Pharmacy Prior Authorization Criteria

Xromi (hydroxyurea)

Indications for Prior Authorization

Xromi (hydroxyurea)

• For diagnosis of Sickle Cell Anemia
  Indicated to reduce the frequency of painful crises and reduce the need for blood transfusions in pediatric patients aged 6 months of age and older with sickle cell anemia with recurrent moderate to severe painful crises.

Criteria

Xromi

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 6 months of age or older
AND
• One of the following:
• Patient is unable to swallow solid oral dosage forms (e.g., oral tablet, capsule) due to one of the following:
• Age
• Physical impairment (e.g., difficulties with motor or oral coordination)
• Dysphagia
• Patient is using a feeding tube or nasal gastric tube
OR
• Dosage requirements cannot be met with a solid dosage form

Xromi

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

• Patient demonstrates positive clinical response to therapy

P & T Revisions

2025-04-03, 2025-04-03, 2025-04-03

References

1. Xromi Prescribing Information. Nova Laboratories Ltd. Leicester, United Kingdom. December 2024.

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Revision History

• 2025-04-03: New program for Xromi
• 2025-04-03: New program for Xromi
• 2025-04-03: New Program for Xromi

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