Subject: Specialty Quantity Limit Lonsurf 2979-H P2025

Drug

LONSURF  (trifluridine and tipiracil)

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 the treatment of hepatitis C infection 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
Lonsurf (trifluridine and tipiracil) 15 mg/6.14 mg tablet	100 tablets per 28 days
Lonsurf (trifluridine and tipiracil) 20 mg/8.19 mg tablet	80 tablets per 28 days

FDA-Recommended Dosing

35 mg/m² up to a maximum of 80 mg per dose (based on the trifluridine component) orally twice daily with food on Days 1 through 5 and Days 8 through 12 of each 28-day cycle until disease progression or unacceptable toxicity.

Round dose to the nearest 5 mg increment.

Place of Service:

Outpatient

The above policy is based on the following references:

1. Lonsurf [package insert]. Princeton, NJ: Taiho Oncology, Inc.; August 2023.

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