Subject: Dronabinol Limit Policy 137-H 01-2024
| DRONABINOL PRODUCTS |
|
MARINOL
(dronabinol)
|
|
SYNDROS
(dronabinol oral solution)
|
Policy:
FDA-APPROVED INDICATIONS
Marinol
Marinol is indicated in adults for the treatment of:
• anorexia associated with weight loss in patients with Acquired Immune Deficiency Syndrome
(AIDS).
• nausea and vomiting associated with cancer chemotherapy in patients who have failed to
respond adequately to conventional antiemetic treatments.
Syndros
Syndros is indicated in adults for the treatment of:
• anorexia associated with weight loss in patients with Acquired Immune Deficiency Syndrome
(AIDS).
• nausea and vomiting associated with cancer chemotherapy in patients who have failed to
respond adequately to conventional antiemetic treatments.
|
INITIAL LIMIT QUANTITY
|
|
Limits do not accumulate together; patient is allowed the maximum limit for each drug and strength
|
|
Drug
|
1 Month Limit*
|
3 Month Limit*
|
|
Marinol 2.5 mg, 5 mg, 10 mg (dronabinol capsules)
|
60 capsules / 25 days
|
180 capsules / 75 days
|
|
Syndros (dronabinol oral solution)
|
120 mL / 25 days
|
360 mL / 75 days
|
|
*The duration of 25 days is used for a 30-day fill period and 75 days is used for a 90-day fill period to allow time for refill processing.
|
Place of Service:
Outpatient
The above policy is based on the following references:
- Marinol [package insert]. Parsippany, N J: ThePharmaNetwork, LLC; January 2023.
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 16, 2024
