ibrutinib — CareFirst (Caremark)

Initial criteria

• Member has received at least one prior therapy when Imbruvica is used as a single agent or in combination with rituximab or venetoclax
• OR Imbruvica will be used in combination with rituximab as pretreatment to induction therapy with R-HyperCVAD regimen
• OR Imbruvica will be used as aggressive induction therapy as a component of TRIANGLE regimen: alternating RCHOP + covalent BTK inhibitor (ibrutinib)/RDHA + carboplatin regimen
• OR Imbruvica will be used in combination with rituximab for members aged ≥ 65 years

Reauthorization criteria

• No evidence of unacceptable toxicity or disease progression while on Imbruvica

Approval duration

12 months