CurrentWashington State Health Care AuthorityPolicy 30.90.20.30-1

Elapegademase-lvlr (Revcovi) Coverage Criteria

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Prior authorization and medical-necessity coverage for elapegademase-lvlr (Revcovi) in pediatric and adult clients with ADA-SCID, including initial therapy, reauthorization, monitoring, dosing, and quantity requirements.

Policy Summary

PayerWashington State Health Care Authority

PolicyElapegademase-lvlr (Revcovi) Coverage Criteria

Policy CodePolicy 30.90.20.30-1

Change TypeRevised

Effective DateDecember 1, 2020

Next Review DateN/A

Key ActionSubmit prior authorization using separate initial-approval and reauthorization criteria; each approval is issued for 12 months when all criteria are met.

SourceLink

POLICY UPDATE CHANGES

Added a 0.2 mg/kg dose for Adagen-naive clients.

Approval duration changed from 6 months to 12 months, with reauthorization duration revised to 12 months.

ADA-SCIDCovered indication

12 moInitial approval

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