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
Last review date: December 17, 2018