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Clinical Policy Bulletin:
Obinutuzumab (Gazyva)
Number: 0877



Aetna considers obinutuzumab (Gazyva) medically necessary for use in combination with chlorambucil for previously untreated chronic lymphocytic leukemia (CLL) in individuals without active hepatitis B virus infection. 

Aetna considers obinutuzumab experimental and investigational for all other indications.

Note: * Precertification of obinutuzumab (Gazyva) is required of all Aetna participating providers and members in applicable plan designs.  For precertification of obinutuzumab, call (866) 503-0857, or fax (866) 267-3277.


Chronic lymphocytic leukemia (CLL) represents the most prevalent adult leukemia and the introduction of therapeutic antibodies has increased the number of available treatments. For both previously untreated symptomatic CLL and as salvage therapy, rituximab, a CD20 antibody, is currently widely used in combination-based strategies. Recent data suggest that the addition of rituximab to fludarabine with or without cyclophosphamide prolongs survival in younger patients with CLL. Other improved CD20 antibodies with promising clinical activity, include ofatumumab and obinutuzumab (GA-101). Alemtuzumab, a CD52 antibody, likewise has demonstrated benefit in both symptomatic, previously untreated CLL and in patients with relapsed disease. Also, recent efforts to combine currently applied therapeutic antibodies with other biologic and targeted therapies with efficacy in CLL offers the potential to move toward alternative non-chemotherapy-based treatment approaches (Jaglowski et al, 2010).

Laprevotte et al (2013) reported that rituximab combined with chemotherapy is a standard treatment for CLL.  They investigated whether endogenous IL-8 affects rituximab or obinutuzumab (GA-101) B-leukemic depletion mediated by natural killers. Rituximab, and more significantly obinutuzmab, were effective in B-cell depletion and natural killer activation using whole peripheral blood lymphocytes from untreated CLL patients.

Obinutuzumab was approved on November 1, 2013 by the Food and Drug Administration (FDA) for use in combination with chlorambucil for previously untreated CLL (NCI, 2013). Obinutuzmab is a CD20-cytolytic antibody. The FDA labeling produced by Genentech (2013) lists a boxed warning stating that “hepatitis B Virus (HBV) reactivation, in some cases resulting in fulminant hepatitis, hepatic failure, and death, can occur in patients receiving CD20-directed cytolytic antibodies, including GAZYVA. Screen all patients for HBV infection before treatment initiation. Monitor HBV positive patients during and after treatment with GAZYVA. Discontinue GAZYVA and concomitant medications in the event of HBV reactivation... Progressive Multifocal Leukoencephalopathy (PML) including fatal PML, can occur in patients receiving GAZYVA.”

Dosing and administration of obinutuzumab includes premedication with glucocorticoid, acetaminophen and anti-histamine. Obinutuzumab is to be diluted and administered as intravenous infusion and is not to be administered as an intravenous push or bolus. The recommended dose for 6 cycles (28 day cycles) is as follows: 100 mg on day 1 Cycle 1; 900 mg on day 2 Cycle 1; 1000 mg on day 8 and 15 of Cycle 1; and 1000 mg on day 1 of Cycles 2 through 6 (Genentech, 2013).

An FDA news release stated that "Gazyva’s approval for CLL is based on a study of 356 participants in a randomized open-label multicenter trial comparing Gazyva in combination with chlorambucil to chlorambucil alone in participants with previously untreated CLL...Participants receiving Gazyva in combination with chlorambucil demonstrated a significant improvement in progression free survival: an average of 23 months compared with 11.1 months with chlorambucil alone" (FDA, 2013).

CPT Codes / HCPCS Codes / ICD-9 Codes
HCPCS codes covered if selection criteria are met:
C9021 Injection, obinutuzumab, 10 mg
Other HCPCS codes related to the CPB:
S0172 Chlorambucil, oral, 2mg
ICD-9 codes covered if selection criteria are met:
204.10 - 204.12 Chronic lymphocytic leukemia
Other ICD-9 codes related to the CPB:
070.20 - 070.33 Viral hepatitis B with and without mention of hepatic coma

The above policy is based on the following references:
  1. Jaglowski SM, Alinari L, Lapalombella R et al. The clinical application of monoclonal antibodies in chronic lymphocytic leukemia. Blood. 2010;116(19):3705-3714.
  2. Laprevotte E, Ysebaert L, Klein C, et al. Endogenous IL-8 acts as a CD16 co-activator for natural killer-mediated anti-CD20 B cell depletion in chronic lymphocytic leukemia. Leuk Res. 2013;37(4):440-446.
  3. National Cancer Institute (NCI). FDA Approval for Obinutuzumab. National Cancer Institute at the National Institutes of Health. Bethesda, MD: November 1, 2013. Available at: Accessed November 13, 2013.
  4. U.S. Food and Drug Administration (FDA). FDA approves Gazyva for chronic lymphocytic leukemia. FDA News Release. Silver Spring, MD: FDA; November 1, 2013. Available at: Accessed November 13, 2013.
  5. Genentech, Inc. Gazyva (obinutuzumab). Prescribing Information. Reference ID: 3400019. South San Francisco, CA: Genentech; revised November 2013.


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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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