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Imbruvica (ibrutinib) — United Healthcare

Primary CNS Lymphoma

Initial criteria

  • Diagnosis of primary CNS lymphoma AND (used as second-line or a subsequent therapy OR used as induction therapy if patient is unsuitable or intolerant to high-dose methotrexate)

Reauthorization criteria

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

Approval duration

12 months