WHA

Vonjo (pacritinib)

Indications for Prior Authorization

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.

Criteria

Vonjo

Prior Authorization (Initial Authorization)

Length of Approval: 6 Month(s)

  • Diagnosis of ONE of the following:[1]
    • Primary myelofibrosis
    • Post-polycythemia vera myelofibrosis
    • Post-essential thrombocythemia myelofibrosis
    AND
  • Disease is intermediate or high risk [1]
    • AND
  • Pre-treatment platelet count below 50 x 10^9/L [1]
Vonjo

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

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

  • Guideline ID
    GL-146080

  • Formulary
    premium

  • Effective date
    Jul 1, 2024

  • P&T approval date
    May 19, 2022

P & T Revisions

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

  1. Vonjo Prescribing Information. CTI BioPharma Corp. Seattle, WA. February 2022.
  2. 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.
  3. 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.
  4. Leukemia and Lymphoma Society. Myelofibrosis. Available at https://www.lls.org/myeloproliferative-neoplasms/myelofibrosis. Accessed April 2, 2022.
  1. 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]
  2. 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