Subject: Specialty Quantity Limit Adbry 5126-H P2024

Drug

ADBRY  (tralokinumab-ldrm)

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
Adbry (tralokinumab-ldrm)   150 mg/mL prefilled syringe	4 syringes per 28 days	4 syringes per 14 days	•    Adults: Initial dose of 600 mg (four 150 mg        injections), followed by 300 mg (two 150 mg        injections) administered every other week. After        16 weeks of treatment, for patients with body           weight below 100 kg who achieve clear or almost        clear skin, a dosage of 300 mg every 4 weeks        may be considered.   •    12 to 17 years old: Initial dose of 300 mg (two        150 mg injections), followed by 150 mg (one 150        mg injection) every other week.

  *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. Adbry [package insert]. Madison, NJ: LEO Pharma Inc.; December 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.

April 11, 2024