Sevenfact — Blue Cross Blue Shield of Oklahoma

Initial criteria

• ONE of the following: (A) Continuation of therapy: prescriber states patient has been treated with requested agent (not samples) within past 90 days and is at risk if therapy is changed OR (B) BOTH of the following: (1) ONE of: (A) diagnosis of hemophilia A AND inhibitors to Factor VIII AND on-demand use for bleeds OR (B) diagnosis of hemophilia B AND inhibitors to Factor IX AND on-demand use for bleeds OR (C) another FDA-approved indication for requested agent and route; AND (2) if patient has FDA-labeled indication, then one of: (A) age within FDA labeling for indication OR (B) support for using agent for patient's age for indication
• Prescriber is a specialist in the area (e.g., hematologist, HTC) or has consulted with one
• Patient will NOT use the agent in combination with another Factor VIIa agent
• Patient does NOT have any FDA-labeled contraindications to the requested agent
• ONE of the following: (A) Prescriber verified patient does not have >5 on-demand doses on hand OR (B) Support for having >5 on-demand doses
• Alternative Ohio-specific criteria: member resides in Ohio AND plan is Fully Insured or HIM Shop (SG) AND (A) patient has no FDA-labeled contraindications AND (B) ONE of: (1) patient has another FDA-labeled indication for agent/route OR (2) patient has another compendia-supported indication for agent/route OR (3) prescriber submitted two peer-reviewed journal articles supporting proposed use

Reauthorization criteria

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

Approval duration

12 months (BCBSIL/BCBSTX); ≥3 months (BCBSMT/BCBSNM); up to 3 months (others)