ZYDELIG (idelalisib)

ZYDELIG (idelalisib) 

ORAL ADMINISTRATION

Diagnosis considered for coverage:

Zydelig is a kinase inhibitor indicated for the treatment of patients with:

• Relapsed chronic lymphocytic leukemia (CLL), in combination with rituximab, in patients for whom rituximab alone would be considered appropriate therapy due to other co-morbidities.

Coverage Criteria:

For diagnosis of chronic lymphocytic leukemia (CLL):

• Dose does not exceed maximum amount recommended by the FDA (150 mg orally twice daily); AND
• Prescribed by or in consultation with an oncologist; AND
• Patient has received previous treatment for CLL and disease is considered relapsed.

Reauthorization Criteria:

For diagnosis of CLL:

• Dose does not exceed maximum amount recommended by the FDA (150 mg orally twice daily); AND
• Patient does not show evidence of progressive disease while on therapy. 

Coverage Duration:  

• One year

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:

• 09/01/2014 - new criteria approved by P&T
• 05/17/2022 - Removed requirement to use in combination with rituximab for CLL; added reauthorization criteria; removed coverage criteria for withdrawn indications to treat relapsed follicular B-cell non-Hodgkin's lymphoma and relapsed small lymphocytic lymphoma (SLL).