Subject: Specialty Quantity Limit Braftovi 2617-H P2026

Drug

BRAFTOVI  (encorafenib)

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
Braftovi (encorafenib) 75 mg capsules	180 per 30 days

FDA-recommended Dosing

Melanoma and Non-Small Cell Lung Cancer

Initial dose: 450 mg once daily

Colorectal Cancer

Initial dose: 300 mg once daily

Dose reduction may be required based on adverse reactions or drug interactions with strong or moderate CYP3A4 inhibitors.

Place of Service:

Outpatient

The above policy is based on the following references:

1. Braftovi [package insert]. Boulder, CO: Array BioPharma, Inc.; March 2025.

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 18, 2026