Hympavzi — Highmark
Hemophilia B
Initial criteria
- age ≥ 12 years
- Diagnosis of Hemophilia A (ICD-10: D66) AND no FVIII inhibitors AND prescriber documents severe disease (< 1% of normal factor activity) OR Diagnosis of Hemophilia B (ICD-10: D67) AND no FIX inhibitors AND prescriber documents moderately severe to severe disease (≤ 2% of normal factor activity)
- Using the product for routine prophylaxis
- Previously taken a factor VIII or IX replacement therapy (for example, Adynovate, Advate, Afstyla, Altuviiio, etc.)
Reauthorization criteria
- Prescriber attests member is tolerating therapy and has experienced a therapeutic response defined as disease stability, disease improvement, or delayed disease progression
Approval duration
12 months