voxelotor — CareFirst (Caremark)
sickle cell disease (SCD)
Initial criteria
- Member is age ≥ 4 years
- Pretreatment hemoglobin level ≤ 10.5 g/dL (excluding values due to recent transfusion)
- Prescribed by or in consultation with a hematologist or specialist in sickle cell disease
- Member has one of the following genotypes: sickle hemoglobin C (HbSC), sickle β+-thalassemia (HbSβ+), or other genotypic variants of sickle cell disease (e.g., HbS-O Arab, HbS-Lepore); OR
- Member has homozygous hemoglobin S (HbSS) or sickle β0-thalassemia (HbSβ0) genotype AND any of the following:
- • Inadequate response or intolerance to hydroxyurea
- • Contraindication to hydroxyurea
- • Will use Oxbryta concurrently with hydroxyurea
Reauthorization criteria
- Member is experiencing benefit from therapy as demonstrated by increased hemoglobin levels or maintenance of increased hemoglobin levels since starting treatment
Approval duration
Initial: 6 months; Reauthorization: 12 months