Modeyso (dordaviprone) — Highmark
diffuse midline glioma harboring an H3 K27M mutation with progressive disease following prior therapy
Initial criteria
- age ≥ 1 year
- diagnosis of diffuse midline glioma
- disease harbors an H3 K27M mutation
- progressive disease following prior therapy
Reauthorization criteria
- prescriber attests that the member is tolerating therapy
- therapeutic response defined as one of the following: 1) disease improvement OR 2) delayed disease progression
Approval duration
12 months