Colorado Rocky Mountain Health Plans Prior Auth Inrebic | OpenPayer

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Colorado Rocky Mountain Health Plans Prior Auth Inrebic | OpenPayer

Coverage Criteria for Inrebic (fedratinib)

Initial Authorization - Myelofibrosis

Covered when ALL of the following are met

Initial - Myelofibrosis: Diagnosis of intermediate-2 or high-risk primary or secondary (postpolycythemia vera or post-essential thrombocythemia) myelofibrosis

Authorization issued for 12 months

Reauthorization - Myelofibrosis

Covered when ALL of the following are met

Reauthorization - Myelofibrosis: Documentation that patient has evidence of symptom improvement or reduction in spleen volume while on Inrebic

Authorization issued for 12 months

Initial Authorization - Myeloid/Lymphoid Neoplasms with Eosinophilia

Covered when ALL of the following are met

Initial - Myeloid/Lymphoid Neoplasms with Eosinophilia: Diagnosis of lymphoid, myeloid, or mixed lineage neoplasms with eosinophilia

Authorization issued for 12 months

Initial - Myeloid/Lymphoid Neoplasms with Eosinophilia - molecular requirement: Presence of a JAK2 rearrangement

Authorization issued for 12 months

Reauthorization - Myeloid/Lymphoid Neoplasms with Eosinophilia

Covered when ALL of the following are met

Reauthorization - Myeloid/Lymphoid Neoplasms with Eosinophilia: Patient does not show evidence of progressive disease while on Inrebic therapy

Authorization issued for 12 months

Coverage determinations for Inrebic (fedratinib) are made according to the criteria in this document and the member’s benefit plan. Some states may mandate coverage for off‑label uses or require other compendium references; where applicable, those state mandates and compendia requirements supersede the language in this policy. In addition, individual member benefit design may further limit coverage—providers should confirm member‑specific plan benefits before proceeding.

For administrative processing, prescriptions for members under 19 years of age will automatically process without a coverage review. All other requests are subject to prior authorization and must meet the clinical criteria described in this policy.

Initial Therapy

Initial Therapy

Covered when ALL of the following are met

Initial Therapy - Myelofibrosis: Diagnosis of intermediate-2 or high-risk primary or secondary myelofibrosis

12-month authorization

Initial Therapy - Myeloid/Lymphoid Neoplasms with Eosinophilia: Diagnosis of lymphoid, myeloid, or mixed lineage neoplasms with eosinophilia AND presence of JAK2 rearrangement

12-month authorization

Reauthorization / Continuation Therapy

Reauthorization / Continuation Therapy

Reauthorization criteria

Continuation - Myelofibrosis: Documentation of symptom improvement or reduction in spleen volume

12-month authorization on approval

Continuation - Myeloid/Lymphoid Neoplasms with Eosinophilia: No evidence of progressive disease while on therapy

12-month authorization on approval

Provider Actions and Prior Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Inrebic except for members under 19 years of age, whose prescriptions will automatically process without a coverage review. Requests that meet clinical criteria will typically be authorized for 12 months.

Prior authorization required for members ≥19 years.
Members <19 years: automatic processing without PA; approved for 12 months when criteria met.

Denial Risk

Denial Triggers and Automated Approval Note

Denials may be issued when the submitted documentation does not meet the coverage criteria (for example, diagnosis is not consistent with approved indications, required molecular findings are absent, or documentation of treatment response is missing at reauthorization). Conversely, automated approvals (initial or reauthorization) may be granted based solely on prior claim/medication history, diagnosis codes (ICD-10) and/or claim logic when program-specific automation is in use.

Key Definitions

Myelofibrosis (intermediate-2 or high-risk)

IndicationIntermediate-2 or high‑risk primary or secondary (post‑polycythemia vera or post‑essential thrombocythemia) myelofibrosis

Patient populationAdults with documented intermediate‑2 or high‑risk myelofibrosis

Authorization durationAuthorization issued for 12 months on approval

Myeloid/lymphoid neoplasms with eosinophilia and JAK2 rearrangement

Required diagnosisLymphoid, myeloid, or mixed lineage neoplasms with eosinophilia

Molecular requirementDocumented JAK2 rearrangement (must be present)

Background

Inrebic (fedratinib) is a kinase inhibitor used in the treatment of myeloproliferative neoplasms. This policy covers Inrebic for adults with intermediate‑2 or high‑risk primary or secondary (post‑PV or post‑ET) myelofibrosis, and for lymphoid, myeloid, or mixed‑lineage neoplasms with eosinophilia and a documented JAK2 rearrangement as recommended by NCCN.

When requesting prior authorization, include documentation of the qualifying diagnosis and any supporting test results (for example, evidence of a JAK2 rearrangement for eosinophilia indications). Reauthorization requests must provide the clinical evidence required by the criteria (for example, symptom improvement or reduction in spleen volume for myelofibrosis, or absence of progressive disease for neoplasms with eosinophilia).

Site of Care

Note

Infusion center — no explicit restriction (UM may apply)

No explicit site-of-care restriction for infusion centers is stated in the policy; however, utilization management programs and any applicable supply limits may still apply to therapy delivered in that setting.

Quantity Limits and Dispensing

Inrebic (fedratinib) — supply limits and utilization management

Possible supply limitsSupply limits may be in place for Inrebic (fedratinib)

Automated approval noteAutomated approval or re‑approval processes may be used based on prior claim/medication history, diagnosis codes, and claim logic

Where to check limitsRefer to payer utilization management programs and pharmacy benefit rules for current supply limits