requested Factor IX agent(s) included in this program — Blue Cross Blue Shield of Illinois

Hemophilia B or factor IX deficiency per labeling or compendia

Initial criteria

ALL preferred agents are ineffective, cause adherence barrier, worsen comorbidity, decrease functional ability, or cause adverse reaction or harm [chart notes required] OR ALL preferred agents are not in the best interest of the patient based on medical necessity [chart notes required] OR patient tried another prescription drug in same pharmacologic class or mechanism as all preferred agents and discontinued due to lack of efficacy/effectiveness, diminished effect, or adverse event [chart notes required]
AND if patient has FDA-labeled indication, ONE of: patient’s age is within FDA labeling OR there is support for appropriate age use
AND prescriber is specialist in area of diagnosis (e.g., HTC, hematologist) or has consulted with specialist
AND patient has no FDA-labeled contraindications to requested agent
AND prescriber provides actual prescribed dose including patient’s weight, severity of factor deficiency (severe <1%, moderate ≥1–≤5%, mild >5–40%), inhibitor status, and intended use/regimen (prophylaxis, on-demand, peri-operative)
AND ONE of: patient will not be using requested agent in combination with another Factor IX agent included in program OR there is support for use of more than one unique Factor IX agent (medical records required)

Reauthorization criteria

Patient previously approved for requested agent through plan’s Prior Authorization (if only previous emergency use, must meet initial criteria)
AND prescriber is specialist or consulted with specialist
AND patient has no FDA-labeled contraindications
AND prescriber provides actual prescribed dose with patient’s weight, severity, inhibitor status, and intended regimen
AND ONE of: prescriber verified patient does not have >5 on-demand doses on hand OR support for having >5 doses on hand
AND ONE of: patient will not use with another Factor IX agent OR support for use of more than one unique Factor IX agent (medical records required)

Approval duration

varies: BCBSIL/MT/TX 12 months; BCBSNM emergency/on-demand/peri-operative 3 months, prophylaxis up to 12 months (min 3 months); others emergency up to 2 weeks, peri-operative 1 time, on-demand up to 3 months, prophylaxis up to 12 months