Hemlibra (emicizumab-kxwh) — United Healthcare
Hemophilia A without inhibitors
Initial criteria
- Diagnosis of hemophilia A
- Patient has not developed high-titer factor VIII inhibitors (factor VIII inhibitors < 5 Bethesda units [BU])
- Hemlibra is prescribed for the prevention of bleeding episodes (routine prophylaxis)
Reauthorization criteria
- Documentation of positive clinical response to Hemlibra therapy
Approval duration
12 months