Subject: Specialty Quantity Limit gefitinib-Iressa 2904-H P2024

Drug

IRESSA  (gefitinib)

gefitinib

Policy:

I.  PROGRAM DESCRIPTION

The standard limit is designed to allow a quantity sufficient for the most common uses of the medication. If the 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
Iressa (gefitinib) 250 mg tablet	30 per 30 days	60 per 30 days	Standard dosing: 250 mg once daily   Drug Interaction, coadministration with a strong CYP3A4   inducer: 500 mg (two 250 mg tablets) per day

The limits may apply to the generic equivalent medication.

 

  *Coverage up to the exception limits may be provided with prior authorization via the Specialty Post Limit   

Quantity Exception Criteria for approval.

 

Place of Service:

Outpatient

The above policy is based on the following references:

 

1. Iressa [package insert]. Wilmington, DE: AstraZeneca Pharmaceuticals LP; February 2023.
2. Gefitinib [package insert]. Orlando, FL: Ingenus Pharmaceuticals, LLC; April 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