dordaviprone — CareFirst (Caremark)
Diffuse midline glioma harboring an H3 K27M mutation with progressive disease following prior therapy
Initial criteria
- Member is age ≥ 1 year
- Disease harbors an H3 K27M mutation
- Member experienced recurrence or progression following prior therapy
Reauthorization criteria
- No evidence of unacceptable toxicity or disease progression while on current regimen
Approval duration
12 months