Neighborhood Health Plan RI Gazyva Coverage Prior Auth | OpenPayer

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Neighborhood Health Plan RI Gazyva Coverage Prior Auth | OpenPayer

Regimen / Use	Indication / Specific use	Coverage status
Gazyva + chlorambucil
Chronic lymphocytic leukemia (previously untreated) — Gazyva in combination with chlorambucil is an FDA‑approved indication
Gazyva + bendamustine
Follicular lymphoma or marginal zone lymphoma — used in combination with bendamustine for first‑line or subsequent therapy per compendial uses
Gazyva + CHOP or CVP
Follicular lymphoma or nodal marginal zone lymphoma — used in combination with CHOP or CVP for first‑line therapy
Gazyva + lenalidomide
Subsequent therapy for follicular lymphoma or marginal zone lymphoma — combination use for later‑line treatment
Gazyva + vemurafenib
Hairy cell leukemia — initial therapy in members unable to tolerate purine analogs (in combination with vemurafenib)
Gazyva as pretreatment for glofitamab (single dose)
Diffuse large B‑cell lymphoma — single‑dose pretreatment prior to glofitamab (Columvi) administration

Provider Actions and Documentation Requirements

Prior Authorization

Prior Authorization and Duration

Prior authorization is required for requests. Typical initial authorization durations vary by indication but are generally 6 months; some indications allow extensions up to 30 months total where noted. Prior authorization requests should specify the indication and regimen to ensure correct duration is applied.

Authorization commonly: 6 months
Follicular Lymphoma: up to 30 months total when criteria met
Diffuse Large B-Cell Lymphoma (pretreatment with glofitamab): authorization for up to 1 dose in the cycle of glofitamab therapy

Note

Regimen-specific Requirements

Use is covered only for specific combination regimens and conditions listed per lymphoma subtype. Confirm the requested medication will be used in an approved combination or as an approved substitute for rituximab when rituximab intolerance or rare complications are documented.

CLL/SLL: Covered as single agent or in combination with acalabrutinib, venetoclax, bendamustine, or chlorambucil
Follicular Lymphoma: Covered when used with CHOP, CVP, bendamustine, lenalidomide, or as single-agent maintenance; may substitute for rituximab if intolerance/rare complications (e.g., mucocutaneous reactions, Stevens-Johnson syndrome, toxic epidermal necrolysis) are documented
Extranodal or Splenic Marginal Zone Lymphoma: Covered as subsequent therapy in combination with bendamustine or lenalidomide, for maintenance after prior treatment with the medication and bendamustine, or as a rituximab substitute for documented intolerance/rare complications
Nodal Marginal Zone Lymphoma: Covered as first-line with CHOP, CVP, or bendamustine; subsequent therapy with bendamustine or lenalidomide; maintenance after prior treatment with the medication and bendamustine; or as rituximab substitute when intolerance/rare complications documented
Diffuse Large B-Cell Lymphoma: Covered when used as pretreatment for glofitamab (authorization up to 1 dose in the glofitamab cycle)
Histologic transformation and other high-grade B‑cell lymphomas, mantle cell lymphoma, Burkitt lymphoma, HIV-related B‑cell lymphomas, post-transplant lymphoproliferative disorders, Castleman’s disease: Covered when used as a substitute for rituximab in members with documented rituximab intolerance or rare complications

Denial Risk

Not Covered Indications and Denial Risk

The requested use is not covered when it is experimental or investigational, or when the regimen/indication does not match the specified covered combinations and conditions above. Requests lacking documentation of rituximab intolerance when submitted as a rituximab substitute, or lacking clear regimen details, are at high risk for denial.

Not covered: uses outside the listed lymphoma subtypes, unsupported combination regimens, or unproven/experimental indications
Denial risk: requests without documentation of rituximab intolerance for substitution, or without clear indication/regimen details

Documentation Required

Required Clinical Documentation

When requesting coverage as a rituximab substitute due to intolerance or rare complications, provide clinical documentation describing the adverse reaction (for example: paraneoplastic pemphigus, Stevens-Johnson syndrome, lichenoid dermatitis, vesiculobullous dermatitis, toxic epidermal necrolysis) and why continuation with rituximab is not possible. For combination regimens, include treatment intent (first-line, subsequent, maintenance), prior therapies, and dosing schedule.

Document the lymphoma subtype and line of therapy (first-line, subsequent, maintenance)
List concomitant regimen (e.g., CHOP, CVP, bendamustine, lenalidomide, acalabrutinib, venetoclax, chlorambucil)
If substituting for rituximab, include detailed clinical evidence of intolerance or the specific rare complication
For glofitamab pretreatment, indicate planned glofitamab cycle and that the request is for the pretreatment dose

Covered Combination Regimens and Specific Uses

Example regimen	Mapped indication / typical use	Coverage status
Gazyva + chlorambucil
Chronic lymphocytic leukemia (previously untreated) — FDA‑approved combination
Gazyva + bendamustine
Follicular lymphoma; Extranodal, splenic, or nodal marginal zone lymphoma — first‑line or subsequent therapy per compendial guidance
Gazyva + CHOP or CVP
Follicular lymphoma; Nodal marginal zone lymphoma — first‑line combination chemotherapy regimens
Gazyva + lenalidomide
Subsequent therapy for follicular lymphoma or marginal zone lymphoma — combination regimen for later lines of therapy
Gazyva + vemurafenib
Hairy cell leukemia — initial therapy for members unable to tolerate purine analogs (combination with vemurafenib)
Gazyva (single‑dose) as pretreatment for glofitamab
Diffuse large B‑cell lymphoma — single pretreatment dose prior to glofitamab (Columvi) therapy