Pharmacy Prior Authorization Criteria

Ojemda (tovorafenib)

Indications for Prior Authorization

Ojemda (tovorafenib)

• For diagnosis of Pediatric low-grade glioma (LGG) harboring a BRAF fusion or rearrangement, or BRAF V600 mutation
  Indicated for the treatment of patients 6 months of age and older with relapsed or refractory pediatric low-grade glioma (LGG) harboring a BRAF fusion or rearrangement, or BRAF V600 mutation.

Criteria

Ojemda

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)
For diagnosis of Pediatric low-grade glioma

• Diagnosis of pediatric low-grade glioma
AND
• Disease is relapsed or refractory
AND
• Disease has a BRAF fusion or rearrangement, or BRAF V600 mutation as detected by an FDA-approved test or a test performed at a facility approved by Clinical Laboratory Improvement Amendments (CLIA)
AND
• Patient does not have known or suspected diagnosis of neurofibromatosis type 1 (NF-1)
AND
• Patient is 6 months of age or older
AND
• Disease has progressed on or after at least one line of prior systemic therapy (e.g., chemotherapy)

Ojemda

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)
For diagnosis of Pediatric low-grade glioma

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

P & T Revisions

2024-07-03

References

1. Ojemda Prescribing Information. Day One Biopharmaceuticals, Inc. Brisbane CA 94005. May 2024.

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Revision History

• 2024-07-03: New program

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