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 as determined by an FDA-authorized test in adult and pediatric patients 1 year and older.

• For diagnosis of Relapsed or Refractory Acute Myeloid Leukemia
  Indicated for the treatment of relapsed or refractory acute myeloid leukemia (AML) with a susceptible nucleophosmin 1 (NPM1) mutation in adult and pediatric patients 1 year and older who have no satisfactory alternative treatment options.

Criteria

Revuforj

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)
For diagnosis of Relapsed or Refractory Acute Leukemia

• Diagnosis of acute leukemia
AND
• Disease is relapsed or refractory
AND
• Presence of lysine methyltransferase 2A gene (KMT2A) translocation as detected by an FDA-approved test or a test performed at a facility approved by Clinical Laboratory Improvement Amendments (CLIA)
AND
• Patient is 1 year of age or older

Revuforj

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)
For diagnosis of Relapsed or Refractory Acute Myeloid Leukemia

• Diagnosis of acute myeloid leukemia (AML)
AND
• Disease is relapsed or refractory
AND
• Presence of a susceptible nucleophosmin 1 (NPM1) mutation as detected by an FDA-approved test or a test performed at a facility approved by Clinical Laboratory Improvement Amendments (CLIA)
AND
• Patient is 1 year of age or older

Revuforj

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)
For diagnosis of All indications listed above

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

P & T Revisions

2025-12-08, 2025-04-14, 2024-12-24

References

1. Revuforj Prescribing Information. Syndax Pharmaceuticals, Inc. October 2025.

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Revision History

• 2025-12-08: For relapsed or refractory acute leukemia, updated indication verbiage and added genetic testing verbiage to mutation criterion. New indication for relapsed or refractory acute myeloid leukemia added, PA applied. Reference updated.
• 2025-04-14: Added Revuforj 25mg to guideline
• 2024-12-24: New Program.

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