Turalio (pexidartinib) — United Healthcare

Initial criteria

• Patient is less than 19 years of age OR
• Diagnosis of tenosynovial giant cell tumor (TGCT) / pigmented villonodular synovitis (PVNS) OR
• Diagnosis of one of the following: Langerhans Cell Histiocytosis, Erdheim-Chester Disease, Rosai-Dorfman Disease AND Colony stimulating factor 1 receptor (CSF1R) mutation positive OR
• Drug is recognized for treatment of the cancer indication by the National Comprehensive Cancer Network (NCCN) Drugs and Biologics Compendium with a Category of Evidence and Consensus of 1, 2A, or 2B

Reauthorization criteria

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

Approval duration

12 months