Medical Policy

Effective Date:11/01/2018 Title:Aliqopa (copanlisib)
Revision Date: Document:BI586:00
CPT Code(s):C9030, J9057
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Aliqopa (copanlisib) requires prior authorization.

2)    Aliqopa is used to treat relapsed follicular lymphoma.

Medical Statement

Aliqopa (copanlisib) is considered medically necessary for patients meeting the following criteria:

1)    Patient is 18 years of age or older AND

2)    Diagnosis of relapsed follicular lymphoma AND

3)    Have received at least two (2) prior systemic treatments (one of which must be Zydelig).



Codes Used In This BI:


C9030 – copanlisib, 1mg

Intentially left empty

1)    Aliqopa Prescribing Information. Bayer HealthCare Pharmaceuticals Inc. Whippany, NJ. September 2017.

2)    Clinical Pharmacology. Accessed online 09-04-2018.

Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.