Subject: Specialty Quantity Limit Zurzuvae 6271-H P2024

Drug

ZURZUVAE  (zuranolone)

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 the treatment of 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
Zurzuvae (zuranolone) 20 mg capsules	28 capsules per 14 days
Zurzuvae (zuranolone) 25 mg capsules	28 capsules per 14 days
Zurzuvae (zuranolone) 30 mg capsules	14 capsules per 14 days

FDA-recommended Dosing

Recommended dosage: 50 mg once daily for 14 days.

Reduce dosage to 40 mg once daily if patient experiences CNS depressant effects.

Reduce dosage to 30 mg once daily for the following scenarios:

• Concomitant use with a strong CYP3A4 inhibitor
• Hepatic or renal impairment

Place of Service:

Outpatient

The above policy is based on the following references:

1. Zurzuvae [package insert]. Cambridge, MA: Sage Therapeutics, 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.

April 20, 2025