Besremi — Highmark
Polycythemia Vera (PV)
Preferred products
- generic hydroxyurea
Initial criteria
- Age ≥ 18 years
- Diagnosis of Polycythemia Vera (PV)
- Member meets one of the following: (i) Low-risk PV defined by age < 60 years AND no prior history of thrombosis OR (ii) High-risk PV defined by age ≥ 60 years OR prior history of thrombosis AND has experienced therapeutic failure, contraindication, or intolerance to plan-preferred generic hydroxyurea
Approval duration
12 months