Siklos — Highmark
sickle cell anemia (sickle cell disease) with recurrent painful crises
Preferred products
- generic hydroxyurea
Initial criteria
- Member meets one (1) of the following criteria: 1) For Siklos, age ≥ 2 years; OR 2) For Xromi, age 6 months to 17 years
- Diagnosis of sickle cell anemia (ICD-10: D57)
- Prescriber attests that member is experiencing painful, recurrent sickle cell crises
- Member has experienced therapeutic failure or intolerance to plan-preferred, generic hydroxyurea
- If the request is for Xromi, member has an inability to swallow tablets
Reauthorization criteria
- If the request is for Xromi, the member is ≤ 17 years of age
- Member meets one (1) of the following: 1) Reduction in painful sickle cell crises; OR 2) Reduction in blood transfusions
Approval duration
12 months