Subject: Specialty Quantity Limit Xermelo 2752-H P2023

Drug

XERMELO  (telotristat ethyl)

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
Xermelo   250 mg tablet	84 tablets   per 28 days	Carcinoid syndrome diarrhea in adults:250 mg three times daily

 

Place of Service:

Outpatient

The above policy is based on the following references:

1. Xermelo [package insert]. Deerfield, IL: TerSera Therapeutics LLC; September 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.

February 11, 2024