CurrentCignaPolicy N/A

Oncology - Daurismo Prior Authorization Policy

Cigna prior authorization policy governing coverage of Daurismo (glasdegib tablets) for oncology indications, specifying approval criteria, duration, and non-covered uses for members under Cigna-administered health benefit plans.

Policy Summary

PayerCigna

PolicyOncology - Daurismo Prior Authorization Policy

Policy CodePolicy N/A

Change TypeClarified (annual revision, no criteria changes)

Effective Date

Next Review Date

Key ActionPrior authorization is recommended; approve for 1 year when documentation shows glasdegib is used in combination with cytarabine.

POLICY UPDATE CHANGES

Annual Revision indicated 'No criteria changes.'

1Covered Indication (FDA-approved)

1 yearApproval Duration

Any other useNot covered (experimental/investigational)

Coverage Summary & Stance

Cigna prior authorization policy for Daurismo (glasdegib) — covered with criteria. Prior authorization is recommended and approvals are provided for 1 year when the patient meets the specified criteria for the FDA‑approved indication (see criteria).

FDA‑Approved Indication (Initial Therapy)

FDA-Approved Indication

Approve for 1 year if the patient meets BOTH of the following (A and B):

Patient is ≥ 18 years of age
Patient is using the medication in combination with cytarabine

Not Covered / Experimental Uses

Permitted uses are those that meet the FDA‑approved indication and the policy approval criteria (see the evidence and criteria sections for the specific requirements). Any use not meeting the FDA‑approved indication or supported by the policy’s cited evidence is considered experimental, investigational, or unproven and is not covered under this policy.

Prior Authorization & Documentation Requirements

Prior Authorization

Prior authorization required

Prior authorization is recommended for prescription benefit coverage of Daurismo; approvals are provided for a duration of 1 year when criteria are met.

Approval duration: 1 year

Documentation Required

Documentation of combination therapy

Provider must document that glasdegib is being used in combination with cytarabine as part of the indication.

Evidence & Guidance

Evidence sources:

• Daurismo tablets prescribing information, Pfizer; December 2024 (prescribing information).

• NCCN Acute Myeloid Leukemia Clinical Practice Guidelines (version 1.2025 - December 20, 2024) — NCCN recommendation category: 2A (useful in certain circumstances / lower‑intensity treatment settings).

Drug Background & Definitions

Daurismo (glasdegib) is a hedgehog pathway inhibitor indicated, in combination with low‑dose cytarabine, for newly diagnosed acute myeloid leukemia in adults who are ≥ 75 years of age or who have comorbidities that preclude intensive induction chemotherapy. The NCCN (v1.2025) addresses Daurismo for selected lower‑intensity induction, consolidation, and follow‑up uses in patients who are not candidates for intensive therapy, with recommendations categorized as 2A.

Definitions:

• Daurismo: Brand name for glasdegib tablets (Pfizer), a hedgehog pathway inhibitor.