Subject: Specialty Quantity Limit Lunsumio 5730-H P2023a

Drug

LUNSUMIO  (mosunetuzumab-axgb)

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 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
Lunsumio   (mosunetuzumab-   axgb) 1mg/mL   single-dose vial	3 vials per 8 days	Recommended dosage: 21-Day Treatment Cycles    Cycle 1 Day 1 – 1 mg IV over at least 4 hours     Cycle 1 Day 8 - 2 mg IV over at least 4 hours      Cycle 1 Day 15 – 60 mg IV over at least 4 hours       Cycle 2 Day 1 – 60 mg IV over 2 hours if tolerated        Cycle 3 and following cycles - Day 1 – 30 mg IV over 2        hours if tolerated   Dose modifications may be needed due to adverse reactions.
Lunsumio   (mosunetuzumab-   axbg) 30 mg/30 mL   single-dose vial	2 vials per 21 days

 

Place of Service:

Outpatient

The above policy is based on the following references:

1. Lunsumio [package insert]. South San Francisco, CA: Genentech, Inc.; December 2022.

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.

December 31, 2023