Pharmacy Prior Authorization Criteria

Tazverik (tazemetostat) - PA, NF

Indications for Prior Authorization

Tazverik (tazemetostat)

• For diagnosis of Epithelioid Sarcoma
  Indicated for the treatment of adults and pediatric patients aged 16 years and older with metastatic or locally advanced epithelioid sarcoma not eligible for complete resection. This indication is approved under accelerated approval based on overall response rate and duration of response. Continued approval for this indication may be contingent upon verification and description of clinical benefit in a confirmatory trial(s).

• For diagnosis of Follicular Lymphoma
  Indicated for the treatment of adult patients with relapsed or refractory (R/R) follicular lymphoma (FL) whose tumors are positive for an EZH2 mutation as detected by an FDA-approved test and who have received at least 2 prior systemic therapies. Also indicated for the treatment of adult patients with R/R FL who have no satisfactory alternative treatment options. These indications are approved under accelerated approval based on overall response rate and duration of response. Continued approval for these indications may be contingent upon verification and description of clinical benefit in a confirmatory trial(s).

Criteria

Tazverik

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)
For diagnosis of Epithelioid Sarcoma

• Diagnosis of epithelioid sarcoma
AND
• Disease is one of the following:
• Metastatic
• Locally advanced
AND
• Patient is not eligible for complete resection
AND
• Patient is 16 years of age or older

Tazverik

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)
For diagnosis of Follicular Lymphoma

• Diagnosis of follicular lymphoma
AND
• Disease is one of the following:
• Relapsed
• Refractory

Tazverik

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)
For diagnosis of Epithelioid Sarcoma, Follicular Lymphoma

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

Tazverik

Non Formulary

Length of Approval: 12 Month(s)
For diagnosis of Epithelioid Sarcoma

• Diagnosis of epithelioid sarcoma
AND
• Disease is one of the following:
• Metastatic
• Locally advanced
AND
• Patient is not eligible for complete resection
AND
• Patient is 16 years of age or older

Tazverik

Non Formulary

Length of Approval: 12 Month(s)
For diagnosis of Follicular Lymphoma

• Diagnosis of follicular lymphoma
AND
• Disease is one of the following:
• Relapsed
• Refractory

P & T Revisions

2024-07-31, 2023-07-28, 2022-07-26, 2021-11-19, 2021-07-28, 2020-07-27, 2020-02-20

References

1. Tazverik prescribing information. Epizyme, Inc. Cambridge, MA. December 2023.

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Revision History

• 2024-07-31: 2024 Annual Review. Added age criteria for epithelioid sarcoma indication. Updated references.
• 2023-07-28: Annual Review
• 2022-07-26: Annual Review
• 2021-11-19: Updated guideline name, guideline type (added Non Formulary)
• 2021-07-28: Annual Review
• 2020-07-27: Program Update: added new follicular lymphoma indication to GL
• 2020-02-20: New Program

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