Subject: Specialty Quantity Limit Nemluvio 6593-H P2026

Drug

NEMLUVIO  (nemolizumab-ilto)

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
Nemluvio (nemolizumab-ilto) 30 mg/0.49 mL single-dose prefilled pen	2 pens per 28 days

FDA-recommended Dosing

Prurigo Nodularis

• Adult patients weighing less than 90 kg: Initial dose of 60 mg (two 30 mg injections), followed by 30 mg given every 4 weeks.
• Adult patients weighing 90 kg or more: Initial dose of 60 mg (two 30 mg injections), followed by 60 mg given every 4 weeks.

Atopic Dermatitis

Adults and pediatric patients 12 years of age and older: Initial dose of 60 mg (two 30 mg injections), followed by 30 mg given every 4 weeks. After 16 weeks of treatment, for patients who achieve clear or almost clear skin, a dose of 30 mg given every 8 weeks is recommended.

Place of Service:

Outpatient

The above policy is based on the following references:

1. Nemluvio [package insert]. Dallas, TX: Galderma Laboratories, L.P.; June 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 29, 2026