Imbruvica (ibrutinib) — United Healthcare

Diffuse large B-cell lymphoma (non-GCB DLBCL and non-candidate for transplant)

Initial criteria

Diagnosis of mantle cell lymphoma (MCL) AND (patient has received at least one prior therapy for MCL OR used in pre-treatment therapy in combination with Rituxan (rituximab) to limit the number of cycles with RHyperCVAD regimen)
OR Diagnosis of chronic lymphocytic leukemia (CLL) OR small lymphocytic lymphoma (SLL)
OR (Diagnosis of one of the following: histologic transformation to diffuse large B-cell lymphoma, post-transplant lymphoproliferative disorders, extranodal marginal zone lymphoma (EMZL) of the stomach, EMZL of nongastric sites (noncutaneous), diffuse large B-cell lymphoma (non-GCB DLBCL and non-candidate for transplant), HIV-related B-cell lymphoma, high grade B-cell lymphoma, hairy cell leukemia, nodal or splenic marginal zone lymphoma (MZL)) AND used as second-line or subsequent therapy

Patient does not show evidence of progressive disease while on Imbruvica therapy

12 months