Koselugo (selumetinib capsules and granules – AstraZeneca) — Cigna

Initial criteria

• Patient meets ONE of the following (i, ii, iii, iv, or v):
• i. Patient meets BOTH of the following (a and b):
• a) Patient has multisystem Langerhans cell histiocytosis; AND
• b) Patient has symptomatic disease or impending organ dysfunction; OR
• ii. Patient has single system lung Langerhans cell histiocytosis; OR
• iii. Patient meets BOTH of the following (a and b):
• a) Patient has single system bone disease; AND
• b) Patient has not responded to treatment with a bisphosphonate; OR
• iv. Patient has central nervous system disease; OR
• v. Patient has relapsed or refractory disease; AND
• The medication is used as a single agent.

Approval duration

1 year