Pharmacy Prior Authorization Criteria

Alhemo (concizumab-mtci)

Indications for Prior Authorization

Alhemo (concizumab-mtci)

• 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: Hemophilia A (congenital factor VIII deficiency) with or without FVIII inhibitors and Hemophilia B (congenital factor IX deficiency) with or without FIX inhibitors

Criteria

Alhemo

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of one of the following:
• hemophilia A (congenital factor VIII deficiency) with or without factor VIII inhibitors
• hemophilia B (congenital factor IX deficiency) with or 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)

Alhemo

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
AND
• Patient demonstrates positive clinical response to therapy (e.g., reduced bleeding episodes)

P & T Revisions

2025-09-03, 2025-04-30

References

1. Alhemo Prescribing Information. Novo Nordisk Inc. Plainsboro, NJ. July 2025.

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Revision History

• 2025-09-03: Adjusted diagnosis criteria due to updated FDA indication
• 2025-04-30: New Program

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