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Nuwiq — Highmark

Hemophilia A (ICD-10: D66)

Preferred products

  • Adynovate
  • Advate
  • Afstyla
  • Altuviiio
  • Eloctate
  • Esperoct
  • Jivi
  • Kogenate FS
  • Kovaltry
  • Novoeight
  • Xyntha

Initial criteria

  • The member has an FDA-approved diagnosis
  • The member is using the product for Hemophilia A (ICD-10: D66)
  • The member has experienced therapeutic failure or intolerance to one (1) of the following plan-preferred agents, or all are contraindicated: Adynovate, Advate, Afstyla, Altuviiio, Eloctate, Esperoct, Jivi, Kogenate FS, Kovaltry, Novoeight, Xyntha

Reauthorization criteria

  • The member has received previous clotting factor product(s)
  • The prescriber attests that the member is tolerating therapy and has experienced a therapeutic response defined as one (1) of the following: disease stability, disease improvement, or delayed disease progression