HEMLIBRA (emicizumab-kxwh)

HEMLIBRA (emicizumab-kxwh)

OFFICE OR HOME HEALTH ADMINISTRATION

Indications for Prior Authorization:

• Indicated for the routine prophylaxis to prevent or reduce the frequency of bleeding episodes in adult and pediatric patients with hemophilia A (congenital factor VIII deficiency) with or without factor VIII inhibitors

Patients must meet the following criteria for the indication above:

• Diagnosis of hemophilia A (congenital factor VIII deficiency), AND
• Prescribed by or in consultation with a hemophilia specialist, AND
• The patient has factor VIII inhibitors

Dosing:

• Loading dose: 3 mg/kg by subcutaneous injection once weekly for the first 4 weeks
• Maintenance dose:
  • 1.5 mg/kg once every week, OR
  • 3 mg/kg once every two weeks, OR
  • 6 mg/kg once every four weeks
• Discontinue the prophylactic use of bypassing agents the day before starting Hemlibra prophylaxis
• The prophylactic use of factor VIII (FVIII) products may be continued during the first week of Hemlibra prophylaxis

Approval:

• 1 year