Ivosidenib (Tibsovo®)

SELF ADMINISTRATION

Indications for Prior Authorization:

  • Treatment of adult patients with relapsed or refractory Acute Myeloid Leukemia (AML) with a susceptible isocitrate dehydrogenase-1 (IDH1) mutation as detected by an FDA-approved test

Patients must meet the following criteria for the indication(s) above:

  • Patient is 18 years of age or older, AND
  • Patient has a diagnosis of relapsed or refractory AML as confirmed by chart note documentation, AND
  • Patient is isocitrate dehydrogenase-1 (IDH1) mutation positive as confirmed by an FDA-approved test, AND
  • Prescribed by or in consultation with an oncologist, AND
  • Will not be used with strong CYP3A4 inducers, sensitive CYP3A4 substrates, and QT prolonging drugs (when possible)

Dosing:

  • 500mg once daily

Approval:

  • 1 year

Last review date: June 3, 2019