Alprolix — Blue Cross Blue Shield of New Mexico
Hemophilia B (Factor IX deficiency, Christmas disease)
Preferred products
- AlphaNine SD
- Profilnine
Initial criteria
- Target agent(s) will be approved when ALL of the following are met:
- 1. ONE of the following:
- A. The requested agent is eligible for continuation of therapy AND the following:
- • All target agents are eligible for continuation of therapy
- • The prescriber states the patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days AND is at risk if therapy is changed
- OR
- B. BOTH of the following:
- 1. The patient has a diagnosis of hemophilia B (Factor IX deficiency, Christmas disease) AND ONE of the following:
- A. The patient is currently experiencing a bleed AND BOTH of the following:
- 1. The patient is out of medication AND
- 2. The 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: Prophylaxis OR On-demand use for bleeds OR 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 of the preferred agents were discontinued due to lack of efficacy/effectiveness, diminished effect, or adverse event [chart notes required] OR
- E. The patient has intolerance or hypersensitivity to ALL of the preferred agents [chart notes required] OR
- F. The patient has FDA labeled contraindication to ALL of the preferred agents [chart notes required]