Oxbryta (voxelotor) tablets for oral suspension — Highmark
sickle cell disease (SCD)
Preferred products
- generic hydroxyurea
Initial criteria
- age ≥ 4 years
- diagnosis of SCD (ICD-10: D57)
- hemoglobin level ≤ 10.5 g/dL
- therapeutic failure, contraindication, or intolerance to plan-preferred, generic hydroxyurea
- if requesting Oxbryta tablets for oral suspension, member is ≤ 11 years of age
- Oxbryta will not be used in combination with Adakveo (crizanlizumab-tmca)
Reauthorization criteria
- prescriber attests to therapeutic response defined as one of the following:
- improvement in SCD signs, symptoms, or complications
- hemoglobin increase of > 1 g/dL from baseline without concurrent transfusions
- decreased number of transfusions from baseline
Approval duration
12 months