Sevenfact — Blue Cross Blue Shield of Montana

Initial criteria

• ONE of the following: the requested agent is eligible for continuation of therapy AND the prescriber states the patient has been treated with the requested agent within the past 90 days and is at risk if therapy is changed OR the patient meets initial start criteria
• Patient criteria for new starts: ONE of the following: (A) diagnosis of hemophilia A AND has inhibitors to Factor VIII AND used for on-demand bleeds OR (B) diagnosis of hemophilia B AND has inhibitors to Factor IX AND used for on-demand bleeds OR (C) other FDA approved indication for the requested agent and route of administration
• If the patient has an FDA labeled indication, then ONE of the following: (A) patient’s age is within FDA labeling for the requested indication OR (B) there is support for using the requested agent for the patient’s age for the indication
• The prescriber is a specialist in the area of the diagnosis or has consulted with one
• The patient will NOT use Sevenfact in combination with another Factor VIIa agent
• The patient does NOT have any FDA labeled contraindications to Sevenfact
• ONE of the following: (A) prescriber verified that patient does not have greater than 5 on-demand doses on hand OR (B) there is support for patient having more than 5 on-demand doses on hand

Reauthorization criteria

• Continuation of therapy if the prescriber states the patient has been treated with Sevenfact within the past 90 days and is at risk if therapy is changed
• The patient continues to meet the above criteria

Approval duration

12 months