Subject: Specialty Quantity Limit Enbrel 2268-H P2023

Drug

ENBREL  (etanercept)

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
Enbrel (etanercept) 25   mg per 0.5 mL   prefilled syringe	8 syringes per   28 days	N/A	RA/PsA/AS   •   50 mg every week   PsO   •   Loading dose: 50 mg twice a week        for 3 months   •   Maintenance dose: 50 mg every        week   Pediatric PsO/PJIA/PsA   •   Weight < 63 kg: 0.8 mg per kg        every week   •   Weight ≥ 63 kg: 50 mg every week
Enbrel (etanercept) 25   mg per 0.5 mL   single-dose vial	8 vials per 28 days	16 vials per   28 days
Enbrel (etanercept) 50   mg per 1 mL prefilled   syringe/cartridge	4 syringes/   cartridges   per 28 days	8 syringes/   cartridges per   28 days
Enbrel (etanercept) 50   mg per mL SureClick   autoinjector	4 autoinjectors   per 28 days	8 autoinjectors   per 28 days

Abbreviations: RA = rheumatoid arthritis; PsA = psoriatic arthritis; AS = ankylosing spondylitis; PsO = plaque psoriasis; PJIA = polyarticular juvenile idiopathic arthritis
*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. Enbrel [package insert]. Thousand Oaks, CA: Immunex Corporation; June 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.

February 11, 2024