Pharmacy Prior Authorization Criteria

Ojjaara (momelotinib) - PA, NF

Indications for Prior Authorization

Ojjaara (momelotinib)

• For diagnosis of Myelofibrosis
  Indicated for the treatment of intermediate or high risk myelofibrosis (MF), including primary MF or secondary MF [post-polycythemia vera (PV) and post-essential thrombocythemia (ET)], in adults with anemia.

Criteria

Ojjaara

Prior Authorization (Initial Authorization)

Length of Approval: 6 Month(s)
For diagnosis of Myelofibrosis

• Diagnosis of one of the following:
• Primary myelofibrosis
• Post-polycythemia vera myelofibrosis
• Post-essential thrombocythemia myelofibrosis
AND
• Disease is intermediate or high risk
AND
• Patient has anemia
AND
• One of the following:
• Both of the following:
• Platelet count is greater than or equal to 50 x 10^9/L
AND
• One of the following:
• Trial and failure, contraindication, or intolerance to Jakafi (ruxolitinib)
OR
• For continuation of prior therapy
OR
• Platelet count is less than 50 x 10^9/L

Ojjaara

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)
For diagnosis of Myelofibrosis

• Documentation of positive clinical response to therapy (e.g., symptom improvement, spleen volume reduction)

Ojjaara

Non Formulary

Length of Approval: 6 Month(s)
For diagnosis of Myelofibrosis

• Submission of medical records (e.g., chart notes) confirming a diagnosis of one of the following:
• Primary myelofibrosis
• Post-polycythemia vera myelofibrosis
• Post-essential thrombocythemia myelofibrosis
AND
• Disease is intermediate or high risk
AND
• Patient has anemia
AND
• One of the following:
• Both of the following:
• Submission of medical records (e.g., chart notes) confirming the platelet count is greater than or equal to 50 x 10^9/L
AND
• One of the following:
• Paid claims or submission of medical records (e.g., chart notes) confirming trial and failure, contraindication, or intolerance to Jakafi (ruxolitinib)
OR
• For continuation of prior therapy
OR
• Submission of medical records (e.g., chart notes) confirming the platelet count is less than 50 x 10^9/L

P & T Revisions

2024-11-05, 2024-03-05

References

1. Ojjaara Prescribing Information. GlaxoSmithKline. Durham, NC. September 2023.

---

Revision History

• 2024-11-05: Annual Review. No updates
• 2024-03-05: Addition of a step through Jakafi and NF criteria

---