Pharmacy Prior Authorization Criteria

Rasonque (daraxonrasib) - PA, NF

Indications for Prior Authorization

Rasonque (daraxonrasib)

• For diagnosis of Metastatic pancreatic adenocarcinoma
  Indicated for the treatment of adult patients with metastatic pancreatic adenocarcinoma who have received at least one prior systemic therapy or who are not candidates for multiagent systemic therapy.

Criteria

Rasonque

Prior Authorization (Initial Authorization)

Length of Approval: 6 Month(s)

• Submission of medical records (e.g., chart notes) confirming diagnosis of pancreatic adenocarcinoma
AND
• Submission of medical records (e.g., chart notes) confirming disease is metastatic
AND
• Submission of medical records (e.g., chart notes) or paid claims confirming one of the following:
• Disease has progressed following at least one prior systemic therapy (e.g., chemotherapy FOLFIRINOX, gemcitabine plus nab-paclitaxel, NALIRIFOX or listed in the NCCN Drugs and Biologics Compendium with Categories of Evidence and Consensus of 1, 2A, or 2B)
OR
• Patient is not a candidate for multiagent systemic therapy (e.g., ECOG performance status greater than 3, significant comorbidities [e.g., severe cardiac, pulmonary, hepatic, renal dysfunction], prior treatment related toxicity [e.g., neutropenia, peripheral neuropathy, etc])

Rasonque

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

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

Rasonque

Non Formulary (Initial Authorization)

Length of Approval: 6 Month(s)

• Submission of medical records (e.g., chart notes) confirming diagnosis of pancreatic adenocarcinoma
AND
• Submission of medical records (e.g., chart notes) confirming disease is metastatic
AND
• Submission of medical records (e.g., chart notes) or paid claims confirming one of the following:
• Disease has progressed following at least one prior systemic therapy (e.g., chemotherapy FOLFIRINOX, gemcitabine plus nab-paclitaxel, NALIRIFOX or listed in the NCCN Drugs and Biologics Compendium with Categories of Evidence and Consensus of 1, 2A, or 2B)
OR
• Patient is not a candidate for multiagent systemic therapy (e.g., ECOG performance status greater than 3, significant comorbidities [e.g., severe cardiac, pulmonary, hepatic, renal dysfunction], prior treatment related toxicity [e.g., neutropenia, peripheral neuropathy, etc])

Rasonque

Non Formulary (Reauthorization)

Length of Approval: 12 Month(s)

• Submission of medical records (e.g., chart notes) confirming diagnosis of pancreatic adenocarcinoma
AND
• Submission of medical records (e.g., chart notes) confirming disease is metastatic
AND
• Submission of medical records (e.g., chart notes) or paid claims confirming one of the following:
• Disease has progressed following at least one prior systemic therapy (e.g., chemotherapy FOLFIRINOX, gemcitabine plus nab-paclitaxel, NALIRIFOX or listed in the NCCN Drugs and Biologics Compendium with Categories of Evidence and Consensus of 1, 2A, or 2B)
OR
• Patient is not a candidate for multiagent systemic therapy (e.g., ECOG performance status greater than 3, significant comorbidities [e.g., severe cardiac, pulmonary, hepatic, renal dysfunction], prior treatment related toxicity [e.g., neutropenia, peripheral neuropathy, etc])
AND
• Submission of medical records (e.g., chart notes) confirming patient does not show evidence of progressive disease while on therapy

P & T Revisions

2026-09-14, 2026-09-14

References

1. Rasonque Prescribing Information. Revolution Medicines, Inc. Redwood City, CA. August 2026.
2. NCCN Drugs & Biologics Compendium. Accessed August 2026.

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Revision History

• 2026-09-14: New Program
• 2026-09-14: New Program

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