Pharmacy Prior Authorization Criteria

Romvimza (vimseltinib)

Indications for Prior Authorization

Romvimza (vimseltinib)

• For diagnosis of Tenosynovial Giant Cell Tumor (TGCT)
  Indicated for treatment of adult patients with symptomatic tenosynovial giant cell tumor (TGCT) for which surgical resection will potentially cause worsening functional limitation or severe morbidity.

Criteria

Romvimza

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of tenosynovial giant cell tumor (TGCT)
AND
• Patient is symptomatic
AND
• Surgical resection will potentially cause worsening functional limitation or severe morbidity

Romvimza

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

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

P & T Revisions

2025-03-31

References

1. Romvimza prescribing information. Deciphera Pharmaceuticals, LLC. Waltham, MA. February 2025.

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Revision History

• 2025-03-31: New program

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