Anthem Blue Cross California Columvi (glofitamab-gxbm) Form

Publish Date:

09/01/2023

Last Review Date:

08/18/2023

Overview

• Coding
• References
• Clinical Criteria
• Document History

Overview

This document addresses the use of Columvi (glofitamab-gxbm) an intravenously administered. Columvi is a bispecific CD20-directed CD3 T-cell engager. Columvi is indicated for adults with relapsed or refractory diffuse large B-cell lymphoma (LBCL), not otherwise specified or large B-cell lymphoma arising from follicular lymphoma after two or more lines of systemic therapy.

Columvi has a black box warning for cytokine release syndrome (CRS), including serious or fatal reactions.

Clinical Criteria

When a drug is being reviewed for coverage under a member’s medical benefit plan or is otherwise subject to clinical review (including prior authorization), the following criteria will be used to determine whether the drug meets any applicable medical necessity requirements for the intended/prescribed purpose.

Columvi (glofitamab-gxbm)

Requests for Columvi (glofitamab-gxbm) may be approved if the following criteria are met:

1. Individual is using for a maximum of 12 cycles; AND
2. Individual is using for one of the following:
   • A. Relapsed or refractory diffuse large B-cell lymphoma, not otherwise specified;
   • B. Large B-cell lymphoma arising from follicular lymphoma; AND
3. Previously had two or more lines of systemic therapy.

Requests for Columvi (glofitamab-gxbm) may not be approved when the above criteria are not met and for all other indications.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

HCPCS

• J9286

ICD-10 Diagnosis

Injection, glofitamab-gxbm, 2.5 mg [Columvi]

1. C83.30-C83.39
   Diffuse large B-cell lymphoma

Document History

Reviewed: 08/18/2023