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.
Glofitamab-gxbm (Columvi) may be considered medically necessary when the following criteria are met:
- Individual is 18 years of age or older; and
- Confirmed diagnosis of relapsed or refractory diffuse large B-cell lymphoma, not otherwise specified (DLBCL, NOS) or large B-cell lymphoma (LBCL) arising from follicular lymphoma; and
- Treatment is utilized after two (2) or more lines of systemic therapy; or
Compendia Sources
- Glofitamab-gxbm (Columvi) may be considered medically necessary for treatment of any of the current category 1 or 2A NCCN recommendations.
The use of glofitamab-gxbm (Columvi) for all other indications not listed in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness cannot be established by the available published peer-reviewed literature.
Procedure Codes
