Subject: Specialty Quantity Limit Lorbrena 2790-H P2024_R

Drug

LOBRENA  (lorlatinib)

Policy:

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.

Covered Quantities

Coverage up to the exception limits may be provided with prior authorization via the Specialty Post Limit Quantity Exception Criteria for approval.

Medication	Standard Limit	Exception Limit
Lorbrena (lorlatinib) 100 mg tablets	30 per 30 days	Not applicable
Lorbrena (lorlatinib) 25 mg tablets	90 per 30 days	150 per 30 days

FDA-recommended Dosing

100 mg orally once daily

Concomitant use of moderate CYP3A inducers:

If concomitant use with moderate CYP3A inducers is unavoidable, increase the dose to 125 mg once daily

Recommended dose reductions for adverse reactions, renal impairment, or drug interactions:

• First dose reduction: 75 mg once daily

• Second dose reduction: 50 mg once daily

Place of Service:

Outpatient

The above policy is based on the following references:

1. Lorbrena [package insert]. New York, NY: Pfizer, Inc.; 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.

January 01, 2025