Revuforj (revumenib) — Highmark
Relapsed or refractory acute leukemia with a KMT2A gene translocation
Initial criteria
- age ≥ 1 year
- Diagnosis of acute leukemia (ICD-10: C91.0, C92.0, C93.0, C94.0, C95.0), classified as relapsed or refractory
- Presence of KMT2A gene translocation
Reauthorization criteria
- Prescriber attests that the member is tolerating therapy
- Prescriber attests that the member has experienced a therapeutic response defined as disease improvement OR delayed disease progression
Approval duration
12 months