Pharmacy Prior Authorization Criteria

Hympavzi (marstacimab-hncq)

Indications for Prior Authorization

Hympavzi (marstacimab-hncq)

• For diagnosis of Prevention or to reduce the frequency of bleeding episodes
  indicated for routine prophylaxis to prevent or reduce the frequency of bleeding episodes in adult and pediatric patients 12 years of age and older with: 1) hemophilia A (congenital factor VIII deficiency) without factor VIII inhibitors, or 2) hemophilia B (congenital factor IX deficiency) without factor IX inhibitors.

Criteria

Hympavzi

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of one of the following:
• hemophilia A (congenital factor VIII deficiency) without factor VIII inhibitors
• hemophilia B (congenital factor IX deficiency) without factor IX inhibitors
AND
• Drug will be used for prophylaxis to prevent or reduce the frequency of bleeding episodes
AND
• Patient is 12 years of age or older
AND
• Prescribed by or in consultation with a hematologist/oncologist
AND
• One of the following: (applies to Hemophilia A only)
• For continuation of prior therapy
OR
• Trial and inadequate response, intolerance, or contraindication to Hemlibra (emicizumab-kxwh)

Hympavzi

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

• Drug continues to be used for prophylaxis to prevent or reduce the frequency of bleeding episodes [A]
AND
• Patient demonstrates positive clinical response to therapy (e.g., reduced bleeding episodes)

P & T Revisions

2025-04-02, 2025-01-08

References

1. Hympavzi Prescribing Information. Division of Pfizer Inc. New York, NY. October 2024.

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End Notes

1. Do not use additional doses of HYMPAVZI to treat breakthrough bleeds. [1]

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Revision History

• 2025-04-02: New Program
• 2025-01-08: New Program

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