CurrentAetnaPolicy N/A

Beqvez (fidanacogene elaparvovec-dzkt) precertification request form

Precertification request form and required clinical information for authorization of Beqvez (fidanacogene elaparvovec-dzkt) for Aetna members; used by prescribing providers and dispensing/administration sites to request start or continuation of therapy.

Policy Summary

PayerAetna

PolicyBeqvez (fidanacogene elaparvovec-dzkt) precertification request form

Policy CodePolicy N/A

Change TypeMinor — no material changes

Effective DateN/A

Next Review DateN/A

Key ActionProvider must complete all form fields legibly and submit precertification to Aetna Precertification Notification (phone/fax).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 pageform length

8document sections

Aetnapayer

Coverage Criteria for Beqvez (fidanacogene elaparvovec-dzkt)

Required clinical criteria for precertification

Precertification requests require completion of ALL the following documented items:

Required clinical confirmations: Documented diagnosis of hemophilia B; prescribed by or in consultation with a hematologist; negative Factor IX inhibitor test result within the past 30 days (or initial positive within 30 days followed by a negative result within two weeks); prior gene therapy status documented (has patient previously received gene therapy?); severe or moderately severe Factor IX deficiency (≤ 2% of normal circulating Factor IX) when applicable; current use of Factor IX prophylactic therapy status documented; current or history of life‑threatening hemorrhage documented; history of repeated serious spontaneous bleeding episodes documented; negative AAVRh74var antibody test result; administration to be provided at an Aetna designated gene therapy treatment center when applicable.

All items correspond to checkboxes on the precertification form and must be completed.

The precertification form specifically asks whether the patient has previously received gene therapy. This prior gene therapy status is collected on the form and must be documented for all requests; it may affect eligibility or coverage decisions.

Coding — Procedure and Diagnosis Codes

Administration CPT codesCPT

Administration code(s) (CPT):

Placeholder for applicable CPT administration codes as indicated on form

Policy Summary

PayerAetna

PolicyBeqvez (fidanacogene elaparvovec-dzkt) precertification request form

Policy CodePolicy N/A

Change TypeMinor — no material changes

Effective DateN/A

Next Review DateN/A

Key ActionProvider must complete all form fields legibly and submit precertification to Aetna Precertification Notification (phone/fax).

SourceLink

On This Page

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Provider Actions and Submission Requirements

Prior Authorization

Prior Authorization Required

Precertification is required for Beqvez (fidanacogene elaparvovec-dzkt). Use the Aetna Medication Precertification Request form and contact Aetna Precertification Notification to submit the request.

Aetna Precertification Notification: Phone 1-866-752-7021 (TTY:711); Fax 1-888-267-3277
Use Medicare Request Form for Medicare Advantage Part B

Step Therapy

No step therapy requirements are specified on this precertification form.

Documentation Required

Required form completion

Provider must complete all form fields legibly including patient demographics, insurance information, prescriber and dispensing/provider details, product information, diagnosis (ICD) codes, and signature/date in the acknowledgement section.

All fields on the one-page form must be completed for precertification review
Request Completed By (Signature Required) and Date must be provided

Documentation Required

Required clinical documentation

Clinical documentation must include confirmation of a documented diagnosis of hemophilia B and that the medication is prescribed by or in consultation with a hematologist. Required clinical items on the form must be completed, including Factor IX inhibitor test results (negative within past 30 days or documented follow-up negative within two weeks of a positive), prior gene therapy history, severity of Factor IX deficiency (≤ 2% for severe/moderately severe), current use of Factor IX prophylactic therapy, history of life‑threatening hemorrhage or repeated serious spontaneous bleeding episodes, and AAVRh74var antibody test result. If applicable, indicate the designated Aetna gene therapy treatment center and place of administration.

Documented diagnosis of hemophilia B: Yes/No
Prescribed by or in consultation with a hematologist: Yes/No
Factor IX inhibitor test result within 30 days: Negative or Positive with documented negative follow-up within 2 weeks
Prior gene therapy treatment: Yes/No
Severity of Factor IX deficiency (≤ 2%): Yes/No
Current Factor IX prophylactic therapy: Yes/No
History of life‑threatening hemorrhage or repeated serious spontaneous bleeds: Yes/No
AAVRh74var antibody test result: Negative/Positive

Denial Risk

Incomplete documentation may trigger denial

Incomplete clinical documentation or missing required form fields may result in denial of the precertification request.

Ensure all required checkboxes and test result dates are provided to avoid denial

Definitions and Test Requirements

inv-12: Negative Factor IX inhibitor test

Test timing requirementNegative Factor IX inhibitor test result must be documented within the past 30 days

Alternate pathwayIf an initial positive inhibitor test occurs, a negative test within two weeks of the initial positive is an acceptable documentation pathway

Form fieldCheckboxes in the clinical information section capture presence/absence of a negative inhibitor test and the initial positive then negative scenario

inv-13: AAVRh74var antibody test

Required antibody testNegative adeno-associated virus serotype Rh74var (AAVRh74var) antibody test result must be documented

Form fieldClinical information section includes a checkbox to indicate negative AAVRh74var antibody test result

RelevanceDocumented serostatus for AAVRh74var is required as part of precertification clinical information for Beqvez

Primary ICD Code:	Primary diagnosis ICD code placeholder
Secondary ICD Code:	Secondary diagnosis ICD code placeholder
Other ICD Code:	Other diagnosis ICD code placeholder

OpenPayer

Beqvez (fidanacogene elaparvovec-dzkt) precertification request form

Coverage Criteria for Beqvez (fidanacogene elaparvovec-dzkt)

Coding — Procedure and Diagnosis Codes

Provider Actions and Submission Requirements

Background

Definitions and Test Requirements