Subject: Specialty Quantity Limit metyrosine-Demser 6392-H P2025

Drug

DEMSER  (metyrosine)

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

The limits may apply to the generic equivalent medication.

Medication	Standard Limit
Demser (metyrosine) 250 mg capsules	480 capsules per 30 days

FDA-recommended Dosing

250 mg orally four times daily. This may be increased by 250 mg to 500 mg every day to a maximum of 4 g/day in divided doses.

Place of Service:

Outpatient

The above policy is based on the following references:

1. Demser [package insert]. Bridgewater, NJ: Bausch Health US, LLC.; July 2021.
2. metyrosine [package insert]. Bridgewater, NJ. Amneal Pharmaceuticals LLC.; 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.

June 07, 2025