CurrentMass General Brigham Health PlanPolicy N/A

Alhemo (conicizumab) — routine prophylaxis for hemophilia A and B

Policy governs prior authorization requirements for pharmacy benefit coverage of Alhemo (conicizumab) as routine prophylaxis to prevent or reduce bleeding episodes in patients with hemophilia A or B age 12 and older; applies to Mass General Brigham Health Plan Commercial/Exchange members and specialty pharmacy dispensing.

Policy Summary

PayerMass General Brigham Health Plan

PolicyAlhemo (conicizumab) — routine prophylaxis for hemophilia A and B

Policy CodePolicy N/A

Change TypeCriteria revisedbenefit clarified to pharmacy only

Effective DateFeb 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization and document diagnosis, age (≥12), hematologist involvement, prophylaxis intent, and discontinuation of other prophylactic factor therapies.

SourceLink

POLICY UPDATE CHANGES

Updated criteria to require that member will discontinue prophylactic therapies.

Policy updated to indicate it no longer applies to the medical benefit.

Supplemental indication expanded to include patients without inhibitors.

≥12minimum age for coverage

12 moapproval duration

prior authprogram type

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Coverage Criteria

Initial Authorization — Authorization may be granted when ALL of the following are met

Authorization may be granted when ALL of the following are met:

Initial Authorization Criteria: 1. One of the following diagnoses: a) hemophilia A (congenital factor VIII deficiency) with or without factor VIII inhibitors; b) hemophilia B (congenital factor IX deficiency) with or without factor IX inhibitors. 2. Requested medication will be used for prophylaxis to prevent or reduce the frequency of bleeding episodes. 3. Member is 12 years of age or older. 4. Requested medication is prescribed by or in consultation with a hematologist. 5. Member will discontinue use of other prophylactic therapies.

Continuation/Reauthorization — Reauthorization (Continuation of Therapy): requests will be approved when ALL of the following are met

Reauthorization (Continuation of Therapy): requests will be approved when ALL of the following are met:

Reauthorization Criteria: 1. Requested medication continues to be used for prophylaxis to prevent or reduce the frequency of bleeding episodes. 2. Member demonstrates a positive clinical response to therapy (e.g., reduced frequency or severity of bleeds). 3. Member is not using the requested medication in combination with prophylactic Factor VIII or Factor IX therapies.

Authorization may be granted for members who are new to the plan within the past 90 days only if the member is currently receiving treatment with the requested medication. Coverage does not apply when the product was obtained solely as samples or through the manufacturer's patient assistance programs.

Use of conicizumab in combination with routine prophylactic Factor VIII or Factor IX therapies is not covered. As a condition of approval, the member must discontinue other prophylactic therapies prior to or at initiation of conicizumab; reauthorization requires continued absence of concurrent prophylactic FVIII or FIX therapy.

Coding and Eligibility

Covered CPT Codesmixed

No codes listed

Minimum age — 12 years

Minimum age for coverage12 years (member must be 12 years of age or older)

Age-related approval noteApplies to adult and pediatric patients 12 years and older as indicated in the overview

Reauthorization age checkReauthorization requires member remains age ≥12 at time of request

Provider Actions and Requirements

Prior Authorization

Prior authorization required; specialty pharmacy dispensing

Prior authorization is required for coverage under the pharmacy benefit. These medications are designated specialty and must be filled through a contracted specialty pharmacy.

Step Therapy

No step therapy required

No step therapy requirement is specified in this policy.

Documentation Required

Required documentation to support authorization

Document the diagnosis (hemophilia A or B), the member's age (at least 12 years), that the medication will be used for prophylaxis, and that the medication is prescribed by or in consultation with a hematologist. Also document that the member will discontinue other prophylactic factor therapies.

Background

Conicizumab (Alhemo) is a tissue factor pathway inhibitor (TFPI) antagonist indicated for routine prophylaxis to prevent and reduce bleeding episodes in patients with hemophilia A or B, with or without inhibitors. The policy covers use for prophylaxis in members aged 12 years and older when prescribed by or in consultation with a hematologist and when other prophylactic factor therapies are discontinued.

Definitions

prophylaxis — Routine prophylaxis definition

DefinitionRoutine prophylaxis: ongoing preventive therapy intended to prevent or reduce the frequency of bleeding episodes in patients with hemophilia A or B.

Indication contextPolicy authorizes use when the requested medication will be used for prophylaxis to prevent or reduce bleeding frequency.

PopulationIndicated for patients 12 years of age and older with hemophilia A or B, with or without inhibitors, when used as routine prophylaxis.

Concurrent therapy restrictionNot covered when used in combination with prophylactic Factor VIII or Factor IX therapies; other prophylactic therapies must be discontinued.