Sevenfact — Blue Cross Blue Shield of Texas

Initial criteria

• ONE of the following: A. Continuation of therapy (treated with requested agent within past 90 days and at risk if therapy is changed) OR B. For new starts, ONE of the following: hemophilia A with inhibitors to Factor VIII and used on-demand for bleeds; hemophilia B with inhibitors to Factor IX and used on-demand for bleeds; or other FDA approved indication for requested agent and route
• If FDA labeled indication: ONE of the following: patient age is within FDA labeling OR support for using the agent for patient’s age for the indication
• Prescriber is a specialist in the area of the patient’s diagnosis (e.g., hemophilia treatment center, hematologist with hemophilia experience) or has consulted with a specialist in that area
• Patient will not be using the requested 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 has ≤5 on-demand doses on hand OR B. Support for patient having >5 on-demand doses on hand

Approval duration

12 months