CurrentCignaPolicy N/A

Cabergoline Drug Quantity Management Policy - Per Days

Defines quantity limits and override criteria for generic cabergoline 0.5 mg tablets for Cigna-administered benefit plans, including retail and home delivery maximums and condition-specific allowed quantities.

Policy Summary

PayerCigna

PolicyCabergoline Drug Quantity Management Policy - Per Days

Policy CodePolicy N/A

Change TypeRevisedClarified

Effective Date

Next Review DateJul 3, 2024

Key ActionApprovals (including overrides) are provided for 1 year; ensure the requested quantity meets the policy's retail or home delivery maximums or an applicable diagnosis-specific override.

SourceLink

POLICY UPDATE CHANGES

Override criteria updated to specify numeric maximums per 28 days (retail) and per 84 days (home delivery) for acromegaly, Parkinson's disease, restless legs syndrome, and Cushing's syndrome.

Policy updated to reflect the existing quantity limits when product is obtained via home delivery.

8retail max per 28 days

24home max per 84 days

88hyperprolactinemia max per 28 days

1,120Parkinson's max per 28 days

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56acromegaly/Cushing's max per 28 days

Coverage Criteria

Drug quantity limits and override criteria

Cabergoline 0.5 mg tablets are covered as medically necessary when the Drug Quantity Management criteria below are met; approvals are provided for 1 year. Standard dispensed maximums apply unless a diagnosis-specific override criterion is met.

Standard quantity limits: Retail maximum: 8 tablets per 28 days; Home delivery maximum: 24 tablets per 84 daysretail=8/28 days; home=24/84 days

8 tablets provide 4 weeks of therapy at 0.5 mg twice weekly (or 12 weeks at home delivery).

Override criteria by diagnosis

Hyperprolactinemia: Approve quantity not to exceed 88 tablets per 28 days (retail) or 264 tablets per 84 days (home delivery)88/28 days; 264/84 days
Patients may require doses up to 11 mg/week to overcome resistance.
Acromegaly: Approve quantity not to exceed 56 tablets per 28 days (retail) or 168 tablets per 84 days (home delivery)56/28 days; 168/84 days
Acromegaly dosing reported 0.3 mg/week to 7 mg/week.
Parkinson's disease: Approve quantity not to exceed 1,120 tablets per 28 days (retail) or 3,360 tablets per 84 days (home delivery)1,120/28 days; 3,360/84 days
Doses up to 20 mg/day have been used.
Cushing's syndrome: Approve quantity not to exceed 56 tablets per 28 days (retail) or 168 tablets per 84 days (home delivery)56/28 days; 168/84 days
Dosing reported up to 7 mg/week.

Any exception that does not meet the specific Drug Quantity Management criteria listed in this policy is considered not medically necessary. Approvals are only provided when the patient’s diagnosis and requested quantity conform to the limits or the diagnosis-specific override criteria described below.

Requests that exceed the stated standard maximum dispensing amounts and are not supported by one of the diagnosis-specific override criteria are considered not medically necessary. Standard maximums are 8 tablets per 28 days (retail) or 24 tablets per 84 days (home delivery); higher quantities require meeting the applicable override criteria for hyperprolactinemia, acromegaly, Parkinson’s disease, or Cushing’s syndrome.

Provider Actions & Authorization

Prior Authorization

Authorization duration

All approvals for cabergoline are provided for 1 year in duration. Providers requesting authorization should note the approval period when scheduling follow-up and renewal requests.

Approval duration: 1 year

Note

Provider operational note

This policy applies to Cigna-administered health benefit plans; however, individual plan documents may supersede this policy. Providers should confirm whether the member's specific plan is administered by Cigna for coverage determinations or if the Cigna role is utilization review only.

Verify member's benefit plan terms and any applicable exclusions before submitting requests

Background

Cabergoline is a dopamine agonist indicated for hyperprolactinemic disorders (including idiopathic causes and prolactin-secreting pituitary adenomas). Recommended starting dosing for hyperprolactinemia is typically 0.25 mg twice weekly, with increases by 0.25 mg twice weekly as needed; some patients may require substantially higher doses to overcome resistance. Off-label uses of cabergoline that are addressed in this policy include acromegaly, Parkinson’s disease, and Cushing’s syndrome, where reported dosing can be much higher than for hyperprolactinemia (for example, up to several mg per week or higher in Parkinson’s disease).

Definitions

inv-09: Hyperprolactinemia — definition/key-value for hyperprolactinemic disorders.

DefinitionHyperprolactinemic disorders: conditions of elevated prolactin including idiopathic causes or pituitary adenomas treated with cabergoline.

Typical starting dose0.25 mg twice weekly (may be increased by 0.25 mg twice weekly up to 1 mg twice weekly).

Potential higher-dose requirementSome patients may require doses up to 11 mg/week to overcome resistance.

Initial Therapy Criteria

Initiation

Standard dosing and dispensing guidance for initiation.

Initial hyperprolactinemia dosing: Recommended starting dose: 0.25 mg twice weekly; increase by 0.25 mg twice weekly up to a maximum of 1 mg twice weekly (4 x 0.5 mg tablets/week). Dose adjustments should not occur more frequently than every 4 weeks.

Initiation dispensing: Dispense within standard quantity limits (Retail: 8 tablets per 28 days; Home delivery: 24 tablets per 84 days) unless an override diagnosis applies.

Continuation / Refill Criteria

Refill/renewal

Approvals for continuation are granted for up to 1 year; renewals must meet standard quantity limits or the diagnosis-specific override criteria.

Continuation approvals: Renewals granted for up to 1 year provided ongoing diagnosis is documented and requested quantity remains within policy limits or meets an override criterion.

Point-of-service rules: If the Drug Quantity Management rule is not met at point of service, coverage will be determined by the criteria in this policy; failure to meet criteria may result in denial.

Step Therapy

Step	Requirement
No step therapy requirement
Coverage is determined by the Drug Quantity Management criteria and any applicable override criteria (see Quantity Limits and COVERAGE CRITERIA). If the Drug Quantity Management rule is not met at point of service, coverage will be determined by the policy criteria; approvals (including overrides) are provided for 1 year.

Quantity Limits

inv-13: Cabergoline 0.5 mg tablets — retail maximum quantity per 28 days (standard/default).

Retail maximum (standard)8 tablets per 28 days

Strength/formCabergoline 0.5 mg tablets

Rationale8 tablets provide 4 weeks of therapy at a dose of 0.5 mg twice weekly.

inv-14: Cabergoline 0.5 mg tablets — home delivery maximum per 84 days (standard/default).

Home delivery maximum (standard)24 tablets per 84 days

Strength/formCabergoline 0.5 mg tablets

Rationale

Site of Care Considerations

Billing Rule

Site-of-care: retail vs home delivery periods

Retail dispensing limits are set per 28 days while home delivery limits are set per 84 days; ensure the dispensing channel is indicated correctly when submitting quantity requests.

Retail maximums are evaluated per 28 days.
Home delivery maximums are evaluated per 84 days.

Step Therapy

Operational: retail dispensing quantity limit (per 28 days)

Retail dispensing has a defined maximum quantity per 28 days (Retail Maximum Quantity per 28 Days = 8 tablets); confirm retail vs home delivery at point of sale to apply the correct limit.

Retail maximum: 8 tablets per 28 days for cabergoline 0.5 mg tablets.

Policy Summary

PayerCigna

PolicyCabergoline Drug Quantity Management Policy - Per Days

Policy CodePolicy N/A

Change TypeRevisedClarified

Effective Date

Next Review DateJul 3, 2024

Key ActionApprovals (including overrides) are provided for 1 year; ensure the requested quantity meets the policy's retail or home delivery maximums or an applicable diagnosis-specific override.

SourceLink

On This Page

Documentation Required

Documentation & benefit-plan considerations

When requesting coverage or exceptions for cabergoline, providers must supply supporting clinical documentation that demonstrates medical necessity and that the request meets the coverage criteria. Also verify member benefit plan limits, formulary status, and any prior authorization requirements at the point of service.

Provide clinical rationale and relevant records (diagnosis, prior treatments, response)
Confirm member benefit plan terms and formulary/prior authorization rules

Denial Risk

Drug quantity rule & denial risk

Cabergoline quantity limits apply at point of service: retail max 8 tablets per 28 days; home delivery max 24 tablets per 84 days. If the Drug Quantity Management rule is not met at point of sale, coverage will be determined by the policy criteria and may be denied if criteria are not satisfied.

Retail maximum: 0.5 mg tablets — 8 tablets per 28 days
Home delivery maximum: 0.5 mg tablets — 24 tablets per 84 days
Failure to meet quantity rule at point of service risks denial; submit exception requests with supporting documentation

24 tablets provide 12 weeks of therapy at a dose of 0.5 mg twice weekly when dispensed via home delivery.

inv-15: Cabergoline 0.5 mg tablets for hyperprolactinemia — override max per 28 days.

Override max (retail)88 tablets per 28 days

Override max (home delivery)264 tablets per 84 days

ContextApplicable when patient has hyperprolactinemia; supports higher doses needed for resistance (up to 11 mg/week).

inv-16: Cabergoline 0.5 mg tablets for hyperprolactinemia — override max per 84 days.

Override max (home delivery)264 tablets per 84 days

Override max (retail)88 tablets per 28 days

ContextApproved when diagnosis is hyperprolactinemia; accommodates patients requiring up to 11 mg/week.

inv-17: Cabergoline 0.5 mg tablets for acromegaly or Cushing's syndrome — override max per 28 days.

Override max (retail)56 tablets per 28 days

Override max (home delivery)168 tablets per 84 days

IndicationApplicable to acromegaly (off-label use; reported doses up to 7 mg/week).

inv-18: Cabergoline 0.5 mg tablets for acromegaly or Cushing's syndrome — override max per 84 days.

Override max (home delivery)168 tablets per 84 days

Override max (retail)56 tablets per 28 days

IndicationApplicable to acromegaly or Cushing's syndrome (Cushing's dosing reported up to 7 mg/week).

inv-19: Cabergoline 0.5 mg tablets for Parkinson's disease — override max per 28 days.

Override max (retail)1,120 tablets per 28 days

Override max (home delivery)3,360 tablets per 84 days

IndicationApplicable to Parkinson's disease (off-label high-dose use; reported up to 20 mg/day).

inv-20: Cabergoline 0.5 mg tablets for Parkinson's disease — override max per 84 days.

Override max (home delivery)3,360 tablets per 84 days

Override max (retail)1,120 tablets per 28 days

IndicationApplicable to Parkinson's disease; supports high-dose regimens described in literature.