aromatase inhibitor, the
recommended dose is 150 mg
orally twice daily.
• When used as monotherapy, the
recommended dose is 200 mg
orally twice daily.
Dose modifications may be required
for adverse reactions, severe hepatic
impairment, or use with moderate or
strong CYP3A inhibitors.
|
|
Verzenio
(abemaciclib)
100 mg tablet
|
|
Verzenio
(abemaciclib)
150 mg tablet
|
|
Verzenio
(abemaciclib)
200 mg tablet
|
Place of Service:
Outpatient
The above policy is based on the following references:
- Verzenio [package insert]. Indianapolis, IN: Eli Lilly and Company; October 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 18, 2023
