CurrentAvMedPolicy Pub. 100-2

Prior authorization for hemophilia and von Willebrand factor replacement therapies

This form and policy govern prior authorization and step-edit requests for outpatient hemophilia and von Willebrand disease factor products for AvMed members, and specifies documentation and HCPCS codes required from prescribers/facilities.

Policy Summary

PayerAvMed

PolicyPrior authorization for hemophilia and von Willebrand factor replacement therapies

Policy CodePolicy Pub. 100-2

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit the completed prior authorization/step-edit request form with required clinical documentation via fax to 1-877-535-1391.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~40listed HCPCS codes (approximate count shown on form)

Allclinical criteria must be met for approval

Faxsubmission method (fax number provided)

Urgent definedstandard for urgent review described

Coverage Criteria for Factor Replacement Therapies

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Clinical Indications and Documentation

Covered when ALL of the following are met:

Primary clinical criteria: Request indicates one of the listed diagnoses (Hemophilia A, Hemophilia B, or von Willebrand Disease); the prescriber has checked the corresponding box on the form and provided the ICD diagnosis code.

All criteria must be met for approval. To support each checked indication, documentation such as lab results, diagnostics, and chart notes must be provided or the request may be denied.

Use of samples to initiate therapy does not meet step edit/preauthorization criteria. Previous therapies will be verified through pharmacy-paid claims or submitted chart notes; therapy started with manufacturer or office samples alone will not satisfy prior authorization requirements.

Requests that are incomplete, incorrect, or illegible — including missing signatures, missing member or prescriber identifiers, or absent supporting documentation — can result in delayed review or denial. All clinical criteria must be met for approval, and documentation such as lab results, diagnostics, and chart notes must be provided for each checked indication on the form.

HCPCS Codes and Weight Documentation

Covered HCPCS Codes (listed on form)HCPCSCovered

J7180	Corifact (factor XIII antihemophilic factor concentrate, human)
J7182	Novoeight (factor VIII, antihemophilic factor, recombinant)
J7183	Injection, Von Willebrand factor complex (Wilate)
J7185	Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha)
J7186	Injection, antihemophilic factor VIII/von Willebrand factor complex (human) (Alphanate)
J7187	Injection, Von Willebrand factor complex (Humate-P)
J7188	Obizur (antihemophilic Factor VIII (Recombinant), Porcine Sequence)
J7189	Factor VIIa (antihemophilic factor, recombinant) NovoSeven RT
J7190	Factor VIII (antihemophilic factor [human]) per IU (Alphanate, Koate-DVI, Monoclate-P, Hemofil M)
J7192	Factor VIII (antihemophilic factor, recombinant) per IU (Recombinate, Kogenate FS, Advate)

1–10 of 27

1/3

Weight — required form fields

WeightWeight and date weight obtained (if applicable) required on form; fields labeled 'Weight (if applicable)' and 'Date weight obtained' must be completed when relevant.

Where recorded on form'Weight (if applicable):' and 'Date weight obtained:' fields under Drug Information section.

PurposeUsed to calculate dosing for factor replacement products when applicable.

Provider Submission, Documentation, and Prior Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for the listed HCPCS codes. Submit the completed PA/step-edit request form via fax to 1-877-535-1391. Authorization can be delayed or denied if the form is incomplete, incorrect, illegible, or supporting documentation is missing.

Fax: 1-877-535-1391
Listed HCPCS codes must be checked on the form

Step Therapy

Step-Edit and Samples

Use of samples to initiate therapy does not meet step edit/preauthorization criteria. Previous therapies will be verified through pharmacy paid claims or submitted chart notes. For urgent reviews, call the AvMed Pre-Authorization Department if lack of timely review could seriously jeopardize the member's life, health, or ability to regain maximum function.

Samples do not satisfy step-therapy requirements
Previous therapies verified via pharmacy claims or chart notes
For urgent reviews, contact AvMed Pre-Authorization Department

Documentation Required

Required Submission Details and Supporting Documentation

Provide complete drug and clinical details to avoid delays: include drug name, form, and strength; dosing schedule; length of therapy; diagnosis with ICD code; member weight and date weight obtained (if applicable); and indicate if standard or urgent review is requested.

Drug name/form/strength
Dosing schedule and length of therapy
Diagnosis and ICD code
Weight and date weight obtained (if applicable)
Indicate Standard Review or request urgent review where appropriate

Documentation Required

Administrative Form Requirements

The prescribing physician must sign and clearly print their name (preprinted stamps are not valid). Include member identifiers, prescriber NPI, office contact name, phone and fax numbers. All required administrative fields on the PA form must be completed to prevent processing delays.

Prescriber signature and printed name (no preprinted stamps)
Member name and AvMed member number
Prescriber NPI
Office contact name, phone number, and fax number
Date of birth and date of signature

Denial Risk

Incomplete Information or Missing Documentation

Authorization may be delayed or denied if the PA/step-edit form or supporting documentation is incomplete, incorrect, illegible, or missing. Ensure all requested clinical documentation (lab results, diagnostics, chart notes) is provided to support each clinical criterion checked on the form.

Incomplete/illegible forms may delay or deny authorization
Provide lab results, diagnostics, and chart notes to support clinical criteria

Definitions and Documentation Notes

Clinical criteria — documentation and approval

Approval requirementAll criteria must be met for approval; the form states 'All criteria must be met for approval.'

Supporting documentationFor each checked indication, provide documentation including lab results, diagnostics, and/or chart notes; otherwise request may be denied.

Checked indicationsProviders must check the applicable diagnosis box (Hemophilia A, Hemophilia B, von Willebrand Disease) and provide the corresponding ICD code.

Consequence of missing docsRequests lacking required supporting documentation for checked criteria may be denied or delayed.

OpenPayer

Prior authorization for hemophilia and von Willebrand factor replacement therapies

Coverage Criteria for Factor Replacement Therapies

HCPCS Codes and Weight Documentation

Provider Submission, Documentation, and Prior Authorization Requirements

Policy Background

Definitions and Documentation Notes