Pharmacy Prior Authorization Criteria

Copiktra (duvelisib)

Indications for Prior Authorization

Copiktra (duvelisib)

• For diagnosis of Chronic Lymphocytic Leukemia (CLL)/Small Lymphocytic Lymphoma (SLL)
  Indicated for the treatment of adult patients with relapsed or refractory chronic lymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL) after at least two prior therapies.

Criteria

Copiktra

For state-mandated plans in Illinois or other states where applicable: Step therapy requirements do NOT apply. Beginning January 1, 2026, step therapy requirements or use of the authorization of alternative covered medications in a manner that effectively creates a step therapy requirement will not be imposed.

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of chronic lymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL)
AND
• Disease is relapsed or refractory
AND
• Trial and failure, contraindication, or intolerance to at least two prior therapies for CLL/SLL (e.g., Leukeran [chlorambucil], Calquence [acalabrutinib], Gazyva [obinutuzumab], Arzerra [ofatumumab], Venclexta [venetoclax], Bendeka [bendamustine], Imbruvica [ibrutinib], Rituxan [rituximab], etc.) [2]

Copiktra

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

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

P & T Revisions

1970-01-01, 2025-12-18, 2025-11-04, 2024-11-05, 2023-10-25, 2023-07-05, 2022-10-31, 2021-10-11, 2020-10-26, 2019-10-29

References

1. Copiktra Prescribing Information. Verastem, Inc. Needham, MA. July 2024.
2. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma v3.2025. Available by subscription at: https://www.nccn.org/professionals/physician_gls/pdf/cll.pdf. Accessed October 10, 2025

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Revision History

• 2025-12-18: no criteria changes, added IL statute operational note
• 2025-11-04: Annual Review. No criteria changes. Background updates.
• 2024-11-05: Annual Review. Background updates only.
• 2023-10-25: 2023 UM Annual Review. No criteria changes
• 2023-07-05: Removed specialist requirement
• 2022-10-31: 2022 Annual Review - Removed withdrawn indication of follicular lymphoma indication
• 2021-10-11: 2021 UM Annual Review
• 2020-10-26: UM Annual Review.
• 2019-10-29: 2019 Annual Review - SL - 10.29.19

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