IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan or government program (e.g., TennCare), the express terms of the health plan or government program will govern.
POLICY
I. INDICATIONS
The indications below including FDA-approved indications and compendial uses are considered a covered benefit provided that all the approval criteria are met and the member has no exclusions to the prescribed therapy.
A. FDA-Approved Indications
Aliqopa is indicated for the treatment of adult patients with relapsed follicular lymphoma (FL) who have received at least two prior systemic therapies.
B. Compendial Uses
1. Gastric MALT lymphoma (extranodal marginal zone lymphoma of the stomach), subsequent therapy for relapsed or refractory disease after 2 prior therapies
2. Non-gastric MALT lymphoma (extranodal marginal zone lymphoma of nongastric sites), subsequent therapy for relapsed or refractory disease after 2 prior therapies
3. Nodal marginal zone lymphoma subsequent therapy as a single agent for relapsed or refractory disease after 2 prior therapies
4. Splenic marginal zone lymphoma, subsequent therapy as a single agent for relapsed or refractory disease after 2 prior therapies
All other indications are considered experimental/investigational and not medically necessary.
II. CRITERIA FOR INITIAL APPROVAL
A. Follicular Lymphoma (FL)
Authorization of 12 months may be granted to members with follicular lymphoma (FL) when the requested medication will be used as subsequent therapy after at least two prior therapies.
B. Gastric MALT Lymphoma (Extranodal Marginal Zone Lymphoma of the Stomach) and Non-gastric MALT Lymphoma (Extranodal Marginal Zone Lymphoma of Nongastric Sites)
Authorization of 12 months may be granted to members with gastric or non-gastric mucosa-associated lymphoid tissue (MALT) lymphoma (extranodal marginal zone lymphoma of the stomach and nongastric sites) when the requested medication will be used as subsequent therapy after at least two prior therapies.
C. Nodal Marginal Zone Lymphoma
Authorization of 12 months may be granted to members with nodal marginal zone lymphoma when the requested medication will be used as subsequent therapy after at least two prior therapies as a single agent.
D. Splenic Marginal Zone Lymphoma
Authorization of 12 months may be granted to members with splenic marginal zone lymphoma when the requested medication will be used as subsequent therapy after at least two prior therapies as a single agent.
III. CONTINUATION OF THERAPY
Authorization of 12 months may be granted for continued treatment in members requesting reauthorization for an indication listed in Section II when there is no evidence of unacceptable toxicity or disease progression while on the current regimen.
APPLICABLE TENNESSEE STATE MANDATE REQUIREMENTS
BlueCross BlueShield of Tennessee’s Medical Policy complies with Tennessee Code Annotated Section 56-7-2352 regarding coverage of off-label indications of Food and Drug Administration (FDA) approved drugs when the off-label use is recognized in one of the statutorily recognized standard reference compendia or in the published peer-reviewed medical literature.
ADDITIONAL INFORMATION
For appropriate chemotherapy regimens, dosage information, contraindications, precautions, warnings, and monitoring information, please refer to one of the standard reference compendia (e.g., the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) published by the National Comprehensive Cancer Network®, Drugdex Evaluations of Micromedex Solutions at Truven Health, or The American Hospital Formulary Service Drug Information).
REFERENCES
1. Aliqopa [package insert]. Whippany, NJ: Bayer HealthCare Pharmaceuticals, Inc.; March 2023.
2. The NCCN Drugs & Biologics Compendium® © 2023 National Comprehensive Cancer Network, Inc. Available at: http://www.nccn.org. Accessed June 2, 2023.1. Aliqopa [package insert]. Whippany, NJ: Bayer HealthCare Pharmaceuticals, Inc.; March 2023.
ORIGINAL EFFECTIVE DATE: 11/24/2017
MOST RECENT REVIEW DATE: 6/11/2024
ID_CHS
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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