Subject: Specialty Quantity Limit Enbrel 2268-H P2025

Drug

ENBREL  (etanercept)

Policy:

Program Description

The standard limit is designed to allow a quantity sufficient for the most common uses of the medication. If the member’s plan allows a quantity limit exception review for the requested medication, coverage of an additional quantity may be provided up to the exception limit with prior authorization.

Covered Quantities

Coverage up to the exception limits may be provided with prior authorization via the Specialty Post Limit Quantity Exception Criteria for approval.

Medication	Standard Limit	Exception Limit
Enbrel (etanercept) 25 mg per 0.5 mL prefilled syringe	8 syringes per 28 days	N/A
Enbrel (etanercept) 25 mg per 0.5 mL single-dose vial	8 vials per 28 days	16 vials per 28 days
Enbrel (etanercept) 50 mg per mL prefilled syringe/cartridge	4 syringes/cartridges per 28 days	8 syringes/cartridges per 28 days
Enbrel (etanercept) 50 mg per mL SureClick autoinjector	4 autoinjectors per 28 days	8 autoinjectors per 28 days

FDA-recommended Dosing

Abbreviations: RA = rheumatoid arthritis; PsA = psoriatic arthritis; AS = ankylosing spondylitis; PsO = plaque psoriasis; PJIA = polyarticular juvenile idiopathic arthritis

RA/PsA/AS

50 mg every week

PsO

• Loading dose: 50 mg twice a week for 3 months
• Maintenance dose: 50 mg every week

Pediatric PsO/PJIA/PsA

• Weight less than 63 kg: 0.8 mg per kg every week
• Weight greater than or equal to 63 kg: 50 mg every week

Place of Service:

Outpatient

The above policy is based on the following references:

1. Enbrel [package insert]. Thousand Oaks, CA: Immunex Corporation; October 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.

February 16, 2026