CurrentBlue Cross Blue Shield - IowaPolicy 05.05.57

Voranigo_Benefit_Application

Defines coverage, prior authorization criteria, dosing/quantity limits, documentation requirements, and reauthorization rules for Voranigo (vorasidenib) for members 12 years and older with susceptible IDH1 or IDH2 mutated central nervous system tumors.

Policy Summary

PayerBlue Cross Blue Shield - Iowa

PolicyVoranigo_Benefit_Application

Policy CodePolicy 05.05.57

Change TypeRevised (Jan 2026)

Effective DateNov 30, 2024

Next Review Date

Key ActionSubmission of medical record documentation confirming presence of an IDH1 or IDH2 mutation is necessary to initiate prior authorization review; approvals are for 12 months.

SourceLink

POLICY UPDATE CHANGES

Reviewed and revised January 2026; current effective date listed as February 4, 2026.

12+Minimum age for coverage

12 monthsTypical authorization duration

60/30dStd limit (10 mg)

30/30dStd limit (40 mg)

Coverage Summary

Defines coverage, prior authorization criteria, dosing/quantity limits, documentation requirements, and reauthorization rules for Voranigo (vorasidenib) for members 12 years and older with susceptible IDH1 or IDH2 mutated central nervous system tumors. Prior authorization is required and approvals may be granted when the member meets the specified initial approval criteria for adjuvant use or for progressive/recurrent disease and the requested use is as a single agent.

Minimum age for coverage: 12+ years

Typical authorization duration: 12 months

Provider Actions & Requirements

Prior Authorization

Prior authorization required

Submission of medical record documentation confirming presence of an IDH1 or IDH2 mutation is necessary to initiate prior authorization review; approvals are for 12 months.

Approvals are for 12 months
Documentation must confirm presence of IDH1 or IDH2 mutation

Documentation Required

Required mutation testing documentation

Provide medical record documentation of isocitrate dehydrogenase-1 (IDH1) or isocitrate dehydrogenase-2 (IDH2) mutation.

Documentation Required

Clinical status for certain high-grade tumors

For WHO grade 2 or 3 oligodendroglioma and WHO grade 2 astrocytoma, document Karnofsky Performance Status (KPS) greater than or equal to 60.

KPS >= 60

Billing Rule

Quantity limits

Quantity limits apply and approvals may be subject to FDA-recommended dosing and dosing limits. Follow FDA recommended dosing and dose reduction guidance when applicable.

Voranigo 10 mg tablet Standard Limit = 60 capsules per 30 days
Voranigo 40 mg tablet Standard Limit = 30 capsules per 30 days

Clinical Evidence & References

Evidence:

• FDA package insert: Voranigo [package insert], Servier Pharmaceuticals LLC.; April 2025

Background

Voranigo is indicated for treatment of adult and pediatric patients 12 years and older with Grade 2 astrocytoma or oligodendroglioma with a susceptible IDH1 or IDH2 mutation following surgery. Compendial uses include: recurrent or progressive IDH1/IDH2 mutated WHO grade 2 astrocytoma or oligodendroglioma; adjuvant treatment of IDH1/IDH2 mutated WHO grade 2 astrocytoma or oligodendroglioma; and certain IDH1/IDH2 mutated high-grade gliomas including H3‑mutated high‑grade glioma, high‑grade astrocytoma with piloid features (HGAP), and WHO grade 3 pleomorphic xanthoastrocytoma (PXA).

KPS: Karnofsky Performance Status

IDH1/IDH2: Isocitrate dehydrogenase-1 or isocitrate dehydrogenase-2 mutation

Revision History

2024-11-30effective_date

Effective date: 2024-11-30.

2026-01-01last_review

Last review date: 2026-01-01.

2026-01review_revision