Subject: Specialty Quantity Limit Retevmo 3876-H P2024b

Drug

RETEVMO  (selpercatinib)

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
Retevmo (selpercatinib) 40 mg capsules	90 per 30 days	Adult and adolescent patients 12 years of age or older   recommended dosing is based on body weight:   •   Less than 50 kg: 120 mg twice daily   •   50 kg or greater: 160 mg twice daily   Pediatric patients 2 to less than 12 years of age recommended   dosing is based on body surface area:   •   0.33 to 0.65 m2: 40mg three times daily   •   0.66 to 1.08 m2: 80mg twice daily   •   1.09 to 1.52 m2: 120mg twice daily   •   ≥1.53 m2: 160mg twice daily   Dose reduction may be required for adverse reactions, severe   hepatic impairment, or for concomitant use with strong or moderate   CYP3A inhibitors.
Retevmo (selpercatinib) 40 mg tablets	90 per 30 days
Retevmo (selpercatinib) 80 mg capsules	120 per 30 days
Retevmo (selpercatinib) 80 mg tablets	120 per 30 days
Retevmo (selpercatinib) 120 mg tablets	60 per 30 days
Retevmo (selpercatinib) 160 mg tablets	60 per 30 days

 

 

Place of Service:

Outpatient

The above policy is based on the following references:

RETEVMO

1. Retevmo [package insert]. Indianapolis, IN: Lilly USA, LLC; May 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.

August 18, 2024