Subject: Specialty Quantity Limit Vistogard 2998-H P2023

Drug

VISTOGARD  (uridine triacetate)

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
Vistogard   (uridine triacetate)   10 grams oral   granules packet	20 packets per 5 days	Adults: 10 grams (1 packet)    orally every 6 hours for 20 doses   Pediatric: 6.2 grams/m2 of body   surface area (not to exceed 10   grams per dose) orally every 6   hours for 20 doses

 

Place of Service:

Outpatient

The above policy is based on the following references:

1. Vistogard [package insert]. Rockville, MD: Wellstat Therapeutics Corporation; February 2017.

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.

April 15, 2023