Hemlibra® (emicizumab-kxwh)

Covered only for routine prophylaxis of bleeding in patients newborn and older with congenital hemophilia A (with or without factor VIII inhibitors); on‑demand use or non‑hemophilia‑A indications are excluded. Authorization requires hematologist/hemophilia‑specialist prescribing or consultation, subcutaneous weight‑based dosing per policy (loading 3 mg/kg weekly ×4; maintenance 1.5 mg/kg weekly OR 3 mg/kg every 2 weeks OR 6 mg/kg every 4 weeks), documentation of diagnosis and prophylaxis intent, patient weight and treatment plan, and is authorized up to 12 months.

"Documentation that the request is for routine prophylaxis of bleeding episodes (clinical note stating prophylaxis intent)."

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