Subject: Specialty Quantity Limit Voxzogo 5070-H P2023

Drug

VOXZOGO  (vosoritide)

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 increasing linear growth in pediatric
          patients with achondroplasia who are 5 years of age and older
          with open epiphyses 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
Voxzogo   (vosoritide)   single-dose vial   0.4 mg	30 per   30 days	Subcutaneous injection once daily based on   patient’s actual body weight:
		Actual Body weight 10-11 kg 12-16 kg 17-21 kg 22-32 kg 33-43 kg 44-59 kg 60-89 kg ≥90 kg	Vial strength for reconstitution 0.4 mg 0.56 mg 0.56 mg 0.56 mg 1.2 mg 1.2 mg 1.2 mg 1.2 mg	Dose 0.24 mg 0.28 mg 0.32 mg 0.4 mg 0.5 mg 0.6 mg 0.7 mg 0.8 mg	Injection Volume 0.3 mL 0.35 mL 0.4 mL 0.5 mL 0.25 mL 0.3 mL 0.35 mL 0.4 mL
Voxzogo   (vosoritide)   single-dose vial   0.56 mg	30 per   30 days
Voxzogo   (vosoritide)   single-dose vial   1.2 mg	30 per   30 days

 

Place of Service:

Outpatient

The above policy is based on the following references:

1. Voxzogo [package insert]. Novato, CA: BioMarin Pharmaceutical Inc.; November 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 11, 2023