Subject: Specialty Quantity Limit Yonsa 2603-H P2023

Drug

YONSA  (fine-particle abiraterone acetate)

Policy:

I.  PROGRAM DESCRIPTION

  The standard limit is designed to allow a quantity sufficient for the most common uses of the medication. If the
  member’s plan allows a quantity limit exception review for the requested medication, coverage of an additional
  quantity may be provided up to the exception limit with prior authorization.


II.  COVERED QUANTITIES

Medication	Standard Limit	Exception Limit*	FDA-recommended dosing
Yonsa   (abiraterone)   125 mg tablets	120 per 30 days	240 per 30 days	Standard dosing: 500 mg (four 125 mg tablets) once  daily  Drug interaction, coadministration with a strong  CYP3A4 inducer: 500 mg (four 125 mg tablets) twice  daily

 *Coverage up to the exception limits may be provided with prior authorization via the Specialty Post Limit Quantity
  Exception Criteria for approval.

 

Place of Service:

Outpatient

The above policy is based on the following references:

1. Yonsa [package insert]. Cranbury, NJ: Sun Pharmaceutical Industries, 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.

December 31, 2023