Pharmacy Prior Authorization Criteria

Revcovi (elapegademase-IvIr)

Indications for Prior Authorization

Revcovi (elapegademase-IvIr)

• For diagnosis of Adenosine deaminase severe combined immune deficiency (ADA-SCID)
  Indicated for the treatment of adenosine deaminase severe combined immune deficiency (ADA-SCID) in pediatric and adult patients.

Criteria

Revcovi

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of adenosine deaminase deficiency (ADA) with severe combined immunodeficiency (SCID)

Revcovi

Prior Authorization (Reauthorization)

Length of Approval: 24 Month(s)

• Patient demonstrates positive clinical response to therapy

P & T Revisions

2025-02-05, 2024-02-01, 2023-01-25, 2022-01-26, 2021-09-27, 2021-05-21, 2020-01-08

References

1. Revcovi Prescribing Information. Chiesi USA, Inc. Cary, NC 27518. August 2022
2. Immune Deficiency Foundation Patient & Family Handbook for Primary Immunodeficiency Diseases. Fifth Edition. 2013.

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Revision History

• 2025-02-05: 2025 Annual Review. No criteria changes.
• 2024-02-01: No criteria changes. Updated references.
• 2023-01-25: Update program
• 2022-01-26: Annual Review
• 2021-09-27: Addition of EHB formulary to guideline, no changes to criteria
• 2021-05-21: Addition of EHB formulary to guideline, no changes to criteria
• 2020-01-08: 2020 Annual Review

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