TAZVERIK (tazematostat)
Indication(s) for Prior Authorization:
Adults and pediatric patients aged 16 years and older with metastatic or locally advanced epithelioid sarcoma not eligible for complete resection.
Adult patients with relapsed or refractory follicular lymphoma 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.
Adult patients with relapsed or refractory follicular lymphoma who have no satisfactory alternative treatment options.
Coverage criteria:
For diagnosis of Epithelioid Sarcoma:
- Diagnosis of metastatic or locally advanced epithelioid sarcoma; AND
- Patient is not eligible for complete resection; AND
- Patient is age 16 years or older; AND
- Dose does not exceed 1600 mg per day.
For diagnosis of Follicular Lymphoma:
- Diagnosis of relapsed or refractory follicular lymphoma; AND
- Patient must have ONE of the following:
- Tumors are positive for an EZH2 mutation as detected by an FDA-approved test AND patient has disease progression despite treatment with TWO prior systemic therapies for follicular lymphoma; OR
- Patient has no satisfactory alternative treatment options
Dosing:
Recommended dosage: 800 mg taken twice daily.
Coverage Duration:
1 year
Authorization is Not Covered for the Following:
Non-FDA approved indications that are not listed in this policy do not meet the coverage criteria established by the Western Health Advantage (WHA) Pharmacy and Therapeutics Committee.
Additional Information:
- Avoid coadministration of strong and moderate CYP3A inhibitors with Tazverik. Reduce the dose of Tazverik if coadministration of moderate CYP3A inhibitors cannot be avoided.
- Avoid coadministration of strong and moderate CYP3A inducers with Tazverik.