Subject: Specialty Quantity Limit Tegsedi 2775-H P2024

Drug

TEGSEDI  (inotersen)

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 FDA-approved indication fall within the standard limits. Coverage of an additional quantity may be reviewed on a case-by-case basis upon request.

COVERED QUANTITIES

Medication	Standard Limit	FDA-recommended dosing
Tegsedi (inotersen) 284 mg/1.5 mL single-dose prefilled syringe	4 prefilled syringes   per 28 days	284 mg administered by subcutaneous injection once weekly.

 

Place of Service:

Outpatient

The above policy is based on the following references:

1. Tegsedi [package insert]. Waltham, MA: Sobi, Inc.; January 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.

November 03, 2024