Alhemo (concizumab-mtci) — United Healthcare
Hemophilia B (congenital factor IX deficiency) with or without FIX inhibitors
Initial criteria
- Diagnosis of hemophilia A -AND- Patient is age ≥ 12 years -AND- Prescribed for the prevention of bleeding episodes (routine prophylaxis)
- Diagnosis of hemophilia B -AND- Patient is age ≥ 12 years -AND- Prescribed for the prevention of bleeding episodes (routine prophylaxis)
Reauthorization criteria
- Documentation of positive clinical response to Alhemo therapy
Approval duration
12 months