Subject: Specialty Quantity Limit Xuriden 2999-H P2024

Drug

XURIDEN  (uridine triacetate)

Note:

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
Xuriden (uridine triacetate) oral granules, 2 gram packet	4 packets per day	Hereditary Orotic Aciduria:      Starting dosage: 60 mg/kg once daily; dose may be       increased to 120 mg/kg (not to exceed 8 grams) once      daily for insufficient efficacy.

 

Place of Service:

Outpatient

The above policy is based on the following references:

1. Xuriden [package insert]. West Conshohocken, PA: BTG International Inc.; August 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.

April 17, 2024