Hemlibra (emicizumab-kxwh) — CareFirst (Caremark)
Hemophilia A (congenital factor VIII deficiency) for routine prophylaxis to prevent or reduce the frequency of bleeding episodes in adult and pediatric patients (newborn and older), with or without factor VIII inhibitors
Initial criteria
- Prescribed by or in consultation with a hematologist
- Member is using the requested medication for routine prophylaxis to prevent or reduce the frequency of bleeding episodes
- Member has mild disease and has had an insufficient response to desmopressin or a documented clinical reason for not using desmopressin OR member has moderate or severe disease
- Member will not use the requested medication in combination with Alhemo or Hympavzi
- Member has not previously received treatment with a gene therapy product (e.g., Roctavian) for the treatment of hemophilia A
- Prophylactic use of factor VIII products (e.g., Advate, Adynovate, Eloctate) will be discontinued after the first week of starting therapy with the requested medication
Reauthorization criteria
- Member is experiencing benefit from therapy (e.g., reduced frequency or severity of bleeds)
- Member is not using the requested medication in combination with factor VIII products for prophylactic use
Approval duration
12 months