Adynovate®, Afstyla®, Alprolix®, Altuviiio™, Eloctate®, Esperoct®, Idelvion®, Jivi®, and Rebinyn® Approval Criteria:
- An FDA approved indication; AND
- Requested medication must be prescribed by a hematologist specializing in hemophilia, or a mid-level practitioner with a supervising physician that is a hematologist specializing in hemophilia; AND
- A patient-specific, clinically significant reason why the member cannot use the following:
- Hemophilia A: Advate® or current factor VIII replacement product; OR
- Hemophilia B: Benefix® or current factor IX replacement product; AND
- A half-life study must be performed to determine the appropriate dose and dosing interval.
- Initial approval will be for the duration of the half-life study. If the half-life study shows significant benefit in prolonged half-life, subsequent approvals will be for the duration of one year.