Subject: Specialty Quantity Limit Caprelsa 1790-H P2025

Drug

CAPRELSA  (vandetanib)

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
Caprelsa (vandetanib) 100 mg tablets	60 per 30 days
Caprelsa (vandetanib) 300 mg tablets	30 per 30 days

FDA-recommended Dosing

Standard dosing

300 mg once daily

Severe toxicities, QTc interval prolongation

200 mg (two 100 mg tablets) or 100 mg per day

Renal impairment

200 mg per day

Place of Service:

Outpatient

The above policy is based on the following references:

1. Caprelsa [package insert]. Cambridge, MA: Genzyme Corporation; May 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.

January 01, 2026