Acalabrutinib (Calquence®)


Indications for Prior Authorization:

  • Treatment of adult patients with mantle cell lymphoma (MCL) who have received at least 1 prior therapy

Patients must meet the following criteria for the indication(s) above:

  • Patient is 18 years of age or older, AND
  • Member has mantle cell lymphoma and has had at least 1 prior therapy, AND
  • Patient is not concurrently taking a CYP3A inhibitor or inducer, AND
  • Patient is not concurrently taking a PPI (stagger dosing with H2-receptor antagonists and antacids)


  • 100 mg every 12 hours
  • Dose modifications are recommended for non-hematologic toxicities, thrombocytopenia with bleeding, thrombocytopenia, or neutropenia lasting longer than 7 days


  • 1 year

Last review date: December 17, 2018

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