CurrentCignaPolicy N/A

Jaypirca Drug Quantity Management Policy

Defines quantity limits and medical necessity exceptions for Jaypirca (pirtobrutinib) 50 mg and 100 mg tablets, including expanded per-dispensing quantities when patients are taking CYP3A inducers or inhibitors. Applies to Cigna-administered health benefit plans subject to plan terms.

Policy Summary

PayerCigna

PolicyJaypirca Drug Quantity Management Policy

Policy CodePolicy N/A

Change TypeMaterial and non-material revisions (annual updates and clarifications)

Effective Date

Next Review Date

Key ActionIf the Drug Quantity Management rule is not met at point of service, coverage will be determined by the stated criteria; all approvals are provided for 1 year in duration.

POLICY UPDATE CHANGES

Jaypirca 50mg tablets: Criteria was added to approve 90 tablets per dispensing at retail or 270 tablets at home delivery if the patient is taking a strong CYP3A inhibitor.

Updated the note for CYP3A inducers to remove ritonavir.

Jaypirca 50mg and 100mg tablets: criteria for approving 90 tablets retail / 270 home delivery when taking a moderate or strong CYP3A inducer (and for 50mg when taking a strong CYP3A inhibitor) are present.

2Strengths with specified baseline limits

2Conditions triggering expanded quantity

1Approval duration (years)

Coverage Summary

Defines quantity limits and medical necessity exceptions for Jaypirca (pirtobrutinib) 50 mg and 100 mg tablets, including expanded per‑dispensing quantities when patients are taking CYP3A inducers or inhibitors. Coverage stance: mixed. This policy sets baseline retail and home delivery maximums for Jaypirca tablets and specifies criteria under which larger quantities are considered medically necessary.