Vonjo (pacritinib) — United Healthcare

Primary myelofibrosis

Initial criteria

Patient is less than 19 years of age
OR
Diagnosis of primary myelofibrosis OR post-polycythemia vera myelofibrosis OR post-essential thrombocythemia myelofibrosis
AND ONE of the following:
• Patient has symptomatic lower-risk myelofibrosis AND platelet count < 50 x 10^9/L
OR • Patient has higher-risk myelofibrosis AND platelet count < 50 x 10^9/L
OR • Patient has higher-risk myelofibrosis AND platelet count ≥ 50 x 10^9/L AND symptomatic splenomegaly and/or constitutional symptoms
OR
Used for treatment of myelofibrosis-associated anemia
OR
Diagnosis of accelerated/blast phase myeloproliferative neoplasm
AND ONE of the following:
• Continued treatment near the start of conditioning therapy in transplant candidates for improvement of splenomegaly and other disease-related symptoms
• Palliation in combination with hypomethylating agents (azacitidine or decitabine) as bridging therapy prior to transplant
• Palliation in combination with hypomethylating agents (azacitidine or decitabine) if not a candidate for transplant
OR
Drug recognized for treatment of the cancer indication by the NCCN Drugs and Biologics Compendium with Category of Evidence and Consensus 1, 2A, or 2B

Documentation that patient has evidence of symptom improvement or reduction in spleen volume while on Vonjo

12 months