CurrentMass General Brigham Health PlanPolicy N/A

Brukinsa (zanubrutinib)

Pharmacy benefit prior authorization and quantity limit policy for zanubrutinib (Brukinsa) including specialty pharmacy requirement, coverage criteria for mantle cell lymphoma, marginal zone lymphoma, and Waldenstrom's macroglobulinemia, continuation/reauthorization and quantity limits.

Policy Summary

PayerMass General Brigham Health Plan

PolicyBrukinsa (zanubrutinib)

Policy CodePolicy N/A

Change TypeReferences updated / revised

Effective DateApr 1, 2023

Next Review Date

Key ActionPrior authorization is required for Brukinsa under the pharmacy benefit; specialty designation requires fill at a contracted specialty pharmacy and prior authorization review for members new to the plan currently receiving treatment.

SourceLink

POLICY UPDATE CHANGES

References updated: Effective 4/1/23

3Covered Indications

120/30dQuantity Limit

18+Minimum Age

Coverage Summary

Coverage stance: covered_with_criteria. Subject: Brukinsa (zanubrutinib). Scope: Pharmacy benefit prior authorization and quantity limit policy for zanubrutinib including specialty pharmacy requirement, coverage criteria for mantle cell lymphoma, marginal zone lymphoma, and Waldenstrom's macroglobulinemia, continuation/reauthorization, and quantity limits.

Indications summary: Authorization may be granted for adults (> 18 years) when used for one of the following: mantle cell lymphoma (relapsed or refractory) with ≥1 prior therapy and oncology/hematology specialty involvement; relapsed or refractory marginal zone lymphoma after ≥1 prior anti‑CD20–based regimen with oncology/hematology specialty involvement; or Waldenstrom's macroglobulinemia with oncology/hematology specialty involvement. Appropriate dosing must be documented.

Specialty pharmacy and prior authorization requirements: Brukinsa is designated specialty and must be dispensed at a contracted specialty pharmacy; prior authorization is required under the pharmacy benefit. Initial approvals and reauthorizations are for 12 months, and quantity limits apply (Brukinsa 80 mg — 120 capsules per 30 days).

OpenPayer

Brukinsa (zanubrutinib)

Coverage Summary

Initial Therapy Criteria