CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Besremi (ropeginterferon alfa-2b-njft) drug coverage

Defines indications, inclusion and exclusion criteria, and utilization management requirements for Besremi (ropeginterferon alfa-2b-njft) for treatment of cancer—primarily polycythemia vera—and applies to medication requests processed by Evolent on behalf of Neighborhood Health Plan of Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyBesremi (ropeginterferon alfa-2b-njft) drug coverage

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateNov 29, 2024

Next Review DateN/A

Key ActionProcess and authorize medication requests through Evolent Utilization Management and document support with FDA labeling, CMS-recognized compendia, NCCN/ASCO guidelines, or acceptable peer-reviewed literature showing contraindication/intolerance/failure of hydroxyurea when applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1Primary FDA-supported indication captured (polycythemia vera)

500 mcgSingle dose maximum listed

>=1One qualifying reason to use Besremi instead of hydroxyurea

When Besremi (ropeginterferon alfa-2b-njft) Is Covered

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Continuation Request Exemption

Continuation requests for a not-approvable medication shall be exempt provided ALL of the following are met:

ALL of the following

The requested medication was used within the last year
The member has not experienced disease progression and/or no intolerance to the requested medication
No additional medication(s) are being added to the continuation request

Medically Necessary / Polycythemia Vera (Initial or Switch to Besremi)

Besremi may be used as monotherapy in members with confirmed polycythemia vera when ANY ONE of the following is met:

ANY of the following

Contraindication to hydroxyurea (e.g., childbearing age)
Intolerance to hydroxyurea
Lack of therapeutic response to hydroxyurea