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.

FDA-Recommended Dosing

Asthma

Adults and adolescent patients 12 years of age and older

30 mg every 4 weeks for the first 3 doses, followed by 30 mg every 8 weeks

Pediatric patients 6 to 11 years of age

Less than 35 kg

10 mg every 4 weeks for the first 3 doses, followed by 10 mg every 8 weeks

Greater than or equal to 35 kg

30 mg every 4 weeks for the first 3 doses, followed by 30 mg every 8 weeks

Eosinophilic Granulomatosis with Polyangiitis (EGPA)

30 mg every 4 weeks

Hypereosinophilic Syndrome (HES)

30 mg every 4 weeks