Subject: Specialty Quantity Limit Piqray 3091-H P2025

Drug

PIQRAY  (alpelisib)

Policy:

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 all FDA-approved indications fall within the standard limits. Coverage of an additional quantity may be reviewed on a case-by-case basis upon request.

Covered Quantities

Medication	Standard Limit
Piqray (alpelisib) 300 mg daily dose (packaged as Piqray 150 mg tablets)	56 tablets per 28 days
Piqray (alpelisib) 250 mg daily dose   (packaged as Piqray 200 mg and Piqray 50 mg tablets)	56 tablets (28- 200 mg tablets + 28- 50 mg tablets) per 28 days
Piqray (alpelisib) 200 mg daily dose (packaged as Piqray 200 mg tablets)	28 tablets per 28 days

FDA-recommended Dosing

The recommended dose of Piqray is 300 mg once daily.

Dose reductions as needed for adverse reactions.

Place of Service:

Outpatient

The above policy is based on the following references:

1. Piqray [package insert]. East Hanover, NJ: Novartis Pharmaceuticals Corporation; January 2024.

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 07, 2025