CurrentCignaPolicy N/A

Graft-Versus-Host Disease - Rezurock Prior Authorization Policy

Prior authorization criteria for coverage of Rezurock (belumosudil tablets) for treatment of chronic graft-versus-host disease in eligible patients under Cigna-administered health benefit plans.

Policy Summary

PayerCigna

PolicyGraft-Versus-Host Disease - Rezurock Prior Authorization Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateMay 7, 2025

Key ActionObtain prior authorization and document prior systemic therapies and clinical response for approval.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥12min patient age

≥2prior lines required

1 yrauth duration

Not coveredother uses

Coverage Criteria for Rezurock (belumosudil)

FDA-Approved Indication

Rezurock is covered as medically necessary for chronic GVHD when the following criteria are met.

Approval path: Approve for 1 year if the patient meets ONE of the following (A or B)

A) Initial Therapy: Patient meets ALL of: i. Patient is ≥ 12 years of age; ii. Patient has chronic graft-versus-host disease; iii. Patient has tried at least two systemic medications for chronic graft-versus-host disease;

Examples of systemic medications include ruxolitinib, axatilimab, ibrutinib, imatinib, hydroxychloroquine, methotrexate, rituximab, pentostatin, interleukin-2, methylprednisolone, cyclosporine, tacrolimus, sirolimus, etanercept products, and mycophenolate mofetil.

B) Patient Currently Receiving Rezurock: Prescriber documents that the patient demonstrates a beneficial clinical response (examples: reduction in corticosteroid dose, disease stabilization, and/or symptomatic improvement).

Policy Summary

PayerCigna

PolicyGraft-Versus-Host Disease - Rezurock Prior Authorization Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateMay 7, 2025

Key ActionObtain prior authorization and document prior systemic therapies and clinical response for approval.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Provider Requirements and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization required for prescription benefit coverage. Approvals are provided for 1 year when criteria are met.

Step Therapy

Prior Systemic Therapy Requirement

For initial therapy, the patient must have tried at least two systemic medications for chronic graft-versus-host disease prior to approval. Examples of systemic medications include ruxolitinib (Jakafi), axatilimab (Niktimvo), ibrutinib (Imbruvica), imatinib, hydroxychloroquine, methotrexate, rituximab, pentostatin, interleukin-2 (e.g., aldesleukin/Proleukin), methylprednisolone, cyclosporine, tacrolimus, sirolimus, etanercept products, and mycophenolate mofetil.

Documentation Required

Required Documentation

Prescribers should document patient age, diagnosis (chronic graft-versus-host disease), the specific prior systemic medications tried, and the rationale for continuation when requesting approval.

Denial Risk

Not Medically Necessary Uses

Requests for Rezurock (belumosudil) that do not meet the specified criteria (including uses other than the FDA-approved indication or lacking required prior therapies/documentation) are considered not medically necessary and may be denied.

Covered Regimens and Dosing

Regimen	Indication	Coverage status	Notes / Required criteria
Rezurock (belumosudil tablets)
Chronic graft-versus-host disease after failure of prior systemic therapies
Covered
Approve for 1 year if patient meets ONE of the following: A) Initial therapy — patient ≥ 12 years old, diagnosis of chronic GVHD, and has tried at least two systemic medications for chronic GVHD (examples: ruxolitinib, axatilimab, ibrutinib, imatinib, hydroxychloroquine, methotrexate, rituximab, pentostatin, interleukin-2, corticosteroids, cyclosporine, tacrolimus, sirolimus, etanercept products, mycophenolate mofetil); OR B) Patient currently receiving Rezurock — prescriber documents a beneficial clinical response (e.g., corticosteroid dose reduction, disease stabilization, or symptomatic improvement).

Definitions

inv-09: Chronic GVHD definition

DefinitionChronic graft-versus-host disease (GVHD): an immune-mediated complication occurring after allogeneic hematopoietic cell transplantation characterized by multi-organ involvement; referenced here as the FDA‑approved indication for Rezurock.

Typical onset/contextOccurs following allogeneic hematopoietic cell transplantation and may present with multi‑organ manifestations.

Age criterion (policy)Policy references the FDA indication for patients ≥ 12 years of age.

Therapy context (policy)Indication in this policy applies after failure of at least two prior lines of systemic therapy.

Relevance to coverageChronic GVHD is the specific condition for which Rezurock (belumosudil) is covered when policy criteria are met.

OpenPayer

Graft-Versus-Host Disease - Rezurock Prior Authorization Policy

Coverage Criteria for Rezurock (belumosudil)

Provider Requirements and Prior Authorization

Covered Regimens and Dosing

Line of Therapy Criteria

Definitions

Background