Subject: Specialty Quantity Limit erlotinib-Tarceva 1756-H P2023
|
TARCEVA
(erlotinib)
|
|
erlotinib
|
Policy:
I. PROGRAM DESCRIPTION
The standard limit is designed to allow a quantity sufficient for
the most common uses of the medication. If 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
|
|
Tarceva (erlotinib)
25 mg tablets
|
60 per 30 days
|
Not applicable
|
Non-small cell lung cancer
(NSCLC): 150 mg once daily
Pancreatic cancer: 100 mg
once daily
- Up to 300 mg if cigarette
smoker
- Up to 450 mg if co-
administered with a strong
CYP3A4 inducer
|
|
Tarceva (erlotinib)
100 mg tablets
|
30 per 30 days
|
120 per 30 days
|
|
Tarceva (erlotinib)
150 mg tablets
|
30 per 30 days
|
90 per 30 days
|
* Coverage up to the exception limits may be provided with prior authorization via the Specialty Post Limit
Quantity Exception Criteria for approval.
**The limits may apply to the generic equivalent medication.
Place of Service:
Outpatient
The above policy is based on the following references:
1. Tarceva [package insert]. South San Francisco, CA: Genentech
USA, Inc.; October 2016.
2. Erlotininb [package insert]. Pennington, NJ: Zydus Pharmaceuticals
USA, Inc.; April 2020.
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.
August 18, 2023
