Tibsovo (ivosidenib) — Highmark
relapsed or refractory myelodysplastic syndromes (MDS)
Initial criteria
- age ≥ 18 years
- diagnosis of relapsed or refractory MDS (ICD-10 D46)
- disease is IDH1 mutation-positive as detected by an FDA-approved companion diagnostic test
Reauthorization criteria
- prescriber attests that the member is tolerating therapy and has experienced a therapeutic response defined as either disease improvement or delayed disease progression
Approval duration
12 months