CurrentColorado Rocky Mountain Health Plans | UnitedHealthcare Pharmacy Clinical Pharmacy ProgramsPolicy 2025 P 1312-6

Tazverik®(tazemetostat) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Prior authorization/notification criteria for coverage of tazemetostat (Tazverik) for UnitedHealthcare Commercial Plans, covering pediatric (<19) automatic approvals, epithelioid sarcoma, and relapsed/refractory follicular lymphoma (with EZH2 mutation or per NCCN recommendations). Authorization periods are specified and program may use automated claim history for approvals.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyTazverik®(tazemetostat) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Policy CodePolicy 2025 P 1312-6

Change TypeAnnual review (no coverage changes)

Effective DateJun 1, 2025

Next Review Date

Key ActionProviders must obtain prior authorization/notification per the listed clinical criteria for coverage; members under 19 process without coverage review.

SourceLink

POLICY UPDATE CHANGES

Annual review performed March 2025 with no changes to coverage criteria; references updated.

March 2024 annual review added NCCN recommendations to background and added criteria to relapsed/refractory follicular lymphoma based on NCCN recommendations.

March 2022 annual review added unknown EZH2 mutation status to criteria per NCCN guidelines.

March 2021 added coverage criteria for new indication for follicular lymphoma.

Program created March 2020 as new prior authorization program for Tazverik.

3Covered Indication Categories

Coverage Summary

coverage_stance: covered_with_criteria

scope_summary: Prior authorization/notification criteria for coverage of tazemetostat (Tazverik) for UnitedHealthcare Commercial Plans, covering pediatric (<19) automatic approvals, epithelioid sarcoma, and relapsed/refractory follicular lymphoma (with EZH2 mutation or per NCCN recommendations).

dates.effective: 2025-06-01

dates.last_review: 2025-03-01

status: CURRENT

Patients less than 19 years of age

Tazverik will be approved based on the following criterion:

ALL of the following

Patient is less than 19 years of age
Authorization will be issued for 12 months.

Epithelioid Sarcoma - Initial Authorization

Tazverik will be approved based on all of the following criteria:

ALL of the following

Diagnosis of epithelioid sarcoma
Disease extent (one of)
- Metastatic
- Locally advanced
Disease is not eligible for complete resection

Epithelioid Sarcoma - Reauthorization

Tazverik will be approved based on the following criterion:

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

Authorization will be issued for 12 months.

Relapsed or Refractory Follicular Lymphoma - Initial Authorization

Tazverik will be approved based on both of the following criteria:

ALL of the following

Diagnosis of relapsed or refractory follicular lymphoma
One of
- Subsequent therapy in EZH2 mutation positive disease after 2 prior therapies
- Second-line therapy irrespective of EZH2 mutation status for older or infirm patients with indications for treatment (i.e., other therapy options are not expected to be tolerable)
- Third-line and/or subsequent therapy (if not previously given) irrespective of EZH2 mutation status in patients with indications for treatment

Relapsed or Refractory Follicular Lymphoma - Reauthorization

Tazverik will be approved based on the following criterion:

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

Authorization will be issued for 12 months.

NCCN Recommended Regimens

Recognition by NCCN Drugs and Biologics Compendium:

Drug has been recognized for treatment of the cancer indication by NCCN with a Category of Evidence and Consensus of 1, 2A, or 2B

Provider Requirements & Authorization Process

Prior Authorization

Prior authorization required for Tazverik (except <19)

Providers must obtain prior authorization/notification per the listed clinical criteria for coverage. Members under 19 years of age will process without a coverage review. When criteria are met, authorization will be issued for 12 months.

Prior authorization/notification required per clinical criteria
Members <19: prescription automatically processes without coverage review
Authorization period = 12 months when criteria are met

Documentation Required

Clinical evidence for reauthorization

For reauthorization, documentation must demonstrate that the patient does not show evidence of progressive disease while on Tazverik therapy in order to qualify for continued approval.

Applicable Codes

ICD-10 (diagnosis logic may be used for automated approvals)ICD-10

No codes listed

NDC / Drug billingNDC

No codes listed

Clinical Evidence & References

NCCN recognition: The drug is recognized in the NCCN Drugs and Biologics Compendium with Category of Evidence and Consensus levels 1, 2A, or 2B for the cancer indications listed.

Package insert: Epizyme, Inc. August 2024 package insert cited as a reference. Note: the approved indications are under accelerated approval, and continued approval may be contingent upon verification of clinical benefit in confirmatory trials.

Background

Background: Tazverik (tazemetostat) is an EZH2 methyltransferase inhibitor approved for metastatic or locally advanced epithelioid sarcoma not eligible for complete resection and for relapsed/refractory follicular lymphoma (EZH2-mutated after ≥2 prior systemic therapies, or for certain patients irrespective of EZH2 status per NCCN guidance).

Accelerated approval and confirmatory trials: These indications were granted under accelerated approval based on overall response rate and duration of response; continued approval may depend on verification of benefit in confirmatory trial(s).

NCCN recommendations and scope: NCCN recommends Tazverik in certain follicular lymphoma settings (preferred second-line for older or infirm patients irrespective of EZH2 status, and third-line/subsequent therapy where indicated). This policy applies to UnitedHealthcare Commercial Plans prior authorization/notification program and notes that prescriptions for members <19 years will automatically process without coverage review.

Administrative context: Program (Prior Authorization/Notification) details include P&T approval history and an effective date of 6/1/2025; automated approvals may be used based on claim/medication history, diagnosis codes, and program logic as allowed by UnitedHealthcare.

Revision History

2025-06-01revisedLatest

P&T approval recorded; annual review performed March 2025 with no changes to coverage criteria; references updated. Effective date 6/1/2025.

2024-03-01revised

March 2024 annual review added NCCN recommendations to the background and added criteria to relapsed/refractory follicular lymphoma based on NCCN recommendations; references updated.

2022-03-01revised

March 2022 annual review added unknown EZH2 mutation status to criteria per NCCN guidelines; references updated.