Alprolix — Blue Cross Blue Shield of Montana

Hemophilia B (Factor IX deficiency, Christmas disease)

Preferred products

ONE of the following must be met:
A. Continuation of therapy: patient has been treated with the requested agent (not samples) within the past 90 days AND is at risk if therapy is changed.
OR
B. New therapy initiation: BOTH of the following:
1. The patient has a diagnosis of hemophilia B (Factor IX deficiency, Christmas disease) AND ONE of the following:
A. Patient is currently experiencing a bleed AND BOTH of the following:
1. Patient is out of medication AND
2. Patient needs to receive a ONE TIME emergency supply of medication
OR
B. BOTH of the following:
1. The requested agent is being used for ONE of the following purposes:
A. Prophylaxis OR
B. On-demand use for bleeds OR
C. Peri-operative management of bleeding
AND
2. ONE of the following:
A. The requested agent is a preferred agent OR
B. The patient is currently being treated with and 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 preferred agents were discontinued due to lack of efficacy, diminished effect, or adverse event [chart notes required] OR
E. The patient has intolerance or hypersensitivity to ALL preferred agents [chart notes required] OR
F. The patient has an FDA-labeled contraindication to ALL preferred agents [chart notes required]