Alhemo — Cigna

Hemophilia B without Factor IX Inhibitors

Initial criteria

Patient is 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 B as evidenced by a baseline (without Factor IX replacement therapy) Factor IX level of ≤ 2%; AND
Patient meets ONE of the following (a or b): a) BOTH of the following: (1) Factor IX inhibitor titer testing has been performed within the past 30 days; AND (2) Patient does not have a positive test for Factor IX inhibitors of ≥ 1.0 Bethesda units/mL; OR b) Patient has not received Factor IX therapy in the past; AND
According to the prescriber, prophylactic use of Factor IX products will be discontinued before the initial Alhemo dose; AND
The medication is prescribed by or in consultation with a hemophilia specialist

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 IX products will not occur while receiving Alhemo; AND
According to the prescriber, patient experienced a beneficial response to therapy; AND
The medication is prescribed by or in consultation with a hemophilia specialist

1 year