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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

09-J2000-09

Original Effective Date: 03/15/14

Reviewed: 09/13/17

Revised: 10/15/17

Subject: Ibrutinib (Imbruvica®)

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Dosage/ Administration Position Statement Billing/Coding Reimbursement Program Exceptions Definitions
           
Related Guidelines Other References Updates  
           

DESCRIPTION:

Ibrutinib (Imbruvica®) was initially approved by the U.S. Food and Drug Administration (FDA) in November 2013 for treatment of mantle cell lymphoma (MCL) in individuals who have received at least one prior therapy, and, in February 2014, for chronic lymphocytic leukemia (CLL) in individuals who have received at least one prior therapy. Ibrutinib was later FDA approved for the treatment of CLL in individuals with a 17p deletion (July 2014), including those who are treatment naïve and previously treated, and for the treatment of patients with Waldenström's Macroglobulinemia (January 2015). In March 2016, the indication was expanded to include first-line treatment of CLL in patients without a 17p deletion. Previously, first-line CLL treatment was limited to patients with a 17p deletion. In January 2017, ibrutinib was FDA approved for the treatment of patients with marginal zone lymphoma (MZL) who require systemic therapy and have received at least one prior anti-CD20-based therapy. In August 2017, ibrutinib was FDA approved for the treatment of adult patients with chronic graft-versus-host disease (cGVHD) after failure of one or more lines of systemic therapy. Prior to FDA approval ibrutinib received orphan drug status for the treatment of MCL (December 2012), CLL (February 2012), WM (October 2013), nodal MZL (February 2015), splenic MZL (February 2015), and extranodal MZL (mucosa associated lymphoid tissue [MALT type] lymphoma) (February 2016). Ibrutinib inhibits Bruton’s tyrosine kinase to inhibit enzymatic activity and malignant B-cell proliferation and survival. Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) is a mature B-cell lymphoma and comprises approximately 7% of newly diagnosed cases of Non-Hodgkin’s Lymphoma (NHL). CLL and SLL are different manifestation of the same disease and are managed in much the same way. The main difference is that in CLL the abnormal lymphocytes are found in bone marrow and blood, while in SLL they are predominately found in the lymph nodes and bone marrow.

Ibrutinib’s safety and effectiveness were first evaluated in a single-arm, open-label clinical trial of 111 patients with previously treated (median of 3 previous treatments) mantle cell lymphoma in which patients received ibrutinib 560 mg/day. Complete response occurred in 17.1% of patients and partial response in 48.6%, with a median duration of response of 17.5 months. Lymphocytosis (temporary increase of 50% or greater in lymphocyte count) occurred in 33% of patients and resolved by a median of 8 weeks. The most common adverse reactions (≥20%) in patients with MCL were thrombocytopenia, diarrhea, neutropenia, anemia, fatigue, musculoskeletal pain, peripheral edema, upper respiratory tract infection, nausea, bruising, dyspnea, constipation, rash, abdominal pain, vomiting and decreased appetite. Ibrutinib carries a warning of embryo-fetal toxicity. Bleeding events including bruising of any grade occurred in 48% of patients.

National Comprehensive Cancer Network (NCCN) Guidelines for B-cell Lymphoma (Version 3.2017), CLL/SLL (Version 2.2017), Hairy Cell Leukemia (Version 2.2017), and Waldenström's Macroglobulinemia/ Lymphoplasmacytic Lymphoma (Version 1.2017) recommend ibrutinib for mantle cell lymphoma, CLL/SLL, hairy cell leukemia, and Waldenström's macroglobulinemia/ lymphoplasmacytic lymphoma when first-line treatment has failed. For CLL/SLL, combination therapy of ibrutinib + bendamustine + rituximab is only listed as treatment option for a specific subset of patients; age less than 65 years without significant comorbidities and without a del(17p) mutation (category 2B). The NCCN also recommends use as a first-line therapy option for CLL/SLL with or without a del(17p) mutation and for Waldenström's macroglobulinemia/lymphoplasmacytic lymphoma.

POSITION STATEMENT:

Comparative Effectiveness

The Food and Drug Administration has deemed the drug(s) or biological product(s) in this coverage policy to be appropriate for self-administration or administration by a caregiver (i.e., not a healthcare professional). Therefore, coverage (i.e., administration) in a provider-administered setting such as an outpatient hospital, ambulatory surgical suite, physician office, or emergency facility is not considered medically necessary.

Initiation of ibrutinib (Imbruvica) meets the definition of medical necessity for members diagnosed with ANY of the following conditions when ALL associated criteria are met:

1. Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)

a. If used first-line for previously untreated disease: ibrutinib will be used as monotherapy

b. If used second-line or later for previously treated disease - EITHER of the following (“i” or “ii”):

i. Ibrutinib will be used as monotherapy

ii. ALL of the following:

• Ibrutinib will be used in combination with both bendamustine (Treanda, Bendeka) and rituximab (Rituxan)

• The member does NOT have a del(17p) mutation – lab documentation of the fluorescence in situ hybridization (FISH) cytogenetic test results must be submitted

• Member is less than 65 years of age without significant comorbidities

b. Dosage does not exceed 420 mg (three 140 mg capsules/day)

2. Chronic graft-versus-host disease (cGVHD)

a. The member is diagnosed with cGVHD following an allogenic hematopoietic stem cell (bone marrow) transplant

b. Member’s disease is refractory to an adequate trial of combination therapy with a systemic corticosteroid AND a calcineurin inhibitor (i.e., cyclosporine or tacrolimus). Corticosteroid monotherapy is acceptable for members who have an intolerance or contraindication to a calcineurin inhibitor (the specific intolerance or contraindication must be provided)

c. Dosage does not exceed 420 mg (three 140 mg capsules/day)

3. Gastric MALT (mucosa-associated lymphoid tissue) lymphoma (a type of extranodal marginal zone lymphoma of MALT)

a. Ibrutinib is used as second-line or later therapy for relapsed or refractory disease

b. Member has been previously treated with rituximab or a rituximab-containing regimen for their disease

c. Member will use ibrutinib as monotherapy

d. Dosage does not exceed 560 mg/day (four 140 mg capsules/day)

4. Hairy cell leukemia

a. Ibrutinib is used as third-line or later therapy for previously treated disease

b. Member is experiencing disease progression

c. Member will use ibrutinib as monotherapy

d. Dosage does not exceed 420 mg/day (three 140 mg capsules/day)

5. Mantle cell lymphoma (MCL)

a. The diagnosis has been confirmed by tissue biopsy with appropriate histology and immunophenotyping

b. EITHER of the following (“i” or “ii”):

i. BOTH of the following (“1” and “2”):

1. Member has had an inadequate response to at least one prior therapy for treatment of their MCL*

2. Member will use ibrutinib as monotherapy

ii. ALL of the following (“1”, “2”, “3”, and “4”):

1. Member has newly diagnosed, previously untreated MCL

2. Member is older than 65 years of age

3. Ibrutinib will be used in combination with rituximab (Rituxan)

4. Use is for pre-treatment to limit the number of cycles of less-aggressive therapy with a modified R-hyper-CVAD regimen (rituximab, cyclophosphamide, doxorubicin, vincristine, and dexamethasone)

c. Dosage does not exceed 560 mg/day (four 140 mg capsules/day)

6. Nodal marginal zone lymphoma

a. Ibrutinib is used as second-line or later therapy for relapsed or refractory disease

b. Member has been previously treated with rituximab or a rituximab-containing regimen for their disease

c. Member will use ibrutinib as monotherapy

d. Dosage does not exceed 560 mg/day (four 140 mg capsules/day)

7. Non-gastric MALT lymphoma (a type of extranodal marginal zone lymphoma of MALT)

a. Ibrutinib is used as second-line or later therapy for relapsed or refractory disease

b. Member has been previously treated with rituximab or a rituximab-containing regimen for their disease

c. Member will use ibrutinib as monotherapy

d. Dosage does not exceed 560 mg/day (four 140 mg capsules/day)

8. Splenic marginal zone lymphoma

a. Ibrutinib is used as second-line or later therapy for relapsed or refractory disease

b. Member has been previously treated with rituximab or a rituximab-containing regimen for their disease

c. Member will use ibrutinib as monotherapy

d. Dosage does not exceed 560 mg/day (four 140 mg capsules/day)

9. Waldenström's macroglobulinemia (a.k.a. lymphoplasmacytic lymphoma)

a. Member is symptomatic (e.g., hyperviscosity, neuropathy, symptomatic adenopathy or organomegaly, amyloidosis, cryoglobulinemia, cold agglutinin disease, presence of cytopenia)

b. Laboratory documentation of the member’s baseline (i.e., within 60 days prior to initiating treatment with ibrutinib) serum IgM level is provided

c. Member will use ibrutinib as monotherapy

d. Dosage does not exceed 420 mg/day (three 140 mg capsules/day)

*The use of corticosteroid monotherapy does NOT constitute as “an inadequate response to at least one prior therapy” for purposes of this requirement.

Duration of approval: 6 months

Continuation of ibrutinib (Imbruvica) meets the definition of medical necessity when ALL of the following criteria are met:

1. Authorization or reauthorization for ibrutinib has been previously approved by Florida Blue or another health plan in the past 2 years for the treatment of MCL, CLL/SLL, cGVHD, hairy cell leukemia, gastric or non-gastric MALT lymphoma, nodal or splenic marginal zone lymphoma, or Waldenström's macroglobulinemia/lymphoplasmacytic lymphoma, OR the member previously met ALL indication-specific initiation criteria.

2. The member did NOT have progressive disease during treatment with ibrutinib

3. Dosage does not exceed the following:

a. CLL/SLL, cGVHD, hairy cell leukemia, and Waldenström's macroglobulinemia - 420 mg/day (three 140 mg capsules/day)

b. Other indications - 560 mg/day (four 140 mg capsules/day)

Duration of approval: 1 year.

DOSAGE/ADMINISTRATION:

THIS INFORMATION IS PROVIDED FOR INFORMATIONAL PURPOSES ONLY AND SHOULD NOT BE USED AS A SOURCE FOR MAKING PRESCRIBING OR OTHER MEDICAL DETERMINATIONS. PROVIDERS SHOULD REFER TO THE MANUFACTURER’S FULL PRESCRIBING INFORMATION FOR DOSAGE GUIDELINES AND OTHER INFORMATION RELATED TO THIS MEDICATION BEFORE MAKING ANY CLINICAL DECISIONS REGARDING ITS USAGE.

FDA-approved

• Mantle cell lymphoma (MCL) in patients who have received at least one prior therapy: 560 mg taken orally once daily (four 140 mg capsules once daily)

• Chronic lymphocytic leukemia (with or without 17p deletion): 420 mg taken orally once daily (three 140 mg capsules once daily)

• Waldenström's macroglobulinemia: 420 mg taken orally once daily (three 140 mg capsules once daily)

• Marginal zone lymphoma in patients who require systemic therapy and have received at least one prior anti-CD20-based therapy: 560 mg taken orally once daily (four 140 mg capsules once daily)

Chronic graft-versus-host disease (cGVHD) after failure of one or more lines of systemic therapy: 420 mg taken orally once daily (three 140 mg capsules once daily)

Dose Adjustments

Toxicity

• Interrupt ibrutinib therapy for any Grade 3 or greater non-hematological, Grade 3 or greater neutropenia with infection or fever, or Grade 4 hematological toxicities.

• Once the symptoms of the toxicity have resolved to Grade 1 or baseline (recovery), ibrutinib therapy may be reinitiated at the starting dose.

• If the toxicity reoccurs, reduce dose by one capsule (140 mg per day).

• A second reduction of dose by 140 mg may be considered as needed.

• If these toxicities persist or recur following two dose reductions, discontinue ibrutinib.

Hepatic Impairment

• For patients with mild liver impairment (Child-Pugh A), the recommended dose is 140 mg daily (one capsule).

• Avoid the use in patients with moderate or severe hepatic impairment (Child-Pugh B and C).

Use with CYP3A Inhibitors

A dose reduction or avoiding use of ibrutinib may be warranted for moderate or strong CYP3A4 inhibitors and depends on if use is for a B-cell malignancy or cGVHD. Refer to the product labeling for the specific recommendations.

Drug Availability

140 mg capsule

PRECAUTIONS:

Boxed Warning

None

Contraindications

None

Precautions/Warnings

Hemorrhage: Monitor for bleeding. Ibrutinib may increase the risk of hemorrhage in patients receiving antiplatelet or anticoagulant therapies. Consider the benefit-risk of withholding treatment for at least 3 to 7 days pre and post-surgery depending upon the type of surgery and the risk of bleeding.

Infections: Monitor patients for fever and infections and evaluate promptly. Cases of progressive multifocal leukoencephalopathy (PML) have occurred.

Myelosuppression/Cytopenias: Check complete blood counts monthly.

Atrial Fibrillation: Monitor patients for atrial fibrillation. Patients who develop arrhythmic symptoms (e.g., palpitations, lightheadedness) or new onset dyspnea should have an ECG performed.

Hypertension: Monitor blood pressure and treat as needed.

Tumor Lysis Syndrome (TLS): Monitor patients at risk for TLS (e.g. high tumor burden)

Second Primary Malignancies: Other malignancies have occurred in patients, including skin cancers, and other carcinomas.

Embryo-Fetal Toxicity: Can cause fetal harm. Advise women of the potential risk to a fetus and to avoid pregnancy while taking the drug.

BILLING/CODING INFORMATION:

The following codes may be used to describe:

HCPCS Coding

J8999

Prescription drug, oral, chemotherapeutic, Not Otherwise Specified

ICD-10 Diagnosis Codes That Support Medical Necessity

C83.00

Small cell B-cell lymphoma unspecified site

C83.01

Small cell B-cell lymphoma, lymph nodes of head, face, and neck

C83.02

Small cell B-cell lymphoma, intrathoracic lymph nodes

C83.03

Small cell B-cell lymphoma, intra-abdominal lymph nodes

C83.04

Small cell B-cell lymphoma, lymph nodes of axilla and upper limb

C83.05

Small cell B-cell lymphoma, lymph nodes of inguinal region and lower limb

C83.06

Small cell B-cell lymphoma, intrapelvic lymph nodes

C83.07

Small cell B-cell lymphoma, spleen

C83.08

Small cell B-cell lymphoma, lymph nodes of multiple sites

C83.09

Small cell B-cell lymphoma, extranodal and solid organ sites

C83.10

Mantle cell lymphoma, unspecified site

C83.11

Mantle cell lymphoma, lymph nodes of head, face, and neck

C83.12

Mantle cell lymphoma, intrathoracic lymph nodes

C83.13

Mantle cell lymphoma, intra-abdominal lymph nodes

C83.14

Mantle cell lymphoma, lymph nodes of axilla and upper limb

C83.15

Mantle cell lymphoma, lymph nodes of inguinal region and lower limb

C83.16

Mantle cell lymphoma, intrapelvic lymph nodes

C83.17

Mantle cell lymphoma, spleen

C83.18

Mantle cell lymphoma, lymph nodes of multiple sites

C83.19

Mantle cell lymphoma, extranodal and solid organ sites

C83.50

Lymphoblastic (diffuse) lymphoma, unspecified site

C83.51

Lymphoblastic (diffuse) lymphoma, lymph nodes of head, face, and neck

C83.52

Lymphoblastic (diffuse) lymphoma, intrathoracic lymph nodes

C83.53

Lymphoblastic (diffuse) lymphoma, intra-abdominal lymph nodes

C83.54

Lymphoblastic (diffuse) lymphoma, lymph nodes of axilla and upper limb

C83.55

Lymphoblastic (diffuse) lymphoma, lymph nodes of inguinal region and lower limb

C83.56

Lymphoblastic (diffuse) lymphoma, intrapelvic lymph nodes

C83.57

Lymphoblastic (diffuse) lymphoma, spleen

C83.58

Lymphoblastic (diffuse) lymphoma, lymph nodes of multiple sites

C83.80

Other non-follicular lymphoma, unspecified site

C83.81

Other non-follicular lymphoma, lymph nodes of head, face, and neck

C83.82

Other non-follicular lymphoma, intrathoracic lymph nodes

C83.83

Other non-follicular lymphoma, intra-abdominal lymph nodes

C83.84

Other non-follicular lymphoma, lymph nodes of axilla and upper limb

C83.85

Other non-follicular lymphoma, lymph nodes of inguinal region and lower limb

C83.86

Other non-follicular lymphoma, intrapelvic lymph nodes

C83.87

Other non-follicular lymphoma, spleen

C83.88

Other non-follicular lymphoma, lymph nodes of multiple sites

C83.89

Other non-follicular lymphoma, extranodal and solid organ sites

C85.80 – C85.89

Other specified types of non-Hodgkin lymphoma

C88.00

Waldenström’s macroglobulinemia

C88.08

Other lymphoplasmacytic lymphoma

C88.4

Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue [MALT-lymphoma]

C91.10

Chronic lymphocytic leukemia of B-cell type, not having achieved remission

C91.11

Chronic lymphocytic leukemia of B-cell type, in remission

C91.12

Chronic lymphocytic leukemia of B-cell type, in relapse

C91.40

Hairy cell leukemia not having achieved remission

C91.42

Hairy cell leukemia in relapse

D89.811

Chronic graft-versus-host disease

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Part D: BCBSF has delegated to Prime Therapeutics authority to make coverage determinations for the Medicare Part D services referenced in this guideline.

Medicare Advantage: No National Coverage Determination (NCD) or Local Coverage Determination (LCD) were found at the time of the last guideline review date.

DEFINITIONS:

FISH (Fluorescence In Situ Hybridization): Leukemias, lymphomas, other hematopoietic malignancies and some types of solid tumors can often be characterized by specific chromosomal and genetic abnormalities. FISH studies are used to determine the presence of a known or suspected abnormality. This is particularly useful when there are few or no dividing cells in the sample for cytogenetic analysis.

RELATED GUIDELINES:

Allogeneic Bone Marrow and Stem Cell Transplantation, 02-38240-01
Autologous Bone Marrow and Stem Cell Transplantation, 02-38241-01

Bendamustine (Treanda), 09-J2000-40

Ibrutinib (Imbruvica), 09-J2000-09

Idelalisib (Zydelig), 09-J2000-23

Interferons for Oncology Use, 09-J1000-37

Lenalidomide (Revlimid), 09-J0000-80

Procarbazine (Matulane), 09-J1000-59

Rituximab (Rituxan), 09-J0000-59

OTHER:

None

REFERENCES:

  1. Advani RH, Buggy JJ, Sharman JP. Bruton tyrosine kinase inhibitor ibrutinib (PCI-32765) has significant activity in patients with relapsed/refractory B-cell malignancies. J Clin Oncol. 2013 Jan 1;31(1):88-94.
  2. Burger JA, Tedeschi A, Barr PM, et al. Ibrutinib as Initial Therapy for Patients with Chronic Lymphocytic Leukemia. N Engl J Med. 2015 Dec 17;373(25):2425-37.
  3. Byrd JC, Brown JR, O'Brien S, et al; RESONATE Investigators. Ibrutinib versus ofatumumab in previously treated chronic lymphoid leukemia. N Engl J Med. 2014 Jul 17;371(3):213-23.
  4. Byrd JC, Furman RR, Coutre SE, et al. Targeting BTK with ibrutinib in relapsed chronic lymphocytic leukemia. N Engl J Med. 2013 Jul 4;369(1):32-42. doi: 10.1056/NEJMoa1215637. Epub 2013 Jun 19.
  5. Chanan-Khan A, Cramer P, Demirkan F, et al; HELIOS investigators. Ibrutinib combined with bendamustine and rituximab compared with placebo, bendamustine, and rituximab for previously treated chronic lymphocytic leukaemia or small lymphocytic lymphoma (HELIOS): a randomised, double-blind, phase 3 study. Lancet Oncol. 2016 Feb;17(2):200-11.
  6. Clinical Pharmacology [Internet]. Tampa (FL): Gold Standard, Inc.; 2017 [cited 2017 Jun 15]. Available from: http://www.clinicalpharmacology.com/.
  7. DRUGDEX System [Internet]. Greenwood Village (CO): Thomson Micromedex; Updated periodically [cited 2017 Jun 15]. Available from: http://www.thomsonhc.com/.
  8. Imbruvica (ibrutinib) [package insert]. Pharmacyclics LLC. Sunnyvale (CA): August 2017.
  9. Kahl BS, Longo WL, Eickhoff JC, et al. Maintenance rituximab following induction chemoimmunotherapy may prolong progression-free survival in mantle cell lymphoma: a pilot study from the Wisconsin Oncology Network. Ann Oncol. 2006 Sep;17(9):1418-23.
  10. Koc S, Leisenring W, Flowers ME, et al. Therapy for chronic graft-versus-host disease: a randomized trial comparing cyclosporine plus prednisone versus prednisone alone. Blood. 2002 Jul 1;100(1):48-51.
  11. National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology (NCCN Guidelines). Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma (Version 2.2017) [cited 2017June 26]. Available from: https://www.nccn.org/professionals/physician_gls/pdf/cll.pdf
  12. National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology (NCCN Guidelines). Hairy Cell Leukemia (Version 2.2017) [cited 2017 Mar 21]. Available from: https://www.nccn.org/professionals/physician_gls/pdf/hairy_cell.pdf
  13. National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology (NCCN Guidelines). B-cell Lymphomas (Version 3.2017) [cited 2017June 26]. Available from: https://www.nccn.org/professionals/physician_gls/pdf/b-cell.pdf
  14. National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology (NCCN Guidelines). Waldenström's Macroglobulinemia / Lymphoplasmacytic Lymphoma (Version 1.2017) [cited 2017 June 26]. Available from: http://www.nccn.org/professionals/physician_gls/pdf/waldenstroms.pdf.
  15. NCCN Drugs & Biologics Compendium [Internet]. Fort Washington (PA): National Comprehensive Cancer Network; 2017 [cited 2017 June 15]. Available from: http://www.nccn.org/professionals/drug_compendium/content/contents.asp/.
  16. Niemann CU, Wiestner A. B-cell receptor signaling as a driver of lymphoma development and evolution. Semin Cancer Biol. 2013 Dec;23(6):410-21. Epub 2013 Sep 20.
  17. Orphan Drug Designations and Approval [Internet]. Silver Spring (MD): US Food and Drug Administration; 2017 [cited 2017 Jun 15]. Available from: http://www.accessdata.fda.gov/scripts/opdlisting/oopd/index.cfm/.
  18. Treon SP, Tripsas CK, Meid K, et al. Ibrutinib in previously treated Waldenström's macroglobulinemia. N Engl J Med. 2015 Apr 9;372(15):1430-40.
  19. Treon SP, Xu L, and Hunter Z. MYD88 Mutations and Response to Ibrutinib in Waldenström's Macroglobulinemia. N Engl J Med. 2015 Aug 6;373(6):584-6.
  20. Wang ML, Blum KA, Martin P, et al. Long-term follow-up of MCL patients treated with single-agent ibrutinib: updated safety and efficacy results. Blood. 2015 Aug 6;126(6):739-45.
  21. Wang M, Lee HJ, Thirumurthi S, et al. Chemotherapy-Free Induction with Ibrutinib-Rituximab Followed By Shortened Cycles of Chemo-Immunotherapy Consolidation in Young, Newly Diagnosed Mantle Cell Lymphoma Patients: A Phase II Clinical Trial [abstract]. Blood 2016; 128: abstract 147.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Pharmacy Policy Committee on 09/13/17.

GUIDELINE UPDATE INFORMATION:

03/15/14

New Medical Coverage Guideline.

04/15/14

Revision to guideline; consisting of description, position statement, dosing/administration, references.

10/15/14

Revision to guideline; consisting of position statement, coding

08/15/15

Review and revision to guideline; consisting of description, position statement, dosing/administration, references.

12/15/15

Revision to guideline consisting of updating the position statement and definitions section.

05/15/16

Revision to guideline consisting of updating the position statement based on expanded FDA indication and NCCN guideline updates, and updated references.

08/15/16

Review and revision to guideline consisting of updating the description section, position statement, dosing/administration section, billing/coding information, related guidelines, and references.

12/15/16

Revision to guideline consisting of updating the description section, position statement, and references based on updated NCCN guidelines for CLL/SLL.

05/15/17

Revision to guideline consisting of updating the description section, position statement, dosage/administration section, billing/coding information, and references based on a new FDA approved indication and updated NCCN guidelines for non-Hodgkin lymphomas.

08/15/17

Review and revision to guideline consisting of updating the description section, position statement, dosing/administration section, and references.

10/15/17

Revision to guideline consisting of updating the description section, position statement, dosage/administration section, billing/coding information, and references based on a new FDA approved indication for chronic Graft versus Host Disease (cGVHD).

Date Printed: October 20, 2017: 08:42 AM