Alhemo (concizumab-mtci subcutaneous injection – NovoNordisk) — Cigna

Initial criteria

• Patient age ≥ 12 years; AND
• Patient is using Alhemo for routine prophylaxis to prevent or reduce the frequency of bleeding episodes; AND
• Patient has moderately severe to severe hemophilia A as evidenced by baseline Factor VIII level ≤ 2%; AND
• Factor VIII inhibitor titer testing has been performed within the past 30 days and patient does not have a positive test for Factor VIII inhibitors ≥ 1.0 Bethesda units/mL OR patient has not received Factor VIII therapy in the past; AND
• According to the prescriber, prophylactic use of Factor VIII products will be discontinued before the initial Alhemo dose (use for breakthrough bleeding allowed); AND
• Medication is prescribed by or in consultation with a hemophilia specialist

Reauthorization criteria

• Patient is using Alhemo for routine prophylaxis to prevent or reduce the frequency of bleeding episodes; AND
• According to the prescriber, prophylactic use of Factor VIII products will not occur while receiving Alhemo (use for breakthrough bleeding allowed); AND
• According to the prescriber, patient experienced a beneficial response to therapy (e.g., reduced bleeding events/severity); AND
• Medication is prescribed by or in consultation with a hemophilia specialist

Approval duration

1 year