CurrentUnitedHealthcarePolicy 2025 P 1419-3

Ojjaara (momelotinib) prior authorization and coverage criteria

UnitedHealthcare prior authorization/notification program for Ojjaara (momelotinib) for treatment of myelofibrosis and related myeloproliferative neoplasms; governs pharmacy coverage and renewal criteria for members (automatic processing for members <19 years).

Policy Summary

PayerUnitedHealthcare

PolicyOjjaara (momelotinib) prior authorization and coverage criteria

Policy CodePolicy 2025 P 1419-3

Change TypeUpdates to coverage criteria and program creation (2023–2025)

Effective DateFeb 1, 2026

Next Review Date

Key ActionProviders must obtain prior authorization per this program for members ≥19 years and document diagnosis, clinical need, and supporting clinical data for initial and reauthorization requests.

SourceLink

POLICY UPDATE CHANGES

New program for Prior Authorization/Notification for Ojjaara (momelotinib) established 11/2023.

Modified title from myelofibrosis to myeloproliferative neoplasms and updated coverage criteria based on NCCN guidelines (11/2024).

Updated coverage criteria for higher-risk myelofibrosis per NCCN recommendations (11/2025).

6Initial authorization duration (typical)

12Authorization duration for patients <19 years and NCCN-recognized regimens (months)

≥50Reauthorization platelet threshold (one pathway)

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Patients less than 19 years of age

Automatic approval without coverage review

ALL of the following

Patient is less than 19 years of age

Initial Authorization (Adults and ≥19 years)

Ojjaara will be approved when ONE of the following diagnostic criteria is met:

ANY of the following

Diagnosis of symptomatic lower-risk myelofibrosis
Higher-risk myelofibrosis
- Diagnosis of higher-risk myelofibrosis
- Indication for use
  - Used for the improvement of splenomegaly or other disease-related symptoms
  - Continued treatment as a single agent near to the start of conditioning therapy in transplant candidates for the improvement of splenomegaly and other disease-related symptoms
Accelerated/blast phase myeloproliferative neoplasm
- Diagnosis of accelerated/blast phase myeloproliferative neoplasm
- ANY of the following
  - Used for the improvement of splenomegaly or other disease-related symptoms
  - Continued treatment as a single agent near to the start of conditioning therapy in transplant candidates for the improvement of splenomegaly and other disease-related symptoms

Authorization Duration for Initial Approval

When initial authorization criteria met:

ALL of the following

Authorization will be issued for 6 months (unless patient <19 or NCCN regimens apply)

Reauthorization / Continuation of Therapy

Reauthorization will be approved when ONE of the following pathways is met:

ANY of the following

Pathway 1 (platelets ≥ 50 x 10^9/L)
- Patient is not a transplant candidate or transplant not currently feasible
- Platelets ≥ 50 x 10^9/L>= 50 x 10^9/L
- Presence of symptomatic splenomegaly and/or constitutional symptoms
Pathway 2 (platelets < 50 x 10^9/L)
- Patient is not a transplant candidate or transplant not currently feasible

NCCN Recognized Regimens

Automatic recognition for NCCN compendium-supported regimens

ALL of the following

Drug has NCCN Drugs and Biologics Compendium recognition with Category 1, 2A, or 2B

What Providers Must Do

Prior Authorization

Prior authorization required for Ojjaara (except patients <19)

Providers must obtain prior authorization per this program for members age 19 years and older. Initial approval requires a documented qualifying diagnosis (e.g., symptomatic lower‑risk myelofibrosis; higher‑risk myelofibrosis; or accelerated/blast phase myeloproliferative neoplasm) and indication for use such as improvement of splenomegaly or other disease‑related symptoms or use near start of conditioning therapy in transplant candidates. When initial criteria are met, authorization will be issued for 6 months (12 months for patients <19 years or for NCCN‑recognized regimens where applicable).

Automatic processing (no coverage review) applies to members <19 years (authorization issued for 12 months).
Initial authorization for adults/≥19 years is typically issued for 6 months unless NCCN‑recognized regimens or other exceptions apply.

Documentation Required

Clinical documentation for reauthorization

For reauthorization, document the patient’s transplant candidacy status, current platelet count, and presence of symptomatic splenomegaly and/or constitutional symptoms. When applicable, provide objective evidence of symptom improvement or reduction in spleen volume while on Ojjaara; if such improvement is not yet documented, documentation of dose titration with a plan for discontinuation may be acceptable.

Pathway 1 (non‑transplant candidate): platelets ≥ 50 x 10^9/L plus symptomatic splenomegaly/constitutional symptoms.
Pathway 2 (non‑transplant candidate): platelets < 50 x 10^9/L.
Pathway 3 (transplant candidate): diagnosis of myelofibrosis‑associated anemia and either evidence of symptom/spleen improvement or documented dose titration if improvement not yet seen.

Denial Risk

State mandates and plan benefits may override

Coverage decisions may be affected by state mandates, federal requirements, and the member’s specific benefit plan; where state mandates or alternative compendia requirements apply, they supersede the program language.

Some states mandate coverage for off‑label uses or require use of other compendium references, which can override these criteria.
Federal regulatory requirements and the member’s benefit plan may also impact coverage determinations.

Note

Automated approvals allowed

UnitedHealthcare may grant initial authorizations and reauthorizations based solely on prior claim/medication history, submitted diagnosis codes (ICD‑10), and/or automated claim logic without additional clinical review.

Use of automated approval and re‑approval processes varies by program and therapeutic class.

Policy Updates

2023-11added

New prior authorization/notification program for Ojjaara (momelotinib) was established (P&T approval 11/2023).

2024-11revised

Title modified from myelofibrosis to myeloproliferative neoplasms and coverage criteria updated to align with NCCN guidelines (annual review 11/2024).

2025-11revisedLatest

Coverage criteria updated for higher-risk myelofibrosis per NCCN recommendations (annual review 11/2025); policy last reviewed 2025-11 and effective date set to 2026-02-01.

Policy Summary

PayerUnitedHealthcare

PolicyOjjaara (momelotinib) prior authorization and coverage criteria

Policy CodePolicy 2025 P 1419-3

Change TypeUpdates to coverage criteria and program creation (2023–2025)

Effective DateFeb 1, 2026

Next Review Date

SourceLink

On This Page

OpenPayer

Ojjaara (momelotinib) prior authorization and coverage criteria

Authorization and Medical Necessity Criteria

Policy Identifiers and Codes

What Providers Must Do

Clinical and Indication Summary

Defined Terms

Clinical Thresholds and Authorization Durations

Policy Updates