Pharmacy Prior Authorization Criteria

Siklos (hydroxyurea)

Indications for Prior Authorization

Siklos (hydroxyurea)

• For diagnosis of Sickle Cell Anemia
  Indicated to reduce the frequency of painful crises and to reduce the need for blood transfusions in adult and pediatric patients, 2 years of age and older, with sickle cell anemia with recurrent moderate to severe painful crises.

Criteria

Siklos

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of sickle cell anemia
AND
• Patient has moderate to severe painful crises
AND
• Patient is 2 years of age or older
AND
• One of the following:
• Patient is less than 18 years of age
• Trial and failure, or intolerance to Droxia

Siklos

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

• Patient demonstrates positive clinical response to therapy

P & T Revisions

2025-03-24, 2025-01-20, 2023-12-29, 2023-02-20, 2022-01-12, 2019-11-18

References

1. Siklos Prescribing Information. Addmedica, France. January 2023.

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Revision History

• 2025-03-24: Update to add in reauth criteria for Siklos
• 2025-01-20: 2025 annual review. No clinical changes.
• 2023-12-29: 2024 Annual review: No criteria changes.
• 2023-02-20: 2023 UM Annual Review. No criteria changes. Updated references
• 2022-01-12: 2022 UM Annual Review.
• 2019-11-18: Updated program

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