Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Obinutuzumab (Gazyva) may be considered medically necessary for ANY of the following indications:
Chronic Lymphocytic Leukemia (CLL)
- In individuals with previously untreated CLL used in combination with chlorambucil; or
Follicular Lymphoma (FL)
- In individuals with FL who relapsed after, or are refractory to, a rituximab-containing regimen, and is used in combination with bendamustine followed by obinutuzumab (Gazyva) monotherapy; or
- In adults with previously untreated stage II bulky, III or IV FL when used in combination with chemotherapy followed by obinutuzumab monotherapy in individuals achieving at least a partial remission; or
Compendia Sources
Obinutuzumab (Gazyva) may be considered medically necessary for treatment of any of the current category 1, 2A, or 2B NCCN recommendations
The use of Obinutuzumab (Gazyva) 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 Code
