Criteria
Coverage is subject to the specific terms of the member’s benefit plan.
Federal Employee Program members (FEP) should check with their Retail Pharmacy Program to determine if prior approval is required by calling the Retail Pharmacy Program at 1-800-624-5060 (TTY: 1-800-624-5077). FEP members can also obtain the list through the www.fepblue.org website.
Copanlisib (Aliqopa) may be considered medically necessary in adults for the following indications:
Food and Drug Administration (FDA) Indications
For the treatment of individuals with relapsed FL who have received at least two (2) prior systemic therapies; or
National Comprehensive Cancer Network (NCCN) Recommendations
For ANY of the following indications after two (2) prior therapies:
- As a subsequent therapy for relapsed/refractory disease for ANY of the following:
- FL (grade 1-2); or
- Gastric mucosa associated lymphoid tissue (MALT) lymphoma; or
- Non-gastric MALT lymphoma ; or
- As a subsequent therapy as a single agent for relapsed/refractory disease for ANY of the following:
- Nodal marginal zone lymphoma; or
- Splenic marginal zone lymphoma.
The use of copanlisib (Aliqopa) for any other indication will be considered experimental/investigational and therefore non-covered as published peer reviewed literature does not support its efficacy or safety for any other indication.
Procedure Codes
