Subject: Specialty Quantity Limit Rasuvo 2273-H P2026

Drug

RASUVO  (methotrexate)

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

Brand Name	Generic Name
Rasuvo (methotrexate injection)   single-dose auto-injector for subcutaneous   injection     ·      7.5 mg per 0.15 mL     ·      10 mg per 0.2 mL     ·      12.5 mg per 0.25 mL     ·      15 mg per 0.3 mL     ·      17.5 mg per 0.35 mL     ·      20 mg per 0.4 mL     ·      22.5 mg per 0.45 mL     ·      25 mg per 0.5 mL     ·      30 mg per 0.6 mL	4 injections per 28 days

FDA-recommended Dosing

Rheumatoid arthritis

7.5 mg every week (adjust gradually to achieve an optimal response), up to 20 mg per week

Polyarticular juvenile idiopathic arthritis

10 mg per m² every week (adjust gradually to achieve an optimal response), up to 20 mg per m² per week

Psoriasis

10 mg to 25 mg every week (adjust gradually to achieve an optimal response), up to 30 mg per week

Place of Service:

Outpatient

The above policy is based on the following references:

1. Rasuvo [package insert]. Chicago, IL: Medexus Pharma Inc.; December 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.

April 29, 2026