Alhemo — Highmark

Hemophilia B

Initial criteria

age ≥ 12 years
Diagnosis of Hemophilia A (ICD-10: D66) OR Hemophilia B (ICD-10: D67)
Using the product for routine prophylaxis
AND EITHER documented history of FVIII or FIX inhibitors (≥ 0.6 Bethesda units/mL) OR no documented history of inhibitors AND ALL of the following: previously taken a factor VIII or IX replacement therapy (for example, Adynovate, Advate, Afstyla, Altuviiio, etc.); if Hemophilia A, prescriber documents severe disease (< 1% of normal factor activity); if Hemophilia B, prescriber documents moderately severe to severe disease (≤ 2% of normal factor activity)

Prescriber attests member is tolerating therapy and has experienced a therapeutic response defined as disease stability, disease improvement, or delayed disease progression
Prescriber submits documentation of Alhemo plasma concentration levels AND EITHER Alhemo plasma concentration ≥ 200 ng/mL on consecutive measurements OR < 200 ng/mL on at least two consecutive measurements AND provider attests that benefits of continued treatment outweigh risk of bleeding and alternative therapies not clinically appropriate

initial 6 months; reauthorization 12 months