Pemazyre (pemigatinib) — Highmark
relapsed or refractory myeloid/lymphoid neoplasms (MLN) with FGFR1 rearrangement
Initial criteria
- age ≥ 18 years
- diagnosis of relapsed or refractory myeloid/lymphoid neoplasm (ICD-10: D47.1)
- disease harbors FGFR1 rearrangement
Reauthorization criteria
- prescriber attests member is tolerating therapy
- member has experienced a therapeutic response defined as disease improvement OR delayed disease progression
Approval duration
12 months