Subject: Specialty Quantity Limit Zokinvy 4386-H P2024

Drug

ZOKINVY  (lonafarnib)

Policy:

I.  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.


II.  COVERED QUANTITIES

Medication	Standard Limit	FDA-recommended dosing
Zokinvy (lonafarnib) 50 mg capsules	120 capsules per 30 days	Doses are based on BSA (≥ 0.39 m2) and rounded to                the nearest 25 mg.         Initial dose is 115 mg/m2 twice daily.         After four months, the dose is increased to 150 mg/m2         twice daily.
Zokinvy (lonafarnib) 75 mg capsules	120 capsules per 30 days

 

Place of Service:

Outpatient

The above policy is based on the following references:

1. Zokinvy [package insert]. Palo Alto, CA: Eiger BioPharmaceuticals, Inc.; November 2020.

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 18, 2024