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)    Columvi (glofitamab-gxbm) requires prior authorization.

2)    Columvi is used to treat diffuse large B-cell lymphoma (DLBCL) or large B-cell lymphoma (LBCL).

3)    Columvi is covered under the medical benefit.

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

1. Columvi Prescribing Information. South San Francisco, CA: Genentech, Inc.; June 2023. Available at: https://www.gene.com/download/pdf/columvi_prescribing.pdf. Accessed June 27, 2023.

2. National Comprehensive Cancer Network Guidelines. B-Cell Lymphomas Version 4.2023. Available at https://www.nccn.org/professionals/physician_gls/pdf/b-cell.pdf. Accessed June 27, 2023.