Pharmacy Prior Authorization Criteria

Inrebic (fedratinib)

Indications for Prior Authorization

Inrebic (fedratinib)

• For diagnosis of Myelofibrosis
  Indicated for the treatment of adult patients with intermediate-2 or high-risk primary or secondary (post-polycythemia vera or post-essential thrombocythemia) myelofibrosis (MF).

Criteria

Inrebic

Prior Authorization (Initial Authorization)

Length of Approval: 6 Month(s)

• Diagnosis of one of the following:
• Primary myelofibrosis
• Post-polycythemia vera myelofibrosis
• Post-essential thrombocythemia myelofibrosis

Inrebic

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

• Documentation of positive clinical response to therapy (e.g., symptom improvement, spleen volume reduction)

P & T Revisions

2024-09-02, 2023-09-01, 2023-07-03, 2022-09-23, 2022-05-20, 2021-09-17, 2020-08-12, 2019-10-03

References

1. Inrebic Prescribing Information. Celgene Corporation. Summit, NJ. July 2024.

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Revision History

• 2024-09-02: Annual review 2024. No criteria changes. Background updates only.
• 2023-09-01: Annual review: No criteria changes. Updated references.
• 2023-07-03: Removed specialist requirement
• 2022-09-23: Annual review: no criteria changes.
• 2022-05-20: Update Guideline
• 2021-09-17: 2021 annual review: no changes.
• 2020-08-12: Annual review - no changes.
• 2019-10-03: New program.

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