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INDEX:
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Effective Date: 06/01/2018 Title: Calquence (acalabrutinib)
Revision Date: Document: BI574:00
CPT Code(s): N/A
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.

A.   Calquence (acalbrutinib) requires prior authorization.

B.   Calquence is used to treat mantle cell lymphoma.

C.   Calquence is an oral specialty drug covered under the pharmacy benefit.


Medical Statement

Calquence (acalabrutinib) is considered medically necessary for patients meeting the following criteria:

 

1.    Patient is 18 years of age or older AND

2.    Patient has a diagnosis of mantle cell lymphoma and has received at least one prior therapy for the condition  OR

3.    Patient has a diagnosis of relapsed or refractory Chronic Lymphocytic Leukemia (CLL)/Small Lymphocytic Lymphoma (SLL)

 

NOTE: Calquence (acalabrutinib) should not be used for Imbruvica (ibrutinib) refractory CLL/SLL patients with BTK C481S mutations.


Limits

As an oral specialty medication covered under the pharmacy benefit, Calquence is limited to a maximum 30 day supply per fill.


Reference

1.    Calquence Package Insert. AstraZeneca Pharmaceuticals. October 2017.

2.    Clinical Pharmacology. Accessed online March 12, 2018.

3.    NCCN Drugs and Biologics Compendium. Accessed online March 12, 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.
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