CurrentCignaPolicy N/A

Oncology - Dasatinib Products Drug Quantity Management Policy - Per Rx

Policy Summary

PayerCigna

PolicyOncology - Dasatinib Products Drug Quantity Management Policy - Per Rx

Policy CodePolicy N/A

Change TypeMaterial: Phyrago added; other annual/revision notes

Effective Date

Next Review DateFeb 4, 2026

Key ActionIf a requested quantity exceeds the Drug Quantity Management rule at point of service, request an override with documented clinical criteria; approvals are provided for 1 year.

SourceLink

POLICY UPDATE CHANGES

Phyrago tablets were added to the policy with the same quantity limits and clinical overrides as Sprycel tablets.

Sprycel availability as generic dasatinib was added and generic was substituted through the policy.

Annual revision with no criteria changes noted on 02/20/2024.

6Dasatinib tablet strengths addressed

270Max retail (20 mg exception)

810Max home delivery (20 mg exception)

Retail for 50 mg BID override

180Home delivery for 50 mg BID override

Coverage Summary

Defines retail and home delivery maximum quantity per prescription limits for dasatinib products (Sprycel/generic and Phyrago) and the clinical override criteria that permit exceptions; approvals are for 1 year. Products covered include Sprycel (dasatinib) and Phyrago. The Drug Quantity Management (DQM) program sets per-dispensing maximums but allows exceptions when the specified clinical criteria are met (for example, dosing not corresponding to commercially available dosage forms or a 50 mg twice-daily dose reduction), with approvals granted for one year.

Key Policy Statistics

Dasatinib tablet strengths addressed6

Max retail tablets per Rx (20 mg exception)270

Max home delivery tablets per Rx (20 mg exception)810

Retail tablets per Rx for 50 mg BID override60

Home delivery tablets per Rx for 50 mg BID override180

Quantity Limit Exceptions & Provider Requirements

General Exception Rule

EXCEPTIONS TO THE QUANTITY LIMITS LISTED ABOVE ARE COVERED AS MEDICALLY NECESSARY WHEN THE FOLLOWING CRITERIA ARE MET. ANY OTHER EXCEPTION IS CONSIDERED NOT MEDICALLY NECESSARY.

Request is for dasatinib (Sprycel, generic) 20 mg tablets or Phyrago 20 mg tablets AND the patient is taking a dose that does not correspond to a commercially-available dosage form (i.e., the dose requires multiple tablets of the same strength be used OR would otherwise require two or more strengths to be used).

If met, approve requested quantity up to 270 tablets per dispensing at retail or 810 tablets per dispensing at home delivery.

50 mg tablet override

Exceptions for 50 mg strength

Patient requires a dose reduction to 50 mg twice daily.

If met, approve 60 tablets per dispensing at retail or 180 tablets per dispensing at home delivery.

70 mg, 80 mg, 100 mg, 140 mg tablets

Applicable Codes

N/A - No procedure or diagnosis codes specifiedmixed

No codes listed

Background & Clinical Evidence

Dasatinib is a tyrosine kinase inhibitor indicated for Philadelphia chromosome–positive (Ph+) acute lymphoblastic leukemia (ALL) and Ph+ chronic myeloid leukemia (CML) across various phases and age groups, including pediatric indications. Adult and pediatric dosing recommendations vary by indication and pediatric weight-based bands; CYP3A4 inhibitors and inducers can necessitate dose reduction or increase, and doses may be adjusted for hematologic toxicities. The policy implements quantity limits to promote safe, effective, and economic use of dasatinib.

Prescribing information citations: Sprycel prescribing information July 2024; Phyrago prescribing information August 2025.

Drug Quantity Management (DQM): Program to set maximum dispensed quantities per prescription to promote safe, effective, and economic use; exceptions considered when defined criteria are met.

Revision History

clarifiedLatest

Policy title updated to include 'Products' and Phyrago strengths (20, 50, 70, 80, 100, 140 mg) were added; Phyrago tablets were added to the policy with the same quantity limits and clinical overrides as Sprycel tablets.

02/19/2025revised

Generic dasatinib added and brand 'Sprycel' changed to 'dasatinib' throughout policy in prior revision.

02/20/2024annual_review

Annual revision with no clinical policy statement changes.

Policy Summary

PayerCigna

PolicyOncology - Dasatinib Products Drug Quantity Management Policy - Per Rx

Policy CodePolicy N/A

Change TypeMaterial: Phyrago added; other annual/revision notes

Effective Date

Next Review DateFeb 4, 2026

Key ActionIf a requested quantity exceeds the Drug Quantity Management rule at point of service, request an override with documented clinical criteria; approvals are provided for 1 year.

SourceLink

On This Page

No overrides recommended

Requests for dasatinib (Sprycel/generic) and Phyrago in strengths 70 mg, 80 mg, 100 mg, or 140 mg.

No quantity limit overrides are recommended; must adhere to standard quantity limits.

Prior Authorization

Quantity limit override requires criteria

If a requested quantity exceeds the Drug Quantity Management rule at point of service, coverage will be determined by the documented clinical criteria; approvals are provided for 1 year.

Billing Rule

Adhere to per-dispensing maximum quantities by product/strength

At retail and home delivery dispense no more than the specified maximum quantity per Rx for each strength/product unless an approved exception per criteria is documented.

Documentation Required

Document clinical rationale for exceptions

When requesting an override, document that the patient's dose does not correspond to a commercially-available dosage form or that the patient requires 50 mg twice daily dose reduction as applicable.