Prior Authorization : Preferred Drug List

Sickle Cell Anemia Drugs

Note: The Preferred Drug List Quick Reference provides the most current list of preferred and non-preferred drugs in this drug class.

Oxbryta

For PA requests for Oxbryta, the prescriber is required to complete, sign, and date the PA/DGA form, using Section VI (Clinical Information for Drugs With Specific Criteria Addressed in the ForwardHealth Online Handbook) of the form.

The prescriber is required to send the completed PA/DGA form to the pharmacy where the prescription will be filled. The pharmacy provider will use the completed PA form to submit a PA request to ForwardHealth. Prescribers should not submit the PA form to ForwardHealth.

Pharmacy providers are required to submit the completed PA/DGA form and a completed PA/RF to ForwardHealth.

PA requests for Oxbryta may be submitted on the Portal, by fax, or by mail (but not using the STAT-PA system).

For information about general ForwardHealth PA policy for drugs that require PA approval, prescribers and pharmacy providers may refer to the Standard Pharmacy Policy for Covered and Noncovered Drugs topic. Providers may also refer to this topic for information about what may not be considered criteria to support the need for a drug.

Clinical Criteria for Oxbryta

Clinical criteria that must be documented for approval of a PA request for Oxbryta are all of the following:

• The member has been diagnosed with SCD.
• The member is 4 years of age or older.
• The member will not use Oxbryta in combination with Adakveo or Endari.
• The prescription is written by a hematologist or a provider who specializes in sickle cell disease.
• The member has had one or more VOCs in the past 12 months. (VOC is defined as acute painful crisis or acute chest syndrome for which there was no explanation other than VOC.)
• The member has a baseline hemoglobin level greater than or equal to 5.5 g/dL and less than or equal to 10 g/dL.
• At least one of the following is true:
  • The member has used hydroxyurea for at least three consecutive months and experienced an unsatisfactory therapeutic response.
  • The member experienced a clinically significant adverse drug reaction with hydroxyurea.
  • There is a clinically significant drug interaction between another drug(s) the member is taking and hydroxyurea.
  • The member has a medical condition(s) that prevents the use of hydroxyurea.

Supporting clinical information and a copy of the member's current medical records must be submitted with all PA requests for Oxbryta. The supporting clinical information and medical records must document the following:

• The information listed in the clinical criteria for PA approval
• Details regarding previous medication use
• The member's current treatment plan

If clinical criteria for Oxbryta are met, initial PA requests may be approved for up to 183 days.

Renewal PA requests for Oxbryta may be approved for up to 365 days. Renewal PA requests for members who have SCD must include supporting clinical information and copies of the member's current medical records demonstrating that the member has experienced a response as evidenced by a measurable increase in hemoglobin level from baseline since starting Oxbryta treatment.

Note: All renewal PA requests require the member to be adherent with the prescribed treatment regimen.