CurrentAetnaPolicy N/A

Beqvez (fidanacogene elaparvovec-dzkt) Medication Precertification Request

Precertification request form to collect patient, prescriber, insurance, dispensing, product, diagnosis, and clinical information required by Aetna to review authorization for Beqvez (fidanacogene elaparvovec-dzkt). It is a form (page 1 of 1) to be completed for start or continuation of therapy.

Policy Summary

PayerAetna

PolicyBeqvez (fidanacogene elaparvovec-dzkt) Medication Precertification Request

Policy CodePolicy N/A

Change TypeAdministrative form (no material coverage changes)

Effective Date

Next Review Date

Key ActionComplete and submit the Beqvez precertification form with all required patient, insurance, prescriber, dispensing, product, diagnosis, and clinical information for Aetna review; include required clinical documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes (form is informational/administrative only).

1Form pages

MultipleRequired clinical checkpoints

AetnaPayer

Document overview

This is Aetna’s one-page (Page 1 of 1) precertification request form to collect required information to evaluate authorization requests for Beqvez (fidanacogene elaparvovec-dzkt). It is intended to be completed for either start of treatment or continuation of therapy and collects patient demographics, prescriber and insurance details, dispensing/administration site and CPT code(s), product dose and frequency, primary and other ICD-10 diagnosis codes, and the clinical information and testing results needed for gene therapy eligibility and safety review.

Required clinical information for all requests

Required Clinical Information for All Requests

For ALL Requests (clinical documentation required):

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What providers must do

Prior Authorization

Precertification submission required

Complete and submit the Beqvez precertification form with all required patient, insurance, prescriber, dispensing, product, diagnosis, and clinical information for Aetna review. The precertification form must be filled out and sent using the contact methods listed on the form.

Submit via phone or fax (see contact methods below)

Documentation Required

Clinical documentation required

Provide the following clinical documentation with the precertification request: documented diagnosis of hemophilia B; medication prescribed by or in consultation with a hematologist; Factor IX inhibitor test results with timing (negative within past 30 days, or if positive within past 30 days then a subsequent negative within two weeks); history of prior gene therapy (confirm no prior receipt); current Factor IX activity level indicating severe or moderately severe deficiency (≤ 2% of normal); current use of Factor IX prophylactic therapy; history of life‑threatening hemorrhage and/or repeated serious spontaneous bleeding episodes; negative AAVRh74var antibody test result; and indication of administration at an Aetna designated gene therapy treatment center when applicable.

Documented diagnosis of hemophilia B
Prescribed by or in consultation with a hematologist
Factor IX inhibitor test result (negative within past 30 days, or if positive then a negative test within two weeks of the initial positive)
No prior receipt of gene therapy (history of prior gene therapy)
Factor IX activity level (severe or moderately severe deficiency ≤ 2%)
Current use of Factor IX prophylactic therapy
History of life‑threatening hemorrhage
History of repeated, serious spontaneous bleeding episodes
Negative AAVRh74var antibody test result
Designated Aetna gene therapy treatment center if applicable

Billing Rule

Use Medicare request form for Medicare Advantage Part B

For Medicare Advantage Part B patients, providers must use the Medicare Request Form instead of this Beqvez precertification form.

Prior Authorization

Precertification contact information

Submit precertification requests via the Aetna precertification contact methods provided on the form. Phone and fax options are available for precertification submission and inquiries.

Phone: 1-866-752-7021 (TTY: 711)
Fax: 1-888-267-3277

Definitions and background

This form is used by Aetna to evaluate authorization requests for Beqvez gene therapy and gathers comprehensive information to support that review, including patient demographics and contact details, insurance and member identifiers, prescriber credentials and specialty (e.g., hematologist), place of administration and administration/dispensing details, product name/dose/frequency, primary and secondary ICD diagnosis codes, and specific clinical data and checkpoint responses (e.g., documented hemophilia B diagnosis, hematology involvement, Factor IX inhibitor test timing and results, prior gene therapy, Factor IX activity level, bleeding history, AAVRh74var antibody result, and whether administration will occur at an Aetna-designated gene therapy treatment center).

Definitions

AAVRh74varAdeno-associated virus serotype Rh74var antibody test referenced on the form