Specialty Quantity Limit Otezla 2271-H P2024a - Specialty Pharmacy Clinical Policy Bulletins Aetna Non-Medicare Prescription Drug Plan

Specialty Pharmacy Clinical Policy Bulletins
Aetna Non-Medicare Prescription Drug Plan

Subject: Specialty Quantity Limit Otezla 2271-H P2024a

Drug

OTEZLA (apremilast)

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
Otezla (apremilast) 10 mg/20 mg/30 mg 28-day starter pack	1 pack (55 tablets) per 28 days	Adults PsO/PsA/Behcet’s disease: Day 1 to day 5 dosage titration schedule • Day 1: 10 mg in morning • Day 2: 10 mg in morning and 10 mg in evening • Day 3: 10 mg in morning and 20 mg in evening • Day 4: 20 mg in morning and 20 mg in evening • Day 5: 20 mg in morning and 30 mg in evening Day 6 and thereafter • 30 mg in morning and 30 mg in evening Pediatrics (6-17 years old) PsO weighing at least 20 kg: Day 1 to day 5 dosage titration schedule • Day 1: 10 mg in morning • Day 2: 10 mg in morning and 10 mg in evening • Day 3: 10 mg in morning and 20 mg in evening • Day 4: 20 mg in morning and 20 mg in evening • Day 5: 20 mg in morning and 20 mg in evening Day 6 and thereafter 20 kg to < 50 kg: • 20 mg in morning and 20 mg in evening Greater than or equal to 50 kg: • 30 mg in morning and 30 mg in evening
Otezla (apremilast) 10 mg/20 mg 28-day starter pack	1 pack (55 tablets) per 28 days
Otezla (apremilast) 30 mg tablets	60 tablets per 30 days
Otezla (apremilast) 20 mg tablets	60 tablets per 30 days

Place of Service:

Outpatient

The above policy is based on the following references:

Otezla [package insert]. Thousand Oaks, CA: Amgen Inc.; April 2024.

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 30, 2024

Additional Information

Clinical Policy Bulletin Notes

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