CurrentBlue Cross Blue Shield - AlabamaPolicy N/A

Hemophilia factor product prior authorization / specialty pharmacy dispensing form

This document governs prior authorization and dispensing information for clotting factor products used to treat bleeding disorders (e.g., hemophilia) and is intended for prescribers and specialty pharmacies submitting requests to Blue Cross Blue Shield - Alabama.

Policy Summary

PayerBlue Cross Blue Shield - Alabama

PolicyHemophilia factor product prior authorization / specialty pharmacy dispensing form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete the form in its entirety and provide relevant progress notes and/or bleeding diaries (fax all documents to 1-888-656-0841).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

8document chunks (form sections and bleed entries)

2bleeding episode entries captured

1fax submission number provided

Coverage and Medical Necessity Criteria

Required submission criteria for medical necessity review

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Required patient/prescriber and product details: Patient identifiers and prescriber NPI; product name; dose (IU) requested; dosing frequency; total dose (IU) requested; total number of doses to dispense; total units requested to dispense; retrospective request indicator (Yes/No).

Fields located in Section IV (Clinical/Prescription Information)

Indication and administration: Type of use must be specified (Acute Bleeding Episode; Dental Procedure with procedure date; Episodic; Prophylaxis; Surgical Prophylaxis with procedure date) and place of administration must be documented (Home Infusion; Outpatient Hemophilia Treatment Center; Outpatient Hospital; Provider's Office; Self-administration).

Section IV

Dispensing details: Unit IU per dose, vial strength, assay availability, number of vials requested, and units requested to dispense must be provided; attestation that the assay(s) requested are the closest available to the prescribed dose is required (signature).

Section VI (Dispensing Information)

Bleed documentation: For acute or episodic requests provide bleed records: date of bleed start and end, type/severity of bleed (mild/moderate/severe), location of bleed, number of doses used, and total units (IU) used. The form captures up to two bleed entries (Bleeding and Bleeding 2).

Sections Bleeding and Bleeding 2

Provider Submission and Documentation Requirements

Prior Authorization

Prior Authorization Required for Factor Products

Prior authorization is required for factor products. Complete the form in its entirety and include the clinical/prescription section (product name, dose requested, dosing frequency, total dose/units requested, type and place of use, and retrospective request indicator). Provide relevant progress notes, bleeding diaries, and any supporting documentation (e.g., dates of procedures for dental or surgical prophylaxis). All information and supporting documents must be faxed to 1-888-656-0841. Requests submitted without required prior authorization information may be delayed or denied.

Include clinical/prescription information: product name, dose (IU) requested, dosing frequency, total dose and total units to dispense, number of doses to dispense
Indicate type of use: acute bleeding episode, dental procedure (include date), episodic, prophylaxis, surgical prophylaxis (include date)
Specify place of administration: home infusion, outpatient hemophilia treatment center (HTC), outpatient hospital, provider's office, or self-administration
For dispensing: provide unit IU per dose, vial strength, assay available, number of vials requested, and attest to assay closest to prescribed dose (signature required)
If retrospective, check the Retrospective box and include justification and complete documentation

Denial Risk

Submission Completeness — Documents Required

Submission completeness is required for processing. Incomplete forms or missing documentation (progress notes, bleeding diaries, detailed bleed information such as bleed start/end dates, bleed type and location, number of doses used, and total units used) may result in refusal to process, delay, or denial. Ensure all fields in the clinical/prescription and dispensing sections are completed and that required supporting records are attached. All pages and supporting documents must be faxed together to 1-888-656-0841.

Provide progress notes and/or bleeding diaries with detailed bleed information: date of bleed (start and end), type of bleed (mild/moderate/severe), location of bleed, number of doses used, and total units (IU) used
Attach documentation of procedures when applicable (e.g., dental or surgical procedure dates)
Incomplete forms or missing supporting documents may lead to refusal to process or denial
Fax all completed forms and supporting documents to 1-888-656-0841

Definitions and Use Information

Type of Use

Acute Bleeding EpisodeIntended use to treat an active bleeding event requiring factor replacement.

Dental ProcedureUse for peri-procedural prophylaxis; form includes field to record date of procedure.

EpisodicIntermittent treatment for non-prophylactic, non-surgical bleeds as documented on the form.

ProphylaxisRegular preventive dosing to reduce frequency of bleeding episodes.

Surgical ProphylaxisPeri-operative use to prevent bleeding during surgery; form includes field to record date of procedure.

Place of Administration

Outpatient Hemophilia Treatment Center (HTC)Administration at an outpatient specialized hemophilia treatment center.

Outpatient HospitalAdministration in an outpatient hospital facility setting.

Self-administrationPatient-administered dosing as indicated on the form and attested by prescriber when appropriate.