Prior Auth Protocol

FDA Approved Indications:

For use in the treatment of proliferating infantile hemangioma requiring systemic therapy

Health Net Approved Indications and Usage Guidelines:

Coverage is Not Authorized For:

Non-FDA approved indications, which are not listed in the Health Net Approved Indications and Usage Guidelines section, unless there is sufficient documentation of efficacy and safety in the published literature.
Premature infants with corrected age < 5 weeks, infants weighing <2 kg; heart rate <80 bpm; blood pressure <50/30 mm Hg

General Information:

Hemangeol is available through the Hemangeol Patient Access program, which fills each patients prescription and provides free delivery of Hemangeol directly to their treatment site, caregivers home, or business. Hemangeol Patient Access also offers a comprehensive compliance system to improve adherence to the specific dosing directions given by the physician. To begin the process of setting up the first order of Hemangeol or to obtain more information about the product, the Hemangeol Patient Access program can be reached at 1-855-PFPHARM (737-4276) or at www.hemangeol.com.
Safety and effectiveness for infantile hemangioma have not been established in pediatric patients greater than 1 year of age

Therapeutic Alternatives:

Drug	Dosing Regimen	Dose Limit/ Maximum Dose
Propranolol (Inderal^R) oral solution	0.6 - 1.7 mg/kg PO BID	1.7 mg/kg BID

* Requires Prior Authorization

Recommended Dosing Regimen and Authorization Limit:

Drug	Dosing Regimen	Authorization Limit
Hemangeol	0.6 mg/kg PO BID, followed 1 week later by a dose increase to 1.1 mg/kg BID, followed in another week by a dose increase to the maintenance dose of 1.7 mg/kg PO BID. Adjust doses periodically as the childs weight increases.	Length of Benefit

Product Availability:

Oral solution: 4.28 mg/mL propranolol hydrochloride (equivalent to 3.75 mg propranolol)

References:

Hemangeol [Prescribing Information]. Parsippany, NJ: Pierre Fabre Pharmaceuticals, Inc.; March 2014.