Calquence (acalabrutinib) — CareFirst (Caremark)

Initial criteria

• Authorization may be granted when any of the following are met:
• The requested medication will be used as a single agent for subsequent therapy.
• The requested medication will be used in combination with rituximab for induction therapy.
• The requested medication will be used in combination with rituximab as pre-treatment to limit the number of cycles of induction therapy with R-HyperCVAD (rituximab, cyclophosphamide, vincristine, doxorubicin and dexamethasone) regimen.
• The requested medication will be used in combination with bendamustine and rituximab for previously untreated disease and the member is ineligible for transplant.

Reauthorization criteria

• Authorization may be granted for continued treatment when there is no evidence of unacceptable toxicity or disease progression while on the current regimen.

Approval duration

12 months