Copiktra (duvelisib)
Indications for Prior Authorization
Copiktra (duvelisib)
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For diagnosis of Chronic Lymphocytic Leukemia (CLL)/Small Lymphocytic Lymphoma (SLL)
Indicated for the treatment of adult patients with relapsed or refractory chronic lymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL) after at least two prior therapies.
Criteria
Copiktra
Prior Authorization (Initial Authorization)
Length of Approval: 12 Month(s)
- Diagnosis of chronic lymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL) AND
- Disease is relapsed or refractory AND
- Trial and failure, contraindication, or intolerance to at least two prior therapies for CLL/SLL (e.g., Leukeran [chlorambucil], Calquence [acalabrutinib], Gazyva [obinutuzumab], Arzerra [ofatumumab], Venclexta [venetoclax], Bendeka [bendamustine], Imbruvica [ibrutinib], Rituxan [rituximab], etc.) [2]
Copiktra
Prior Authorization (Reauthorization)
Length of Approval: 12 Month(s)
- Patient does not show evidence of progressive disease while on therapy
P & T Revisions
2024-11-05, 2023-10-25, 2023-07-05, 2022-10-31, 2021-10-11, 2020-10-26, 2019-10-29
References
- Copiktra Prescribing Information. Verastem, Inc. Needham, MA. July 2024.
- National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma v1.2025. Available by subscription at: https://www.nccn.org/professionals/physician_gls/pdf/cll.pdf. Accessed November 5, 2024
Revision History
- 2024-11-05: Annual Review. Background updates only.
- 2023-10-25: 2023 UM Annual Review. No criteria changes
- 2023-07-05: Removed specialist requirement
- 2022-10-31: 2022 Annual Review - Removed withdrawn indication of follicular lymphoma indication
- 2021-10-11: 2021 UM Annual Review
- 2020-10-26: UM Annual Review.
- 2019-10-29: 2019 Annual Review - SL - 10.29.19
HEALTHY LIVING