Aliqopa (copanlisib IV) Utilization Management Medical Policy
Customize your policy alerts
Sign up for Aspirus Arise POLICY: Oncology (Injectable) - Aliqopa Utilization Management Medical Policy alerts
Get alerted when POLICY: Oncology (Injectable) - Aliqopa Utilization Management Medical Policy changes without checking for updates manually.
Monitor payer policy activity
Defines prior authorization, coverage criteria, dosing, and restrictions for Aliqopa (copanlisib IV) for Aspirus Medicare Plans; applies to providers prescribing or requesting coverage for Aliqopa.
Policy notes Bayer voluntarily withdrew Aliqopa from the U.S. market and the FDA withdrawal of the NDA, and retains coverage pathways for patients currently receiving therapy.
Recommended Authorization Criteria
inv-01: Initial Therapy - Follicular Lymphoma
Covered when ALL of the following are met:
Examples of systemic therapies listed in policy include bendamustine, cyclophosphamide, doxorubicin, vincristine, rituximab products, obinutuzumab.
inv-02: Other Supported Indication - Marginal Zone Lymphoma
Covered when ALL of the following are met (applies to marginal zone lymphoma subtypes):
Includes extranodal (stomach and nongastric), nodal, and splenic marginal zone lymphoma.
Coverage of Aliqopa (copanlisib) is not recommended for circumstances that are not specifically listed in the Recommended Authorization Criteria. Criteria will be updated as new published data become available.
As reflected in current guideline and policy guidance, the National Comprehensive Cancer Network (NCCN) B‑Cell Lymphoma guidelines (version 2.2025) no longer recommend Aliqopa for relapsed/refractory follicular lymphoma (grade 1 or 2) and for multiple marginal zone lymphoma subtypes (extranodal stomach, extranodal nongastric, splenic, and nodal). Consistent with this guidance and the document change note, the policy limits approvals to the specific indications and patient populations listed in the Recommended Authorization Criteria and will be updated if new evidence warrants broader use.
Dosing and Regimens
| Regimen | Indication | Authorization Duration | Coverage |
|---|---|---|---|
| Copanlisib 60 mg IV up to three times per 28-day cycle | Relapsed follicular lymphoma in adults currently receiving Aliqopa after > 2 prior systemic therapies | Approve for 1 year | Covered |
| Regimen | Indication | Authorization Duration | Coverage |
|---|---|---|---|
| Copanlisib 60 mg IV up to three times per 28-day cycle | Marginal zone lymphoma subtypes (extranodal stomach and nongastric, nodal, splenic) in adults currently receiving Aliqopa after > 2 prior systemic therapies | Approve for 1 year | Covered |
Coding and Related Operational Notes
| N/A | No explicit CPT/HCPCS/ICD-10/NDC codes listed in policy |
Provider Requirements and Authorization Workflow
Prior authorization required
Prior authorization is recommended for medical benefit coverage of Aliqopa; approval is recommended only when the patient meets the specified Criteria and Dosing for the listed indications. Approvals are provided for the duration noted in the policy and require Aliqopa to be prescribed by or in consultation with a physician who specializes in the condition being treated.
Prior therapy requirement
Approval requires that the patient has received greater than two prior systemic therapies before qualifying under the policy; examples of systemic therapies listed include bendamustine, cyclophosphamide, doxorubicin, vincristine, rituximab products (e.g., Rituxan, biosimilars), and Gazyva (obinutuzumab).
Required documentation
Documentation must demonstrate that the patient is > 18 years of age, is currently receiving Aliqopa, and has received > 2 prior systemic therapies (with types/examples documented); also document that Aliqopa is prescribed by or in consultation with an oncologist per the policy criteria.
Denial triggers
Requests that do not meet the Recommended Authorization Criteria or that are for indications or circumstances not listed will not be recommended for approval.
- Coverage is not recommended for circumstances not listed in the Recommended Authorization Criteria.
- Approvals are limited to patients meeting the policy's listed criteria and dosing.
Therapy Setting and Intent
inv-13: salvage
Background and Drug Information
Aliqopa (copanlisib intravenous infusion) is a PI3K kinase inhibitor indicated historically for the treatment of relapsed follicular lymphoma in adults who have received at least two prior systemic therapies. The policy retains limited, operational coverage pathways for patients currently receiving Aliqopa and specifies authorization requirements including patient age, documentation of prior therapies, and oncologist involvement.
Drug Definition
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.