Ojjaara (momelotinib) — United Healthcare

Initial criteria

• Diagnosis of symptomatic lower-risk myelofibrosis
• OR All of the following: Diagnosis of higher-risk myelofibrosis AND Presence of symptomatic splenomegaly and/or constitutional symptoms AND One of the following: Used as continued therapy near the start of conditioning therapy in a transplant candidate OR Patient is not a transplant candidate or transplant not currently feasible
• OR Diagnosis of myelofibrosis-associated anemia
• OR Both of the following: Diagnosis of accelerated/blast phase myeloproliferative neoplasm AND One of the following: Used for the improvement of splenomegaly or other disease-related symptoms OR Continued treatment as a single agent near to the start of conditioning therapy in transplant candidates for the improvement of splenomegaly and other disease-related symptoms

Reauthorization criteria

• Documentation that patient has evidence of symptom improvement or reduction in spleen volume while on Ojjaara (authorization will be issued for 6 months)
• OR Documentation does not provide evidence of symptom improvement or reduction in spleen volume while on Ojjaara, allow for dose titration with discontinuation of therapy (authorization will be issued for 2 months)

Approval duration

6 months