Hemlibra (emicizumab-kxwh subcutaneous injection) — Cigna

Initial criteria

• Patient is using Hemlibra for routine prophylaxis to prevent or reduce the frequency of bleeding episodes; AND
• Factor VIII inhibitor titer testing has been performed within the past 30 days; AND
• Patient has a positive test for Factor VIII inhibitors of ≥ 0.6 Bethesda units/mL; AND
• According to the prescriber, prophylactic use of bypassing agents will be discontinued; 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 Hemlibra 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 Hemlibra; AND
• Patient is not undergoing immune tolerance induction therapy; AND
• Medication is prescribed by or in consultation with a hemophilia specialist; AND
• According to the prescriber, the patient experienced a beneficial response to therapy (e.g., reduction in bleeding events, severity of bleeding episodes, number of bleeding events that required treatment, and/or number of spontaneous bleeds).

Approval duration

1 year