Pharmacy Prior Authorization Criteria

Ogsiveo (nirogacestat)

Indications for Prior Authorization

Ogsiveo (nirogacestat)

• For diagnosis of Desmoid Tumor
  Indicated for adult patients with progressing desmoid tumors who require systemic treatment.

Criteria

Ogsiveo

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of desmoid tumor
AND
• Disease is progressive
AND
• Patient requires systemic treatment

Ogsiveo

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

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

P & T Revisions

2024-05-14, 2024-02-27, 2024-01-30

References

1. Ogsiveo Prescribing Information. SpringWorks Therapeutics, Inc. Stamford, CT. April 2024.

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Revision History

• 2024-05-14: Addition of Ogsiveo 100mg and 150mg tablets to guideline
• 2024-02-27: Added EHB formulary. No changes to criteria.
• 2024-01-30: New program for Ogsiveo

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