Subject: Specialty Quantity Limit Xpovio 3120-H P2022
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
|
|
Xpovio (selinexor)
80 mg
twice weekly carton
|
1 carton per 28 days
(thirty-two 20 mg tablets
per 28 days)
|
Multiple myeloma (in combination
with bortezomib and
dexamethasone): 100 mg once
weekly on day 1
Dose adjustments due to adverse
reactions
• First reduction: 80 mg once
weekly
• Second reduction: 60 mg once
weekly
• Third reduction: 40 mg once
weekly
Multiple myeloma (in combination
with dexamethasone): 80 mg twice
weekly on days 1 and 3
Dose adjustments due to adverse
reactions
• First reduction: 100 mg once
weekly
• Second reduction: 80 mg once
weekly
• Third reduction: 60 mg once
weekly
Diffuse large B-cell lymphoma:
60 mg twice weekly on days 1 and 3
Dose adjustments due to adverse
reactions
• First reduction: 40 mg twice
weekly
• Second reduction: 60 mg once
weekly
• Third reduction: 40 mg once
weekly
|
|
Xpovio (selinexor)
60 mg
twice weekly carton
|
1 carton per 28 days
(twenty-four 20 mg tablets
per 28 days)
|
|
Xpovio (selinexor)
40 mg
twice weekly carton
|
1 carton per 28 days
(sixteen 20 mg tablets
per 28 days)
|
|
Xpovio (selinexor)
40 mg
twice weekly carton
|
1 carton per 28 days
(eight 40 mg tablets
per 28 days)
|
|
Xpovio (selinexor)
100 mg
once weekly carton
|
1 carton per 28 days
(twenty 20 mg tablets
per 28 days)
|
|
Xpovio (selinexor) 100 mg once weekly carton
|
1 carton per 28 days
(eight 50 mg tablets
per 28 days)
|
|
Xpovio (selinexor)
80 mg
once weekly carton
|
1 carton per 28 days (sixteen
20 mg tablets per 28 days)
|
|
Xpovio (selinexor)
80 mg
once weekly carton
|
1 carton per 28 days
(eight 40 mg tablets
per 28 days)
|
|
Xpovio (selinexor)
60 mg
once weekly carton
|
1 carton per 28 days
(twelve 20 mg tablets
per 28 days)
|
|
Xpovio (selinexor)
60 mg
once weekly carton
|
1 carton per 28 days
(four 60 mg tablets
per 28 days)
|
|
Xpovio (selinexor)
40 mg
once weekly carton
|
1 carton per 28 days
(eight 20 mg tablets
per 28 days)
|
|
Xpovio (selinexor)
40 mg
once weekly carton
|
1 carton per 28 days
(four 40 mg tablets
per 28 days)
|
Place of Service:
Outpatient
The above policy is based on the following references:
- Xpovio [package insert]. Newton, MA: Karyopharm Therapeutics Inc.; July 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.
April 15, 2023
