Koselugo (selumetinib capsules and granules – AstraZeneca) — Cigna

Initial criteria

• Patient meets ONE of the following (i or ii):
• i. Patient is 1 to 18 years of age; OR
• ii. Patient meets BOTH of the following (a and b):
• a) Patient is ≥ 19 years of age; AND
• b) Patient has been previously started on therapy with Koselugo prior to becoming 19 years of age; AND
• Prior to starting Koselugo, the patient had symptomatic, inoperable plexiform neurofibromas, according to the prescriber.

Approval duration

1 year