Tibsovo — CareFirst (Caremark)

Initial criteria

• Diagnosis of newly diagnosed AML with a susceptible IDH1 mutation detected by an FDA-approved test AND (member age ≥ 75 years OR member is not a candidate for or declines intensive induction therapy) AND medication will be used as a single agent or in combination with azacitidine
• Diagnosis of post-induction AML with a susceptible IDH1 mutation AND medication will be used as a single agent or in combination with azacitidine AND member has experienced response to Tibsovo therapy
• Diagnosis of relapsed or refractory AML with a susceptible IDH1 mutation AND medication will be used as a single agent

Reauthorization criteria

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

Approval duration

12 months