Pharmacy Prior Authorization Criteria

Inqovi (decitabine and cedazuridine) - PA, NF

Indications for Prior Authorization

Inqovi (decitabine and cedazuridine)

• For diagnosis of Myelodysplastic Syndromes (MDS)
  Indicated for treatment of adult patients with myelodysplastic syndromes (MDS), including previously treated and untreated, de novo and secondary MDS with the following French-American-British subtypes (refractory anemia, refractory anemia with ringed sideroblasts, refractory anemia with excess blasts, and chronic myelomonocytic leukemia [CMML]) and intermediate-1, intermediate-2, and high-risk International Prognostic Scoring System groups.

Criteria

Inqovi

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of myelodysplastic syndrome
AND
• Patient is intermediate-1, intermediate-2, or high-risk per the International Prognostic Scoring System (IPSS)

Inqovi

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

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

Inqovi

Non Formulary

Length of Approval: 12 Month(s)

• Diagnosis of myelodysplastic syndrome
AND
• Patient is intermediate-1, intermediate-2, or high-risk per the International Prognostic Scoring System (IPSS)

P & T Revisions

2024-07-31, 2024-01-09, 2023-08-08, 2022-07-05, 2022-02-09, 2021-11-22, 2021-07-28, 2021-05-19, 2020-10-07, 2020-07-27, 2019-08-09

References

1. Inqovi prescribing information. Taiho Oncology, Inc. Princeton, NY. March 2022.

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Revision History

• 2024-07-31: 2024 Annual Review. No criteria changes.
• 2024-01-09: Program Update
• 2023-08-08: Annual Review
• 2022-07-05: Annual Review
• 2022-02-09: Addition of EHB formulary to guideline, no changes to criteria
• 2021-11-22: Updated guideline name, added NF section to Inqovi
• 2021-07-28: Annual Review
• 2021-05-19: Addition of EHB formulary to guideline, no changes to criteria
• 2020-10-07: Added new criteria for Inqovi and renamed guideline to Dacogen (decitabine)/Inqovi (decitabine and cedazuridine) tablets
• 2020-07-27: Annual Review: no criteria changed, updated references and background
• 2019-08-09: Annual review. No changes to clinical criteria. Updated references. XC 8/9/19.

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