Subject: Calquence 2397-A SGM P2022
|
CALQUENCE
(acalabrutinib)
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Policy:
I. INDICATIONS
The indications below including FDA-approved indications and
compendial uses are considered a covered benefit provided
that all the approval criteria are met and the member has no
exclusions to the prescribed therapy.
A. FDA-Approved Indications
1. Mantle Cell Lymphoma
Calquence is indicated for the treatment of adult patients
with mantle cell lymphoma (MCL) who have received at
least one prior therapy.
2. Chronic Lymphocytic Leukemia or Small Lymphocytic
Lymphoma
Calquence is indicated for the treatment of adult patients
with chronic lymphocytic leukemia (CLL) or small
lymphocytic lymphoma (SLL).
B. Compendial Use
1. Waldenström Macroglobulinemia/Lymphoplasmacytic
Lymphoma
2. Gastric MALT Lymphoma/Non-gastric MALT Lymphoma
3. Nodal Marginal Zone Lymphoma
4. Splenic Marginal Zone Lymphoma
All other indications are considered experimental/investigational
and not medically necessary.
II. CRITERIA FOR INITIAL APPROVAL
A. Mantle cell lymphoma
Authorization of 12 months may be granted for treatment
of mantle cell lymphoma as a single agent when the
member has received at least one prior therapy.
B. Chronic Lymphocytic Leukemia (CLL)/Small
Lymphocytic Lymphoma (SLL)
Authorization of 12 months may be granted for treatment of
CLL/SLL as a single agent or in combination with
obinutuzumab.
C. Waldenström Macroglobulinemia/Lymphoplasmacytic
Lymphoma
Authorization of 12 months may be granted for subsequent
treatment of Waldenström Macroglobulinemia
/Lymphoplasmacytic Lymphoma as a single agent.
D. Gastric MALT Lymphoma/Non-gastric MALT
Lymphoma/Nodal Marginal Zone Lymphoma/Splenic
Marginal Zone Lymphoma
Authorization of 12 months may be granted for treatment
of gastric MALT lymphoma, non-gastric MALT lymphoma,
nodal marginal zone lymphoma and splenic marginal zone
lymphoma as subsequent therapy for members who are
intolerant to or have contraindications to ibrutinib.
III. CONTINUATION OF THERAPY
Authorization of 12 months may be granted for continued
treatment in members requesting reauthorization for an
indication listed in Section II when there is no evidence of
unacceptable toxicity or disease progression while on the
current regimen.
Place of Service:
Outpatient
The above policy is based on the following references:
- Calquence [package insert]. Wilmington, DE: AstraZeneca Pharmaceuticals LP; November 2019.
- The NCCN Drugs & Biologics Compendium® © 2022 National Comprehensive Cancer Network, Inc. http://www.nccn.org. Accessed June 2, 2022.
Copyright Aetna Inc. All rights reserved. Pharmacy 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.
December 29, 2022
