Pharmacy Prior Authorization Criteria

Revuforj (revumenib)

Indications for Prior Authorization

Revuforj (revumenib)

• For diagnosis of Relapsed or Refractory Acute Leukemia
  Indicated for the treatment of relapsed or refractory acute leukemia with a lysine methyltransferase 2A gene (KMT2A) translocation in adult and pediatric patients 1 year and older.

Criteria

Revuforj

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of acute leukemia
AND
• Disease is relapsed or refractory
AND
• Patient is 1 year of age or older
AND
• Presence of lysine methyltransferase 2A gene (KMT2A) translocation

Revuforj

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

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

P & T Revisions

2024-12-24

References

1. Revuforj Prescribing Information. Syndax Pharmaceuticals, Inc. November 2024

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Revision History

• 2024-12-24: New Program.

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