Subject: Specialty Quantity Limit cinacalcet-Sensipar 1625-H P2022a
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
|
|
Sensipar (cinacalcet)
30mg tablets
|
60 per 30 days
|
Secondary
Hyperparathyroidism:
30, 60, 90, 120, and 180 mg
once daily
Parathyroid Carcinoma and
Primary Hyperparathyroidism:
30 mg twice daily, 60 mg twice
daily, 90 mg twice daily, and
90 mg 3 or 4 times daily
|
|
Sensipar (cinacalcet)
60 mg tablets
|
60 per 30 days
|
|
Sensipar (cinacalcet)
90 mg tablets
|
120 per 30 days
|
*The limits may apply to the generic equivalent medication.
Place of Service:
Outpatient
The above policy is based on the following references:
- Sensipar [package insert]. Thousand Oaks, CA: Amgen, Inc.; December 2019.
- Cinacalcet [package insert]. Cranbury, NJ: Sun Pharmaceuticals Industries, Inc.; December 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.
April 11, 2023
