COPIKTRA (duvelisib)

COPIKTRA (duvelisib)

SELF ADMINISTRATION - ORAL

Indications for Prior Authorization:

Copiktra is a kinase inhibitor 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.

Coverage criteria:

For diagnosis of relapsed or refractory chronic lymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL):

• Patient is 18 years of age or older, AND
• Prescribed by or in consultation with an oncologist, AND
• Patient has tried and failed at least two prior systemic therapies.

Reauthorization Criteria: 

For diagnosis of CLL or SLL:

• Patient dies not show evidence of progressive disease while on Copiktra therapy.

Authorization is not covered for the following: 

• The use of this drug for indications not listed in this policy does not meet the coverage criteria established by the Western Health Advantage (WHA) Pharmacy and Therapeutics (P&T) Committee.

Policy Updates:

• 09/03/2019 - coverage criteria review
• 05/17/2022 - removed criteria management of drug-drug interactions; added reauthorization criteria; removed coverage criteria for relapsed or refractory follicular lymphoma (FL) indication due to withdrawal by the FDA.