Subject: Specialty Quantity Limit Cometriq 1858-H P2024_R

Drug

COMTRIQ  (cabozantinib)

Policy:

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.

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
Cometriq (cabozantinib) Kit   60 mg daily dose blister cards Kit	1 Kit (84 capsules of 20 mg)   per 28 days	n/a
Cometriq (cabozantinib) Kit   100 mg daily dose blister cards Kit	1 Kit (28 capsules of 20 mg, 28 capsules of 80 mg)   per 28 days	2 Kits per 28 days
Cometriq (cabozantinib) Kit   140 mg daily dose blister cards Kit	1 Kit (84 capsules of 20 mg, 28 capsules of 80 mg)   per 28 days	2 Kits per 28 days

FDA RECOMMENDED DOSING

140 mg orally once daily

Dose may need to be modified based on adverse reactions, hepatic impairment, or drug interactions with strong CYP3A4 inducers or inhibitors.

When used with a strong CYP3A4 inducer, increase the daily Cometriq dose by 40mg (for example, from 140 mg to 180 mg daily or from 100 mg to 140 mg daily) as tolerated.

Place of Service:

Outpatient

The above policy is based on the following references:

1. Cometriq [package insert]. Alameda, CA: Exelixis, 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.

January 01, 2025