Copanlisib (Aliqopa™)

OFFICE ADMINISTRATION - MEDICAL BENEFIT

Indications for Prior Authorization:

  • Treatment of adult patients with relpased follicular lympohma (FL) who have received at least two prior systemic therapies

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

  • Prescribed by an oncologist, AND
  • 18 years or older, AND
  • Chart note documentation confirms diagnosis of relapsed follicular lymphoma (FL), AND
  • Patient has tried and failed at least two prior systemic therapies

Dosing:

  • 60 mg administered as a 1-hour IV infusion on days 1, 8, and 15 of a 28-day treatment cycle on an intermittent schedules (three weeks on and one week off).  Modify dosage for toxicity.  Continue treatment until disease progression or unacceptable toxicity.

Last review date: November 29, 2018