Pharmacy Prior Authorization Criteria

Vonjo (pacritinib)

For diagnosis of Primary or Secondary Myelofibrosis
Indicated for the treatment of adults with intermediate or high-risk primary or secondary (post-polycythemia vera or post-essential thrombocythemia) myelofibrosis with a platelet count below 50 x 10^9/L.

Prior Authorization (Initial Authorization)

Length of Approval: 6 Month(s)

AND

AND

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

Patient demonstrates positive clinical response to therapy (e.g., symptom improvement, spleen volume reduction)

2024-04-24, 2023-12-01, 2023-07-03, 2023-04-13, 2022-05-27, 2022-05-20

Vonjo Prescribing Information. CTI BioPharma Corp. Seattle, WA. February 2022.
The NCCN Clinical Practice Guidelines in Oncology - Myeloproliferative Neoplasms. Available at https://www.nccn.org/professionals/physician_gls/pdf/mpn.pdf . version 1.2024. Accessed April 24, 2024.
UpToDate. Myelofibrosis (MF): Management of primary MF and secondary MF. Available at https://www.uptodate.com/contents/myelofibrosis-mf-management-of-primary-mf-and-secondary-mf?search=vonjo&source=search_result&selectedTitle=1%7E1&usage_type=default&display_rank=1. Accessed April 24, 2024.
Leukemia and Lymphoma Society. Myelofibrosis. Available at https://www.lls.org/myeloproliferative-neoplasms/myelofibrosis. Accessed April 2, 2022.

There is no "gold standard" for the diagnosis of PMF, although criteria have been proposed by the Italian Society of Hematology, the World Health Organization (WHO), and others [4]
Secondary myelofibrosis refers to myelofibrosis that develops after polycythemia vera (PV) or essential thrombocythemia (ET). Our approach to evaluation and management of secondary myelofibrosis follows the suggestions for PMF [4]

2024-04-24: 2024 Annual Review
2023-12-01: Program update to standard reauthorization language. No changes to clinical intent.
2023-07-03: Removed specialist requirement
2023-04-13: 2023 Annual Review.
2022-05-27: guideline update
2022-05-20: New PA Criteria