Ixinity — Blue Cross Blue Shield of Illinois
Hemophilia B (Factor IX deficiency, Christmas disease)
Preferred products
- AlphaNine SD
- Profilnine
Initial criteria
- Requested agent will be approved when ALL of the following are met:
- 1. ONE of the following:
- A. The requested agent is eligible for continuation of therapy AND the prescriber states the patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days AND is at risk if therapy is changed OR
- B. BOTH of the following:
- 1. The patient has a diagnosis of hemophilia B (also known as Factor IX deficiency, Christmas disease) AND ONE of the following:
- A. The patient is currently experiencing a bleed AND BOTH of the following:
- • The patient is out of medication AND
- • The patient needs to receive a ONE TIME emergency supply of medication OR
- B. BOTH of the following:
- • The requested agent is being used for ONE of the following: prophylaxis OR on-demand use for bleeds OR peri-operative management of bleeding AND
- • ONE of the following:
- A. The requested agent is a preferred agent OR
- B. The patient is currently being treated with the requested agent and is currently stable on the requested agent [chart notes required] OR
- C. The patient has tried and had an inadequate response to ALL of the preferred agents [chart notes required] OR
- D. ALL of the preferred agents were discontinued due to lack of efficacy or effectiveness, diminished effect, or an adverse event [chart notes required] OR
- E. The patient has an intolerance or hypersensitivity to ALL of the preferred agents [chart notes required] OR
- F. The patient has an FDA labeled contraindication to ALL of the preferred agents [chart notes required]