Rezurock Prior Authorization Criteria - Medicare Part D

Prior Authorization Criteria for Approval

Initial Evaluation

Rezurock will be approved when ALL of the following are met:

1. The patient has a diagnosis of chronic graft-versus-host disease (chronic GVHD)
   AND
2. The patient has failed at least two prior lines of systemic therapy
   AND
3. The patient is within the FDA labeled age for the requested medication
   AND
4. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., hematologist, oncologist) or the prescriber has consulted with a specialist in the area of the patient’s diagnosis
   AND
5. ONE of the following:
   1. The requested quantity (dose) does NOT exceed the program quantity limit
      OR
   2. ALL of the following:
      1. The requested quantity (dose) is greater than the program quantity limit
         AND
      2. The requested quantity (dose) cannot be achieved with a lower quantity of a higher strength that does not exceed the program quantity limit
         AND
      3. The prescriber has provided information in support of therapy with a higher dose for the requested indication

Length of Approval: 12 months

Renewal Evaluation

Rezurock will be approved when ALL of the following are met:

1. The patient has been previously approved for the requested medication through the plan’s Prior Authorization criteria
   AND
2. The patient has a diagnosis of chronic graft-versus-host disease (chronic GVHD)
   AND
3. The patient is within the FDA labeled age for the requested medication
   AND
4. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., hematologist, oncologist) or the prescriber has consulted with a specialist in the area of the patient’s diagnosis|
   AND
5. The patient has had clinical benefit with the requested medication
   AND
6. ONE of the following:
   1. The requested quantity (dose) does NOT exceed the program quantity limit
      OR
   2. ALL of the following:
      1. The requested quantity (dose) is greater than the program quantity limit
         AND
      2. The requested quantity (dose) cannot be achieved with a lower quantity of a higher strength that does not exceed the program quantity limit
         AND
      3. The prescriber has provided information in support of therapy with a higher dose for the requested indication

Length of Approval: 12 months