CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Rezurock (belumosudil) — chronic graft-versus-host disease coverage criteria

Policy governs coverage and authorization criteria for Rezurock (belumosudil) for treatment of chronic graft-versus-host disease (cGVHD) for Medicaid members, including initiation and continuation requirements and quantity limits.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyRezurock (belumosudil) — chronic graft-versus-host disease coverage criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJun 1, 2023

Next Review DateN/A

Key ActionObtain prior authorization and document age ≥12, diagnosis of cGVHD, and failure of ≥2 prior systemic therapies.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12+minimum age for covered indication

≥2required prior systemic therapy lines for coverage

6 monthsauthorization period

30 tabs/30dquantity limit

Medicaidpayer scope

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.

Coverage Criteria for Rezurock (belumosudil)

inv-01: Initial Therapy

Covered when ALL of the following are met

Initial authorization for cGVHD: 1) Member is at least 12 years of age; 2) Medication is prescribed by or in consultation with a hematologist, oncologist, or physician experienced in the management of transplant patients; 3) Documented diagnosis of chronic graft-versus-host disease (cGVHD); 4) Documentation that the member has failed two or more lines of systemic therapy for cGVHD (examples: methylprednisolone, cyclosporine, tacrolimus, sirolimus, mycophenolate mofetil, imatinib); 5) Documentation that Rezurock will not be taken concomitantly with a proton pump inhibitor (PPI) unless the member had an inadequate response to or is contraindicated to histamine H2‑receptor antagonist at the highest appropriate dose; 6) Rezurock will not be prescribed in combination with Imbruvica, Jakafi, or Niktimvo.

Authorization of 6 months may be granted when all criteria met

inv-02: Continuation Therapy

Covered when ALL of the following are met

Continuation authorization for cGVHD: 1) No evidence of unacceptable toxicity on the current regimen; 2) No clinically significant progression of cGVHD while on the current regimen (i.e., progression requiring new systemic therapy); 3) Documented response to therapy with improvement in one or more measures (e.g., patient-reported symptoms such as Lee Symptom Scale, NIH Skin Score, Upper GI Response Score); 4) Medication prescribed by or in consultation with a hematologist, oncologist, or physician experienced in transplant management; 5) Rezurock will not be prescribed in combination with Imbruvica, Jakafi, or Niktimvo; 6) Documentation that Rezurock will not be taken concomitantly with a proton pump inhibitor (PPI) unless the member had inadequate response to or is contraindicated to histamine H2‑receptor antagonist at the highest appropriate dose.

Authorization of 6 months may be granted for continued treatment when criteria met

All uses of Rezurock (belumosudil) outside of the FDA‑approved indication and accepted compendial uses are considered experimental/investigational and not medically necessary.

Specifically, use of Rezurock for indications other than treatment of chronic graft‑versus‑host disease (cGVHD) in patients 12 years and older after failure of at least two lines of systemic therapy is considered experimental/investigational and not medically necessary.

Regimen	Indication	Quantity limit	Coverage status
[
Belumosudil 200 mg orally once daily (1 tablet/day)
,
Chronic graft-versus-host disease (cGVHD)
,
30 tablets per 30 days (200 mg total; 1 tablet per day)
,
Covered
]

Provider Actions and Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Rezurock for cGVHD. Initial and continuation authorizations may be granted for up to 6 months when criteria are met.

Initial authorization: up to 6 months when ALL criteria met
Continuation authorization: up to 6 months when ALL continuation criteria met

Step Therapy

Step Therapy Requirement

Member must have failed two or more lines of systemic therapy for chronic graft-versus-host disease before Rezurock will be authorized.

Step requirement: failure of ≥2 prior systemic therapies (examples: methylprednisolone, cyclosporine, tacrolimus, sirolimus, mycophenolate mofetil, imatinib)

Documentation Required

Required Documentation

Required documentation must be submitted with the prior authorization request to support medical necessity.

Documented diagnosis of chronic graft-versus-host disease (cGVHD)
Member age ≥ 12 years
Documentation that the member has failed two or more prior systemic therapies for cGVHD (list therapies tried and response)
Prescriber specialty: prescribed by or in consultation with a hematologist, oncologist, or physician experienced in management of transplant patients
Documentation that Rezurock will not be taken concomitantly with a proton pump inhibitor (PPI) unless the member had an inadequate response to or is contraindicated to an H2-receptor antagonist at the highest appropriate dose
Documentation that Rezurock will not be prescribed in combination with Imbruvica, Jakafi, or Niktimvo

Denial Risk

Authorization may be denied if required criteria or documentation are missing or not met.

Denial risk: member is younger than 12 years
Denial risk: insufficient documentation of diagnosis of cGVHD
Denial risk: lack of documentation showing failure of ≥2 prior systemic therapies
Denial risk: request is for a non–FDA‑approved indication or exceeds scope
Denial risk: concomitant use with prohibited medications (e.g., Imbruvica, Jakafi, Niktimvo) or improper concurrent PPI use without documented rationale

Definitions and Clinical Terms

Failure of systemic therapy

DefinitionDocumented inadequate response or intolerance to at least two prior lines of systemic therapy for cGVHD

Examples of prior systemic therapiesmethylprednisolone, cyclosporine, tacrolimus, sirolimus, mycophenolate mofetil, imatinib

Documentation requiredMedical record support of inadequate response or intolerance to each prior regimen

Clinically significant progression

DefinitionProgression of cGVHD requiring new systemic therapy (clinically significant progression)

Assessment toolsClinician assessments such as NIH Skin Score, Upper GI Response Score, NIH Symptom Score

Implication for coverageNo clinically significant progression while on current regimen is required for continuation authorization

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyRezurock (belumosudil) — chronic graft-versus-host disease coverage criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJun 1, 2023

Next Review DateN/A

Key ActionObtain prior authorization and document age ≥12, diagnosis of cGVHD, and failure of ≥2 prior systemic therapies.

SourceLink

On This Page

OpenPayer

Rezurock (belumosudil) — chronic graft-versus-host disease coverage criteria

Coverage Criteria for Rezurock (belumosudil)

Covered Regimens and Dosing

Quantity Limits and Coding

Provider Actions and Authorization Requirements

Definitions and Clinical Terms

Line of Therapy Designation

Background