Subject: Specialty Quantity Limit Omvoh 6243-H P2023

Drug

OMVOH  (mirikizumab-mrkz)

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 the treatment of moderately to severe active ulcerative colitis 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
Omvoh (mirikizumab-   mrkz) 300 mg/15 mL   single-dose vial	3 vials per 56 days	Induction dose: 300 mg administered by intravenous   infusion over at least 30 minutes at Weeks 0, 4, and 8.   Maintenance dose: 200 mg administered by subcutaneous   injection (given as two consecutive injections of 100 mg   each) at Week 12, and every 4 weeks thereafter.
Omvoh (mirikizumab-   mrkz) subcutaneous   injection 100 mg/mL   single-dose prefilled   pen	1 carton (2 pens)   per 28 days

 

Place of Service:

Outpatient

The above policy is based on the following references:

1. Omvoh [package insert]. Indianapolis, IN: Eli Lilly and Company.; October 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.

December 31, 2023