Sevenfact — Blue Cross Blue Shield of Illinois

Initial criteria

• ONE of the following: (A) The requested agent is eligible for continuation of therapy AND prescriber states the patient has been treated with the requested agent within the past 90 days (starting on samples is not approvable) and is at risk if therapy is changed OR (B) BOTH of the following:
• 1. ONE of the following: A. The patient has a diagnosis of hemophilia A AND BOTH of the following: (1) The patient has inhibitors to Factor VIII AND (2) The requested agent is being used for on-demand use for bleeds OR B. The patient has a diagnosis of hemophilia B AND BOTH of the following: (1) The patient has inhibitors to Factor IX AND (2) The requested agent is being used for on-demand use for bleeds OR C. The patient has another FDA approved indication for the requested agent and route of administration
• 2. If the patient has an FDA labeled indication, then ONE of the following: (A) The patient’s age is within FDA labeling for the requested indication for the requested agent OR (B) There is support for using the requested agent for the patient’s age for the requested indication
• The prescriber is a specialist in the area of the patient’s diagnosis (hemophilia treatment center or hematologist) or has consulted with such a specialist
• The patient will NOT be using the requested agent in combination with another Factor VIIa agent
• The patient does NOT have any FDA labeled contraindications to the requested agent
• ONE of the following: (A) The prescriber verified that the patient does not have greater than 5 on-demand doses on hand OR (B) There is support for the patient having more than 5 on-demand doses on hand

Reauthorization criteria

• Continuation of therapy allowed when prescriber states patient has been treated with requested agent within past 90 days and is at risk if therapy is changed

Approval duration

12 months (BCBSIL, BCBSTX); ≥3 months (BCBSMT, BCBSNM); up to 3 months (other plans)