Koselugo (selumetinib) — United Healthcare

Initial criteria

• Diagnosis of Langerhans cell histiocytosis
• One of the following:
• a. Presence of MAP kinase pathway mutation
• b. No detectable mutation
• c. Genetic testing not available
• Used as monotherapy

Reauthorization criteria

• Patient does not show evidence of progressive disease while on Koselugo therapy

Approval duration

12 months