CurrentCignaPolicy N/A

Drug Quantity Management Policy - Per Days (Enbrel / etanercept)

Defines retail and home-delivery maximum quantity limits and authorization criteria for Enbrel (etanercept) products for inflammatory conditions, and applies to Cigna-administered health benefit plans.

Policy Summary

PayerCigna

PolicyDrug Quantity Management Policy - Per Days (Enbrel / etanercept)

Policy CodePolicy N/A

Change TypeAdministrative review — no material changes

Effective DateFeb 3, 2025

Next Review DateFeb 3, 2025

Key ActionAuthorize induction quantities for plaque psoriasis when no Enbrel claim exists in the prior 130 days per specified retail or home-delivery limits.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Retail ≤ 8/4maximum retail quantity by strength

Home ≤ 24/12maximum home delivery quantity by strength

84 daysinduction approval duration

One-timeoverride option

Coverage Criteria

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Initiation or induction verification: Absence of claims for Enbrel in the past 130 days verifying the patient is initiating treatment for plaque psoriasis or requires additional induction dosingno Enbrel claim in prior 130 days

Supports approval of induction quantities

25 mg forms — quantity and duration: Approve 16 syringes/vials per 28 days for a total of 84 days at retail OR a one-time home delivery override for 48 syringes/vials16 per 28 days retail; 48 one-time home delivery (total 84 days)

Applies to Enbrel 25 mg/0.5 mL prefilled syringes, single-dose vials, multi-dose vials

50 mg forms — quantity and duration: Approve 8 syringes/autoinjectors/mini cartridges per 28 days for a total of 84 days at retail OR a one-time home delivery override of 24 syringes/autoinjectors/mini cartridges8 per 28 days retail; 24 one-time home delivery (total 84 days)

Applies to Enbrel 50 mg/mL prefilled syringes, prefilled autoinjectors, mini cartridges

Initial Therapy — Induction Dosing

Plaque psoriasis induction

Induction dosing when initiating treatment or requiring additional induction dosing (no Enbrel claims in prior 130 days).

Verification: No claims for Enbrel in the past 130 daysno Enbrel claim in prior 130 days

Triggers induction approval quantities

25 mg forms approval: Approve 16 per 28 days retail for 84 days OR one-time home delivery override of 48 per 84 days16/28d retail; 48 one-time home delivery

For Enbrel 25 mg/0.5 mL prefilled syringes, single-dose vials, multi-dose vials

50 mg forms approval: Approve 8 per 28 days retail for 84 days OR one-time home delivery override of 24 per 84 days8/28d retail; 24 one-time home delivery

For Enbrel 50 mg/mL prefilled syringes, prefilled autoinjectors, mini cartridges

Drug Quantity Limits

Enbrel 25 mg/0.5 mL prefilled syringes/vials — retail maximum quantity

Retail maximum quantity8 prefilled syringes/vials per 28 days

Unit descriptionEnbrel 25 mg/0.5 mL prefilled syringes or single‑dose vials

Equivalent volume4 mL per 28 days (total)

Applies toRetail pharmacy dispensing (not home delivery)

Enbrel 25 mg/0.5 mL prefilled syringes/vials (home delivery) — home delivery maximum quantity

Home delivery maximum quantity24 syringes/vials per 84 days

Unit descriptionEnbrel 25 mg/0.5 mL prefilled syringes or single‑dose vials

Equivalent volume12 mL per 84 days (total)

One‑time overridePolicy allows one‑time home delivery override for induction dosing per criteria

Enbrel 50 mg/mL prefilled syringes/autoinjectors/mini cartridges — retail maximum quantity

Retail maximum quantity4 syringes/autoinjectors/mini cartridges per 28 days

Unit descriptionEnbrel 50 mg/mL prefilled syringes, autoinjectors, or mini cartridges

Equivalent volume4 mL per 28 days (total)

Applies toRetail pharmacy dispensing (not home delivery)

Enbrel 50 mg/mL prefilled syringes/autoinjectors/mini cartridges (home delivery) — home delivery maximum quantity

Home delivery maximum quantity12 syringes/autoinjectors/cartridges per 84 days

Unit descriptionEnbrel 50 mg/mL prefilled syringes, autoinjectors, or mini cartridges

Equivalent volume12 mL per 84 days (total)

One‑time overridePolicy allows one‑time home delivery override for induction dosing per criteria

Provider Actions & Billing Notes

Denial Risk

Quantity rule noncompliance

If the Drug Quantity Management rule is not met at the point of service, coverage will be determined by the Criteria. One-time overrides are provided for 30 days unless otherwise noted.

All approvals are provided for the duration noted in the Criteria.
If rule not met at point of service, submit for review with supporting documentation per criteria.

Prior Authorization

Quantity authorization for induction dosing

For patients initiating therapy or requiring induction dosing for plaque psoriasis, submit documentation verifying the absence of Enbrel claims in the past 130 days to support increased quantity authorization.

Enbrel 25 mg: approve 16 syringes/vials per 28 days for 84 days at retail, or one-time override of 48 syringes/vials at home delivery.
Enbrel 50 mg/mL: approve 8 syringes/autoinjectors/mini cartridges per 28 days for 84 days at retail, or one-time override of 24 syringes/autoinjectors/mini cartridges at home delivery.

Billing Rule

Claims coding and documentation

Submit claims using the most appropriate codes as of the date of service and include supporting documentation that demonstrates the patient meets the criteria (for example, lack of Enbrel claims in the prior 130 days when requesting induction quantities). Claims lacking covered codes or required documentation will be denied.

Include clinical documentation supporting plaque psoriasis diagnosis and induction need.
Attach claim history or pharmacy records showing no Enbrel claims in the past 130 days when requesting induction quantities.

Note

Provider action callout

Render provider-facing alerts to confirm when increased induction quantities are being requested and to prompt inclusion of claim-history documentation. Ensure prior authorization or one-time override codes/requests reference the Drug Quantity Management program and the specific Enbrel presentation.

Prompt: "Has the member had an Enbrel claim in the past 130 days?"
Include note: specify Enbrel presentation (25 mg vs 50 mg/mL) and requested quantity (retail duration or home delivery one-time override).

Definitions

Plaque psoriasis induction dosing — definition

DefinitionPlaque psoriasis induction dosing refers to the starting regimen of 50 mg subcutaneously twice weekly for approximately 3 months (84 days) to achieve initial control.

Typical maintenance following induction50 mg subcutaneously once weekly after induction period

Applies toAdult plaque psoriasis patients (and pediatric per weight‑based guidance where noted)

Background

Etanercept (Enbrel) is a tumor necrosis factor inhibitor (TNFi) indicated for multiple inflammatory conditions including rheumatoid arthritis, plaque psoriasis, psoriatic arthritis, ankylosing spondylitis, and juvenile forms of arthritis. Dosing is by subcutaneous injection; adult dosing for many indications is 50 mg once weekly, while plaque psoriasis induction uses a higher regimen of 50 mg subcutaneously twice weekly for approximately 3 months (84 days) to achieve initial disease control.