Subject: Specialty Quantity Limit Verzenio 2344-H P2025

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
Verzenio (abemaciclib) 50 mg tablet	56 tablets per 28 days
Verzenio (abemaciclib) 100 mg tablet	56 tablets per 28 days
Verzenio (abemaciclib) 150 mg tablet	56 tablets per 28 days
Verzenio (abemaciclib) 200 mg tablet	56 tablets per 28 days

FDA-recommended Dosing

Breast Cancer:

• When used in combination with fulvestrant, tamoxifen, or aromatase inhibitor, the recommended dose is 150 mg orally twice daily.
• When used as monotherapy, the recommended dose is 200 mg orally twice daily.

Dose modifications may be required for adverse reactions, severe hepatic impairment, or use with moderate or strong CYP3A inhibitors.

Place of Service:

Outpatient

The above policy is based on the following references:

1. Verzenio [package insert]. Indianapolis, IN: Eli Lilly and Company; 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