Koselugo — CareFirst (Caremark)

Initial criteria

• Treatment as a single agent for recurrent or progressive disease
• Member has a circumscribed glioma AND either BRAF fusion or BRAF V600E activating mutation positive disease OR disease is WHO grade 1
• OR member has a NF-1 mutated glioma
• OR member has WHO grade 2 pleomorphic xanthoastrocytoma (PXA)

Reauthorization criteria

• No evidence of unacceptable toxicity or disease progression while on the current regimen

Approval duration

12 months