CurrentBlue Cross Blue Shield - IowaPolicy N/A

Ojjaara (momelotinib) — Coverage Criteria

This policy governs prior authorization, coverage criteria, dosing limits, and documentation requirements for Ojjaara (momelotinib) for members of Wellmark Blue Cross and Blue Shield (Blue Cross Blue Shield - Iowa). It affects prescribers (oncologists/hematologists) and patients being treated for myelofibrosis, MF-associated anemia, or related myeloproliferative neoplasms.

Policy Summary

PayerBlue Cross Blue Shield - Iowa

PolicyOjjaara (momelotinib) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and submit documentation of hemoglobin (Hb) <10 g/dL for initial requests; prescriber must be an oncologist or hematologist or consult one.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 moauthorization period

<10 g/dLHb requirement

30/30dquantity limit

200 mginitial dosing

Coverage Criteria for Ojjaara (momelotinib)

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Initial Approval Criteria

Authorization of 12 months may be granted when ANY of the following are met for treatment of myelofibrosis, myelofibrosis-associated anemia, or myeloproliferative neoplasms:

Approved indications: Member has intermediate-risk MF with anemia

Approved indications: Member has MF-associated anemia with symptomatic splenomegaly and/or constitutional symptoms (e.g., fatigue, night sweats, fever, weight loss)

Approved indications: Member has high-risk MF with anemia or symptomatic splenomegaly and/or constitutional symptoms (e.g., fatigue, night sweats, fever, weight loss)

Approved indications: Member has symptomatic accelerated phase or blast phase myeloproliferative neoplasms and the requested agent will be used as a single agent or in combination with azacitidine or decitabine

Continuation of Therapy

Continuation authorizations (12 months) may be granted when ALL of the following are met:

Continuation Therapy: No evidence of unacceptable toxicity

Continuation Therapy: There has been an improvement in symptoms while on the current regimen

Ojjaara (momelotinib) is considered not medically necessary for members who do not meet the criteria set forth above. Members currently receiving Ojjaara as samples or through the manufacturer's patient assistance program must satisfy the policy's initial approval criteria to ensure equitable treatment.

Requests for Ojjaara for members who do not meet the specified coverage criteria will be considered not medically necessary. This applies regardless of how the medication was obtained and helps ensure consistent application of the policy.

Regimen	Indication	Coverage status
Ojjaara (momelotinib) as a single agent	Symptomatic accelerated phase or blast phase myeloproliferative neoplasms	Used alone or in combination with azacitidine or decitabine; coverage granted when indication met

Procedures, Billing Codes, and Lab Thresholds

Procedures and Billing Codesmixed

N/A	No specific CPT/HCPCS/ICD codes provided in the policy

inv-06: Hemoglobin (Hb) — required threshold for initial request

Required Hb for initial requestHemoglobin (Hb) < 10 g/dL (submit chart notes or medical record documentation)

Documentation typeChart notes or medical record documentation of Hb level

PurposeRequired to initiate prior authorization review for initial requests

Prescriber Requirements and Authorization Workflow

Prior Authorization

Prior authorization required (12‑month approvals)

Prior authorization is required. Initial and continuation authorizations may be granted for up to 12 months when the coverage criteria are met; the medication must be prescribed by or in consultation with an oncologist or hematologist.

Step Therapy

No step therapy specified

No step therapy sequence is specified in this policy; coverage eligibility is determined by the clinical criteria for intermediate- or high-risk myelofibrosis, MF-associated anemia with symptoms, or symptomatic accelerated/blast phase myeloproliferative neoplasms.

Documentation Required

Required initial documentation: hemoglobin <10 g/dL

For initial prior authorization requests, submit chart notes or medical record documentation showing hemoglobin (Hb) levels <10 g/dL.

Denial Risk

Not medically necessary if criteria unmet

Requests will be considered not medically necessary if the member does not meet the specified coverage criteria; members receiving samples or manufacturer assistance must still meet the initial approval criteria.

Denials may be issued when clinical criteria in the policy are not met.
Members obtaining medication via samples or patient assistance programs are required to meet the same criteria.

Key Definitions

inv-12: Myelofibrosis (MF) — intermediate- or high-risk MF including primary MF or secondary MF (post-PV and post-ET)

DefinitionIntermediate- or high-risk myelofibrosis (MF), including primary MF or secondary MF (post-polycythemia vera and post-essential thrombocythemia)

FDA-approved populationAdults with anemia and intermediate- or high-risk MF

IncludesPrimary MF and secondary MF (post‑PV, post‑ET)

inv-13: MF-associated anemia with symptoms — symptomatic splenomegaly and/or constitutional symptoms (fatigue, night sweats, fever, weight loss)

Symptom criteriaMF-associated anemia with symptomatic splenomegaly and/or constitutional symptoms (e.g., fatigue, night sweats, fever, weight loss)

Relevant constitutional symptomsFatigue, night sweats, fever, weight loss

Compendial considerationListed as an indication under compendial uses for MF-associated anemia

Background on Ojjaara (momelotinib)

Ojjaara (momelotinib) is indicated for treatment of adults with intermediate- or high-risk myelofibrosis, including primary myelofibrosis and secondary myelofibrosis (post-polycythemia vera or post-essential thrombocythemia), particularly in patients with anemia. The policy requires members to meet the specific clinical criteria described elsewhere in this document for authorization; members receiving samples or assistance must also meet those initial approval criteria to maintain equitable coverage decisions.