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 does not have a positive test for Factor VIII inhibitors of ≥ 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 no later than 4 weeks following the initial Hemlibra dose; 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 Factor VIII products will not occur while receiving Hemlibra; AND
• Medication is prescribed by or in consultation with a hemophilia specialist.

Approval duration

1 year