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Qfitlia — Blue Cross Blue Shield of Montana

hemophilia (patient diagnosis per prescriber specialty)

Initial criteria

  • Quantity Limit for Qfitlia will be approved when ONE of the following is met:
  • 1. The requested quantity (dose) does NOT exceed the program quantity limit OR
  • 2. The requested quantity (dose) exceeds the program quantity limit AND ONE of the following:
  • A. BOTH of the following:
  • 1. The requested agent does NOT have a maximum FDA labeled dose for the requested indication AND
  • 2. There is support for therapy with a higher dose for the requested indication OR
  • B. BOTH of the following:
  • 1. The requested quantity (dose) does NOT exceed the maximum FDA labeled dose for the requested indication AND
  • 2. There is support for why the requested quantity (dose) cannot be achieved with a lower quantity of a higher strength that does NOT exceed the program quantity limit OR
  • C. BOTH of the following:
  • 1. The requested quantity (dose) exceeds the maximum FDA labeled dose for the requested indication AND
  • 2. There is support for therapy with a higher dose for the requested indication

Reauthorization criteria

  • Target Agent will be approved when ALL of the following are met:
  • 1. The patient has been previously approved for the requested agent through the plan’s Prior Authorization process AND
  • 2. ONE of the following:
  • A. The patient has had improvement or stabilization with the requested agent as indicated by the number of breakthrough bleeding episodes (medical records required) OR
  • B. There is support for the continued use of the requested agent (medical records required) AND
  • 3. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., prescriber working in a hemophilia treatment center, hematologist with hemophilia experience), or has consulted with such a specialist AND
  • 4. The requested agent will NOT be used in combination with immune tolerance induction with clotting factor products as prophylactic therapy, hemophilia bypassing agent prophylaxis, or Emicizumab for hemophilia A with inhibitors (except factor VIII/IX for breakthrough bleeds >7 days after initiation of Qfitlia)

Approval duration

initial 6–12 months, renewal 12 months