Revcovi (elapegademase-lvlr)

Revcovi is covered only for the FDA‑approved indication ADA‑SCID in patients with molecular confirmation of bi‑allelic ADA mutations or baseline ADA catalytic activity <1%, prescribed by or in consultation with an immunologist/hematologist/ADA‑SCID specialist, and authorization is limited to 12 months. Coverage requires documentation of genetic or enzymatic confirmation, specialist involvement, patient weight, and prior weekly Adagen dose if transitioning (or use the policy's default starting doses: 0.2 mg/kg weekly if Adagen ≤30 U/kg/unknown; Adagen‑naïve 0.4 mg/kg/week divided as 0.2 mg/kg twice weekly for 12–24 weeks), with dosing conversion and titration rules followed.

"Laboratory documentation of adenosine deaminase catalytic activity at baseline showing absent or very low (less than 1% of normal) activity, if used instead of genetic testing."

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