Alprolix®, BeneFIX®, Idelvion®, Ixinity®, Rebinyn®, Rixubis® (coagulation factor IX [recombinant]) AlphaNine SD® (coagulation factor IX [plasma-derived]) Profilnine® (factor IX complex [plasma-derived])
EVICORE-MEDICAL_DRUG-D5B090C8
Covers the listed recombinant and plasma‑derived Factor IX products (Alprolix, BeneFIX, Idelvion, Ixinity, Rebinyn, Rixubis, AlphaNine SD, Profilnine) for IV on‑demand treatment, routine prophylaxis, and perioperative management of congenital hemophilia B only; long‑acting agents (Alprolix, Idelvion, Rebinyn) are limited for prophylaxis unless the patient has failed (≥3‑month trial), is intolerant to, or has a contraindication to TWO standard‑half‑life recombinant FIX products. Approval is up to 12 months and requires documentation of diagnosis and indication, patient weight, product/age/bleed‑specific dosing calculations (including observed recovery when used), target FIX levels/perioperative plan, and prior‑treatment history for long‑acting requests.
"Coagulation Factor IX (recombinant and plasma-derived) and Factor IX Complex (plasma-derived) are indicated in patients with hemophilia B (congenital Factor IX deficiency) for: On-demand treatment ..."