Subject: Specialty Quantity Limit Scemblix 5043-H P2025

Drug

SCEMBLIX  (asciminib)

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
Scemblix (asciminib) 20 mg tablet	60 tablets per 30 days
Scemblix (asciminib) 40 mg tablet	240 tablets per 30 days
Scemblix (asciminib) 100 mg tablet	120 tablets per 30 days

FDA-recommended Dosing

Philadelphia chromosome positive chronic myeloid leukemia in chronic phase (Ph+CML in CP)

• 80 mg once daily or 40 mg twice daily.
• with T315I mutation: 200 mg twice daily.

Dosage adjustments may be required for adverse reactions.

Place of Service:

Outpatient

The above policy is based on the following references:

1. Scemblix [package insert]. East Hanover, NJ: Novartis Pharmaceuticals Corporation; October 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.

August 02, 2025