Subject: Specialty Quantity Limit Voxzogo 5070-H P2024

Drug

VOXZOGO  (vosoritide)

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 increasing linear growth in pediatric patients with achondroplasia with open epiphyses 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
Voxzogo (vosoritide)single-dose vial 0.4 mg	30 per 30 days	Subcutaneous injection once daily based on patient’s actual body weight:
		Actual Body   weight  3 kg   4 kg   5 kg   6-7 kg   8-11 kg  12-16 kg  17-21 kg  22-32 kg  33-43 kg  44-59 kg  60-89 kg  ≥90 kg	Vial strength for   reconstitution   0.4 mg   0.4 mg   0.4 mg   0.4 mg   0.4 mg   0.56 mg   0.56 mg   0.56 mg   1.2 mg   1.2 mg   1.2 mg   1.2 mg	Dose   0.096 mg   0.12 mg   0.16 mg   0.2 mg   0.24 mg   0.28 mg   0.32 mg   0.4 mg   0.5 mg   0.6 mg   0.7 mg   0.8 mg	Injection Volume   0.12 mL   0.15 mL   0.2 mL   0.25 mL   0.3 mL   0.35 mL   0.4 mL   0.5 mL   0.25 mL   0.3 mL   0.35 mL   0.4 mL
Voxzogo (vosoritide) single-dose vial 0.56 mg	30 per 30 days
Voxzogo (vosoritide) single-dose vial 1.2 mg	30 per 30 days

 

Place of Service:

Outpatient

The above policy is based on the following references:

1. Voxzogo [package insert]. Novato, CA: BioMarin Pharmaceutical 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.

June 09, 2024