Drug Quantity Management Policy - Calquence (acalabrutinib) - Per Rx
Defines per-prescription quantity limits and exceptions for Calquence (acalabrutinib) for Cigna-administered health benefit plans, including retail and home delivery maximums and adjustments when patients take strong CYP3A inducers.
No material clinical or coverage changes in this revision.
Coverage Criteria
Quantity limits and CYP3A inducer exception
Covered as medically necessary when the per‑Rx quantity limits or the CYP3A inducer exception are met; approvals provided for 1 year.
If these limits are met, product is covered as medically necessary.
Examples of strong CYP3A inducers include, but are not limited to, apalutamide, carbamazepine, enzalutamide, mitotane, phenytoin, rifampin, and St. John's wort.
Any request for an exception to the stated product quantity limits that does not meet the policy criteria is considered not medically necessary. The policy’s Drug Quantity Limits specify maximum per‑prescription quantities for Calquence (acalabrutinib) 100 mg capsules or tablets; exceptions that fall outside those defined criteria will be denied as not medically necessary.
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