ModifiedUnitedHealthcarePolicy 2026 P 1465-2

Revuforj® (revumenib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Prior authorization/notification criteria for Revuforj (revumenib) for UnitedHealthcare Commercial Plans, including initial authorization, reauthorization, special handling for patients <19 years, reference to NCCN recognition, and automated approval possibilities. Effective date listed as 2026-04-01 with P&T approvals in 01/2025 and 01/2026.

Policy Summary

PayerUnitedHealthcare

PolicyRevuforj® (revumenib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Policy CodePolicy 2026 P 1465-2

Change TypeAdded FDA-labeled indicationreferences updated

Effective DateApr 1, 2026

Next Review Date

Key ActionRevuforj requires prior authorization/notification per this policy for members 19 years and older; authorization will be issued for 12 months when criteria are met.

SourceLink

POLICY UPDATE CHANGES

Added criteria for new indication per FDA label.

Updated references including Revuforj package insert (Oct 2025) and NCCN Compendium access date.

2Covered indications (ALL, AML with molecular markers)

12 moAuthorization duration

1 yrMinimum patient age per FDA label

Coverage summary

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Scope: This policy provides prior authorization and notification criteria for Revuforj (revumenib) for UnitedHealthcare Commercial Plans, covering treatment of relapsed or refractory acute lymphoblastic leukemia (ALL) and relapsed or refractory acute myeloid leukemia (AML) with specific molecular markers. Revuforj is indicated for patients 1 year and older and is authorized for 12 months when criteria are met. For members under 19 years of age prescriptions will automatically process without a coverage review and be issued for 12 months.

Coverage stance: Revuforj is covered with criteria when used for relapsed/refractory ALL or for relapsed/refractory AML with a documented NPM1 mutation or a KMT2A translocation, consistent with the FDA label and recognition in the NCCN Drugs and Biologics Compendium.

Key facts — Revuforj (revumenib)

Minimum patient age1 year (adult and pediatric patients 1 year and older)

Authorization duration12 months

Covered indications count2

Covered indication 1Acute lymphoblastic leukemia (ALL) — relapsed or refractory

Covered indication 2Acute myeloid leukemia (AML) — relapsed or refractory with EITHER NPM1 mutation OR KMT2A translocation

Effective date2026-04-01

P&T approval dates01/2025; 01/2026

Initial Authorization (Adults and Pediatrics 1 year and older)

Revuforj will be approved based on one of the following (either criterion set):

ONE of the following sets

Acute lymphoblastic leukemia (ALL) pathway
- Diagnosis of acute lymphoblastic leukemia (ALL)
- Disease is relapsed or refractory
Acute myeloid leukemia (AML) pathway
- Diagnosis of acute myeloid leukemia (AML)
- Disease is relapsed or refractory
- ONE of the following molecular findings
  - Positive for nucleophosmin 1 (NPM1) mutation
  - Positive for lysine methyltransferase 2A gene (KMT2A) translocation

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criteria_group

Patients less than 19 years of age

Authorization for patients under 19 will automatically process without coverage review and will be issued for 12 months when criterion met:

ALL of the following

Patient is less than 19 years of age

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criteria_group

Reauthorization / Continuation Therapy

Reauthorization

Reauthorization will be approved when the following is met:

ALL of the following

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

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criteria_group

NCCN Recognition

Supportive criterion

ALL of the following

Drug recognized in the NCCN Drugs and Biologics Compendium with Category of Evidence and Consensus of 1, 2A, or 2B

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criteria_group

Provider actions and billing notes

Prior Authorization

Prior authorization required

Revuforj requires prior authorization/notification per this policy for members 19 years and older; when criteria are met authorization will be issued for 12 months.

Documentation Required

Molecular testing documentation

For the AML pathway, documentation of either a positive NPM1 mutation or a KMT2A translocation is required to meet initial authorization criteria unless the ALL pathway applies.

Billing Rule

Automatic processing for pediatric prescriptions

For members under age 19, prescriptions will automatically process without a coverage review and will be authorized for 12 months.

Denial Risk

Reauthorization denial risk on progression

Reauthorization will be denied if the patient shows evidence of progressive disease while on Revuforj therapy.

Documentation Required

State mandate override

Be aware that some state mandates for off-label use or compendia may supersede policy language; providers must follow applicable state requirements and the member-specific benefit plan.

Background and clinical evidence

FDA indication: Revuforj (revumenib) is a menin inhibitor indicated for the treatment of relapsed or refractory acute leukemia with a KMT2A translocation in adult and pediatric patients 1 year and older, and for relapsed or refractory AML with a susceptible NPM1 mutation in adult and pediatric patients 1 year and older who have no satisfactory alternative treatment options.

References and approvals: Policy content references the Revuforj package insert (October 2025) and recognition in the NCCN Drugs and Biologics Compendium. P&T approval dates are 01/2025 and 01/2026; the program effective date is 04/01/2026.

Revision history

01/2025P&T approval

Program created / New prior authorization program (P&T approval dated 01/2025).

01/2026P&T approval

Annual review and P&T approval (01/2026).

01/2026policy changeLatest

Annual review updated references and added criteria reflecting new FDA-labeled indication per Revuforj package insert (Oct 2025); references updated (NCCN Compendium access 11/18/2025).

Policy Summary

PayerUnitedHealthcare

PolicyRevuforj® (revumenib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Policy CodePolicy 2026 P 1465-2

Change TypeAdded FDA-labeled indicationreferences updated

Effective DateApr 1, 2026

Next Review Date

Key ActionRevuforj requires prior authorization/notification per this policy for members 19 years and older; authorization will be issued for 12 months when criteria are met.

SourceLink

On This Page

OpenPayer

Revuforj® (revumenib) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Coverage summary

Initial Authorization (Adults and Pediatrics 1 year and older)

Reauthorization / Continuation Therapy

Provider actions and billing notes

Applicable codes and diagnosis logic

Background and clinical evidence

Definitions

Revision history