CurrentColorado Rocky Mountain Health PlansPolicy N/A

Alhemo (concizumab-mtci) prior authorization

Defines prior authorization and reauthorization criteria for Alhemo (concizumab-mtci) for routine prophylaxis of bleeding in patients with hemophilia A or B age 12 and older; applies to Colorado Rocky Mountain Health Plans pharmacy management.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyAlhemo (concizumab-mtci) prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization showing diagnosis of hemophilia A or B, patient is ≥12 years, and use for routine prophylaxis.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsauthorization period

>=12minimum age

Hemophilia A/Bcovered diagnoses

Prior Authprogram type

Coverage Criteria for Alhemo (concizumab-mtci)

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Initial Therapy - Hemophilia B

Covered when ALL of the following are met

Initial Authorization - Hemophilia B: (1) Diagnosis of hemophilia B AND (2) Patient is 12 years of age or older AND (3) Prescribed for the prevention of bleeding episodes (i.e., routine prophylaxis)

Authorization issued for 12 months

Coverage may be affected by external or member-specific rules. State mandates, federal regulatory requirements, and the member's specific benefit plan coverage can all impact whether Alhemo is covered. Additionally, other policies and utilization management programs maintained by the plan may apply and influence coverage determinations.

Initial Authorization Criteria

Initial Therapy — Initial Authorization

Initial Authorization

Initial Therapy: Diagnosis of hemophilia A or B AND patient is 12 years of age or older AND prescribed for prevention of bleeding episodes (routine prophylaxis)

Authorization issued for 12 months

Provider Actions and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Alhemo. Initial approvals require documentation of a diagnosis of hemophilia A or hemophilia B, patient age 12 years or older, and use for routine prophylaxis (prevention of bleeding episodes). Authorizations are issued for 12 months.

Initial authorization criteria: diagnosis of hemophilia A or hemophilia B; patient >= 12 years; prescribed for prevention of bleeding episodes (routine prophylaxis)
Authorization duration: 12 months

Note

Automated Approval / Additional Clinical Rules

Not specified in this document — program may use automated approval and re-approval processes based on prior claims/medication history, diagnosis codes (ICD-10), and/or claim logic. Use of automated approval varies by program/therapeutic class. Medical necessity and supply limits may also apply.

Automated approval may be based on previous claim/medication history and diagnosis codes (ICD-10)
Processes and use of automation vary by program/therapeutic class
Medical necessity and supply limits may be enforced

Documentation Required

Required Clinical Documentation

For reauthorization, clinical documentation must demonstrate a positive clinical response to Alhemo therapy. Initial requests must include documentation supporting the diagnosis (hemophilia A or B), patient age, and indication for routine prophylaxis.

Reauthorization requirement: documentation of positive clinical response to therapy
Initial request documentation: diagnosis (hemophilia A or B), patient age (>= 12), and indication for routine prophylaxis

Denial Risk

Denial Conditions

Requests that do not document a diagnosis of hemophilia A or hemophilia B, or that indicate the patient is younger than 12 years of age, may be denied. Requests lacking required documentation of positive clinical response for reauthorization may also be denied.

Denial conditions: missing documented diagnosis of hemophilia A or hemophilia B
Denial conditions: patient age < 12 years
Denial conditions: lack of documentation of positive clinical response for reauthorization

Background

Alhemo (concizumab-mtci) is a tissue factor pathway inhibitor antagonist indicated for routine prophylaxis to prevent or reduce bleeding episodes in adults and pediatric patients 12 years of age and older with hemophilia A or hemophilia B, with or without inhibitors. The policy addresses both initial authorization and reauthorization criteria for prophylactic use of Alhemo in this population.

Definitions

inv-12: routine prophylaxis

DefinitionRoutine prophylaxis: prescribed for the prevention of bleeding episodes (regular preventive therapy)

Indication for AlhemoRoutine prophylaxis to prevent or reduce frequency of bleeding in patients 12 years and older with hemophilia A or B

Authorization requirementInitial approvals require documentation that therapy is for routine prophylaxis (see initial authorization criteria)

Step	Requirement
1	Not specified; program may use automated approval based on prior claim/medication history, diagnosis codes (ICD-10), and/or claim logic per Additional Clinical Rules.
	Use of automated approval and re-approval processes varies by program and/or therapeutic class.