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
• Factor IX inhibitor titer testing has been performed within the past 30 days; AND
• Patient has a positive test for Factor IX inhibitors of ≥ 0.6 Bethesda units/mL; AND
• According to the prescriber, prophylactic use of bypassing agents will be discontinued (use for breakthrough bleeding allowed); AND
• Patient is not undergoing immune tolerance induction therapy; 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 bypassing agents will not occur while receiving Alhemo (use for breakthrough bleeding allowed); AND
• Patient is not undergoing immune tolerance induction therapy; AND
• 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