CurrentUnitedHealthcarePolicy N/A

Revuforj (revumenib) prior authorization

Prior authorization and notification requirements for Revuforj (revumenib) for UnitedHealthcare members, describing coverage criteria for pediatric and adult indications for relapsed/refractory acute leukemias with KMT2A translocation or NPM1 mutation.

Policy Summary

PayerUnitedHealthcare

PolicyRevuforj (revumenib) prior authorization

Policy CodePolicy N/A

Change TypeAdded indication criteriaannual review

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests for Revuforj (approvals issued for 12 months); pediatric patients under 19 auto-process without review.

SourceLink

POLICY UPDATE CHANGES

Added criteria for new indication per FDA label.

Annual review; updated references.

12 moauthorization period

>=1 yrminimum age (FDA)

1/2025, 1/2026P&T approvals

NCCN recCompendium

Coverage Criteria

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COVERAGE CRITERIA

Revuforj will be approved based on one of the following:

Initial Authorization

Pathway 1 - ALL: Diagnosis of acute lymphoblastic leukemia (ALL) AND disease is relapsed or refractory
See chunk 4
Pathway 2 - AML with molecular marker: Diagnosis of acute myeloid leukemia (AML) AND disease is relapsed or refractory AND (positive for NPM1 mutation OR positive for KMT2A translocation)
See chunk 4

Additional note: Authorization period: 12 months when approved

See chunk 4

Pediatric

Patients under 19 years

Pediatric auto-approval: Patient is less than 19 years of age — prescription will automatically process without a coverage review

Authorization will be issued for 12 months

State mandates or a member's specific benefit plan may limit or exclude coverage for Revuforj. Where state law requires coverage for off-label uses or specific compendium references, those mandates supersede the policy language. Providers should verify member benefit details and applicable state requirements prior to initiating therapy, as those factors can alter prior authorization requirements and coverage determinations.

Continuation / Reauthorization

Continuation Therapy

Reauthorization criterion

Continuation: No evidence of progressive disease while on Revuforj therapy

See chunk 5

Reauthorization

Reauthorization will be approved when the following is met:

Reauthorization: Patient does not show evidence of progressive disease while on Revuforj therapy

See chunk 5

Provider Actions & Requirements

Prior Authorization

Prior Authorization Required

Prior authorization required for Revuforj except pediatric patients under age 19 whose prescriptions will automatically process without a coverage review. Authorization for patients <19 will be issued for 12 months.

Applies to Revuforj (revumenib)
Authorization duration for <19: 12 months

Note

State Mandates May Alter Requirements

Some states mandate benefit coverage for off‑label use of medications or require use of specific compendium references. Where state mandates apply, they supersede the benefit document or the notification/authorization criteria in this policy. Providers should verify state‑specific requirements prior to submission.

Documentation Required

Supporting Documentation & Automated Review

Authorization may be approved based on previous claim/medication history, diagnosis codes (ICD‑10), and/or claim logic. UnitedHealthcare may use automated approval and re‑approval processes depending on program and therapeutic class.

Note

Coverage Limitations and Mandates

Coverage is subject to member‑specific benefit plan provisions and utilization management programs. Coverage limitations and state mandates for off‑label uses or compendium requirements may affect whether services are covered.

Background

Revuforj (revumenib) is a menin inhibitor indicated for treatment of relapsed or refractory acute leukemia with a lysine methyltransferase 2A gene (KMT2A) translocation and for relapsed or refractory acute myeloid leukemia with a susceptible NPM1 mutation in patients 1 year of age and older, per the FDA-approved labeling. The policy recognizes relevant NCCN compendium recognition for related regimens and aligns prior authorization requirements with the labeled indications and recognized compendium guidance.

Definitions

Relapsed or refractory acute leukemia — Definitions

TermRelapsed or refractory acute leukemia

DefinitionAcute lymphoblastic leukemia (ALL) or acute myeloid leukemia (AML) that has returned after treatment or is not responding to treatment; Revuforj is indicated in these settings with specific molecular markers (KMT2A translocation or susceptible NPM1 mutation).

Key molecular markersKMT2A (lysine methyltransferase 2A) translocation; susceptible NPM1 mutation

Age range per FDA labelPatients 1 year of age and older (adult and pediatric) for indicated uses

Clinical contextIndication applies to relapsed or refractory disease; for AML, a susceptible NPM1 mutation or KMT2A translocation must be present

Site of Care

Note

Infusion center/site‑of‑care not specified — verify coverage

Site of care is not specified in this policy; coverage for administration at an infusion center may be subject to other utilization management programs or site‑specific rules.

Confirm site‑of‑care coverage and any program‑specific rules with the member’s plan prior to scheduling infusion services.

Policy Summary

PayerUnitedHealthcare

PolicyRevuforj (revumenib) prior authorization

Policy CodePolicy N/A

Change TypeAdded indication criteriaannual review

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests for Revuforj (approvals issued for 12 months); pediatric patients under 19 auto-process without review.

SourceLink

On This Page

OpenPayer

Revuforj (revumenib) prior authorization

Coverage Criteria

Initial Therapy

Continuation / Reauthorization

Provider Actions & Requirements

Background

Definitions

Quantity Limits

Site of Care