momelotinib — CareFirst (Caremark)
myelofibrosis-associated anemia with symptomatic splenomegaly and/or constitutional symptoms
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