Ixinity — United Healthcare

hemophilia B

Preferred products

Diagnosis of hemophilia B
AND one of the following:
1. Submission of documentation showing failure to meet clinical goals (e.g., continuation of spontaneous bleeds, inability to achieve appropriate trough level) after a trial of two of the following recombinant factor products: Benefix, Rixubis
OR 2. Submission of documentation showing history of hypersensitivity to two of the following recombinant factor products: Benefix, Rixubis
OR 3. Physician attestation that patient would preferentially benefit from Ixinity based on one of the following: patient is at high risk for the development of inhibitors (e.g., family history of inhibitors and success with product, current treatment less than 50 days, high risk genetic mutation, history of initial intensive therapy greater than 5 days), patient has developed inhibitors, or patient has undergone immune tolerance induction/immune tolerance therapy
OR 4. Both of the following: patient is currently on Ixinity therapy AND patient has not received a manufacturer supplied sample at no cost in prescriber office, or any form of assistance from a Medexus Pharma sponsored Ixinity Savings Program as a means to establish as a current user of Ixinity

12 months