Subject: Specialty Quantity Limit Venclexta 2997-H P2025

Drug

VENCLEXTA  (venetoclax)

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
Venclexta (venetoclax) 10 mg tablets	120 per 30 days
Venclexta (venetoclax) 50 mg tablets	120 per 30 days
Venclexta (venetoclax) 100 mg tablets	180 per 30 days
Venclexta (venetoclax) Starting Pack   •  Week 1 (14 x 10 mg tablets)   •  Week 2 (7 x 50 mg tablets)   •  Week 3 (7 x 100 mg tablets)   •  Week 4 (14 x 100 mg tablets)	1 pack (42 tablets) per 28 days

FDA-recommended Dosing

Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma

Dose according to a weekly ramp-up schedule over 5 weeks starting at 20 mg daily up to 400 mg daily.

Acute Myeloid Leukemia

Dose and ramp-up depend upon the combination agent, starting at 100 mg daily up to 600 mg daily.

Place of Service:

Outpatient

The above policy is based on the following references:

              1. Venclexta [package insert]. North Chicago, IL: AbbVie Inc.; July 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