momelotinib — CareFirst (Caremark)

Initial criteria

• Member has intermediate-risk MF with anemia OR
• Member has high-risk MF with anemia or symptomatic splenomegaly and/or constitutional symptoms (e.g., fatigue, night sweats, fever, weight loss) OR
• Member has MF-associated anemia with symptomatic splenomegaly and/or constitutional symptoms (e.g., fatigue, night sweats, fever, weight loss) OR
• Member has symptomatic accelerated phase or blast phase myeloproliferative neoplasms and the requested agent will be used as a single agent or in combination with azacitidine or decitabine

Reauthorization criteria

• Member has improvement in symptoms and no unacceptable toxicity

Approval duration

12 months