Subject: Specialty Quantity Limit erlotinib 1756-H P2024

Drug

erlotinib

Policy:

I.  PROGRAM DESCRIPTION

The standard limit is designed to allow a quantity sufficient for the most common uses of the medication. If member’s plan allows a quantity limit exception review for the requested medication, coverage of an additional quantity may be provided up to the exception limit with prior authorization.


II.  COVERED QUANTITIES

Medication	Standard Limit	Exception Limit*	FDA-Recommended dosing
erlotinib 25 mg tablets	60 per 30 days	Not applicable	Non-small cell lung cancer (NSCLC):   150 mg once daily   Pancreatic cancer:   100 mg once daily   –  Up to 300 mg if cigarette smoker   –  Up to 450 mg if co-administered with       a strong CYP3A4 inducer
erlotinib 100 mg tablets	30 per 30 days	120 per 30 days
erlotinib 150 mg tablets	30 per 30 days	90 per 30 days

* Coverage up to the exception limits may be provided with prior authorization via the Specialty Post Limit
Quantity Exception Criteria for approval.
**The limits may apply to the generic equivalent medication.

 

Place of Service:

Outpatient

The above policy is based on the following references:

1. Erlotininb [package insert]. Pennington, NJ: Zydus Pharmaceuticals USA, Inc.; October 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.

August 18, 2024