Brukinsa (zanubrutinib) — United Healthcare

Initial criteria

• (1) All of the following: Diagnosis of follicular lymphoma (FL) AND Disease is relapsed or refractory AND Patient has received at least two or more lines of systemic therapy AND Brukinsa will be used in combination with obinutuzumab
• OR (2) All of the following: Diagnosis of one of the following: Extranodal marginal zone lymphoma (EMZL) of the stomach; Extranodal marginal zone lymphoma of nongastric sites (noncutaneous); Nodal marginal zone lymphoma AND Disease is relapsed, refractory, or progressive AND Patient has received at least one anti-CD20-based regimen (e.g., rituximab, obinutuzumab)
• OR (3) All of the following: Diagnosis of splenic marginal zone lymphoma AND Disease is relapsed or refractory AND Patient has received at least one anti-CD20-based regimen (e.g., rituximab, obinutuzumab)
• OR (4) Diagnosis of mantle cell lymphoma (MCL)

Reauthorization criteria

• Patient does not show evidence of progressive disease while on Brukinsa therapy

Approval duration

12 months