Columvi is considered medically necessary when meeting the following criteria:
Initial Approval Criteria
I.
Diffuse Large B-Cell
Lymphoma or Large B-Cell Lymphoma (must meet all):
a.
Diagnosis of one of the
following (a or b):
i.
DLBCL
ii.
LBCL arising from
follicular lymphoma;
b.
Prescribed by or in
consultation with an oncologist;
c.
Age > 18 years;
d.
Disease is refractory to
or has relapsed after > 2 line of system therapy;
e.
Member is prescribed
Obinutuzumab (Gazyva) as pretreatment, unless contraindicated or clinically
significant adverse effects are experienced;
f.
Dosing is consistent with
FDA-labeling
Approval Duration: 6 months
Continuing Therapy Criteria
1.
Member is responding
positively to therapy;
2.
Member has received < 12
cycles of Columvi
3.
Dosing is consistent with
FDA-labeling
Continuing Therapy Approval Duration: 6 months
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