Aliqopa (copanlisib) IV prior authorization for relapsed follicular lymphoma
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Covers medical prior authorization requirements for Aliqopa (copanlisib) administered IV for AvMed members; describes required provider, member, and clinical documentation and criteria for approval. Affects prescribers, administering sites, and members seeking coverage for this drug.
No material clinical or coverage changes in this revision.
Coverage Criteria for Aliqopa (copanlisib) IV
inv-01: Initial therapy — Covered when ALL of the following are met
Covered when ALL of the following are met
Documentation of prior therapies will be verified via pharmacy claims or chart notes
The use of drug samples to initiate therapy does not satisfy step edit or preauthorization requirements. Requests for coverage must document prior therapies; previous treatments will be verified through pharmacy paid claims or submitted chart notes.
Initial Therapy — Specific Approval Conditions
inv-11: Initial therapy — 4 top-level nodes
Previous therapies will be verified through pharmacy claims or chart notes
Billing and Code Information
Provider Requirements and Submission Instructions
Prior Authorization Required
Prior authorization is required for this medication. Submit requests by fax to 1-877-535-1391 using the signed prescriber request form (preprinted stamps are not valid). Include the HCPCS/administration codes J9999 and/or C9399 on the request as applicable. Allowable review types: standard review unless the practitioner requests an urgent review per AvMed definition.
- Signed prescriber signature required (physician must sign and clearly print name)
- Preprinted signature stamps are not valid
- For urgent review, contact AvMed Pre-Authorization Department per urgent criteria
Samples and Prior Therapy Verification
Samples do not meet prior authorization or step-edit criteria and cannot be used to initiate therapy. Prior therapies listed on the request will be verified by the plan via pharmacy paid-claim history or submitted medical chart notes; provide documentation for prior systemic therapies when applicable.
- Do not rely on samples to satisfy prior therapy requirements
- Attach chart notes or ensure accurate pharmacy history to document prior systemic therapies
Required Submission Information
Provide complete prescriber, member, dosing, diagnosis, and prior therapy information. Incomplete requests may be delayed or denied — include weight and date obtained when weight-based dosing applies.
- Prescriber name, NPI, phone and fax numbers
- Member name and identifiers (as applicable)
- Drug name/form/strength and dosing schedule (e.g., 60 mg IV on Days 1, 8, 15 of 28-day cycle)
- Length of therapy and diagnosis with ICD-10 code
- Weight and date weight obtained (if applicable)
- Documentation of at least two prior systemic therapies for relapsed follicular lymphoma
- Prescriber specialty (oncologist or hematologist) must be indicated
Incomplete or Insufficient Documentation
Authorization may be delayed or denied if the PA form or supporting documentation is missing, incomplete, illegible, or if clinical criteria are not fully met. Ensure all chart notes, lab results, and diagnostics that support requested criteria are included.
- Illegible or missing information (including phone/fax) can delay review
- Provide all supporting clinical documentation for each criterion checked on the form
Administration Site Requirements
Site of care — specify administering location and NPI/DEA (or specialty pharmacy)
Indicate the location/site of drug administration and provide the NPI or DEA number of the administering location, or select the specialty pharmacy option (Proprium Rx) if applicable.
- Provide administering location/site and NPI or DEA # of that location.
- Option to designate Specialty Pharmacy - Proprium Rx.
Clinical Background
Follicular lymphoma is an indolent B‑cell non‑Hodgkin lymphoma that commonly relapses after systemic therapy. For relapsed disease, targeted agents such as PI3K inhibitors may be used; this policy addresses coverage for Aliqopa (copanlisib) IV for members with relapsed follicular lymphoma who have received at least two prior systemic therapies.
Approval requires documentation that the patient is an adult (age >= 18 years), that the prescriber is an oncologist or hematologist, and that dosing follows the approved regimen (60 mg IV on Days 1, 8, and 15 of a 28‑day cycle). Providers must supply supporting clinical documentation and prior therapy records as noted; samples cannot be used to meet prior‑therapy requirements.
Definitions and Key Terms
Step Therapy Requirements
| Requirement | Details |
|---|---|
| Previous therapies must be documented | Previous therapies will be verified through pharmacy paid claims or submitted chart notes |
| Use of samples to initiate therapy does not satisfy step edit/preauthorization requirements | Samples alone do not meet prior authorization criteria; documentation of completed prior therapies is required |
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